MAPPING : dr. NASRUL MUSADIR Sp.

S, FINA (Tgl 7/10/21)

MINA 1
SUBJEKTIF
NO. KAMAR IDENTITAS DIAGNOSIS LABORATORIUM TERAPI PLANING
Keluhan GCS TD
K6B3 Zakaria, lk, - Paresis N.VI 26/10/2021 IV aminofluid 1fls/24jam CT scan nasofaring +
53th bilateral, N.VII,XII Hb : 15 IV triofusin 1fls/24jam kontras (tgl 10/11/21)
sinistra perifer, N.IX,X PO paracetamol 3x500mg
Ht : 43
Tgl masuk : ec susp proses Fisioterapi (+)
PO citicolin 2X500mg
Raber 26/10/2021 metastase dd MG Tr : 425.000
Gizi - Susp tumor PO mecobalamin 3x500mcg Gizi klinik (+)
Leu : 18.300 PO attapulgit 2tab/12jam
Klinik, nasofaring
IPD GEH - Malnutrisi berat GDS : 114 PO sukralfat 3xC2
- PSMBA PO gabapentin 1x300mg
Ur/Cr : 121/1.3 Flumucyl syr 3xc1
Na/K/Cl : IV. pantoprazole
147/4.7/108 1amp/12jam
Minocep gurgle (obat
29/10/21 kumur)
Hb : 14.2
 MINA 1
SUBJEKTIF
NO. KAMAR IDENTITAS DIAGNOSIS LABORATORIUM TERAPI PLANING
Keluhan GCS TD
K1B1 Appan, Lk Kelemaa E4M6V5 - Hemiparesis 02/11/2021 IV, Citicoline 500mg/12jam - USG urologi (8/11/2021)
59 THN n sinistra, paresis IV. Mecobalamin - Fisioterapi (+)
anggota + N.VII XII Hb : 10,4 500mcg/12jam - Saran cardio
Raber gerak kiri sinistra central Flumucyl syr 3x200mg
Ht : 31 Kalitake stop
IPD Tgl masuk : (sequele) e.c. Kalitake 3x1sach
01/11/2021 recurrent stroke Tr : 325 Adalat Oros 1x30mg Lovenov besok stop,
CARDIO iskhemik Lovenox 2x0,4cc ganti Xarelto 1x10mg
Leu : 9,8
(lepas IV. omeprazole 40mg/12jam (senin malam)
rawat) - DM type 2 GDS : 346 Dioven 1x80 mg
Ur/Cr : 100/2,5 -Saran GH :
- Hipertensi stage Na/K/Cl : IVFD Nacl 0,9 %
1 139/5.7/113 Herbesser 1x10mg
- AKI Flumucyl 3x1
04/11/2021

- hipokalaemia HbA1c : 8
Kolesterol (total) :
136
HDL : 37
LDL : 69
TGL : 120
Ur/Cr : 68/2,1
Na/K/Cl :
136/4,7/114
 MINA 1
SUBJEKTIF
NO. KAMAR IDENTITAS DIAGNOSIS LABORATORIUM TERAPI PLANING
Keluhan GCS TD
K3B2 Irham - Severe headace + 20/10/2021 IV. Citicoline 500mg/12jam -
Syahputera, epilepsy on terapi IV. Paracetamol 1gr/8jam
Kepra 2x500mg
Lk, 18 THN Hb : 15,3 Depakote 2x250mg
- AVM Asam Folat 1x1
Ht : 44
Tgl Masuk : - Post DSA Tr : 374
20/10/2021 Leu : 7,1
GDS : 130
Ur/Cr : 30/0,8
Na/K/Cl :
143/4,5/
 MINA 2
SUBJEKTIF
NO. KAMAR IDENTITAS DIAGNOSIS LABORATORIUM TERAPI PLANING
Keluhan GCS TD
K6B1 Elfina Mutia E4 138/72 Dx. Oedem cerebri + 06/11/2021 IV. Citicoline 500mg/12 jam -
Sari, pr, 37 M6 Cephal hematom ar Hb : 13,6 Drip. Paracetamol 1g/8jam
IV. Ondancetron 1 amp/8 jam
tahun V5 Frontal dextra Ht :40 IV. Ceftriaxone 1 g/ 12 jam
Loading Manitol 300
Tr : 320
Tanggal selanjutnya 150 cc / 6 jam
Masuk : Leu : 16,6 Domperidone 3x1
6/11/21 GDS : 111
Ur/Cr : 0,9/22
Na/K/Cl :
142/3,7/112
 MINA 1
SUBJEKTIF
NO. KAMAR IDENTITAS DIAGNOSIS LABORATORIUM TERAPI PLANING
Keluhan GCS TD
K2B1 Imran, lk, 59 Kelemah E4 146/76 Dx. Hemiparesis 06/11/2021 IV. Citicoline 500mg/12 jam Konsul cardio (+),
thn an M6 dextra + paresis N. Hb : 14 S.C lovenox 0,6cc/12jam
dijawab di ruangan
anggota V5 VII, XII dextra sentral Ht :40
Tanggal gerak ec. Stroke Iskemik
Tr : 387
Masuk : kanan tipe emboli
6/11/21 Leu : 11,2
GDS : 92
Ur/Cr : 30/0,9
Na/K/Cl :
144/3,8/109
 MINA 2
SUBJEKTIF
NO. KAMAR IDENTITAS DIAGNOSIS LABORATORIUM TERAPI PLANING
Keluhan GCS TD
K5B3 Zainah, pr, 65 E3 137/77 Dx. Penurunan 06/11/2021 IV. Paracetamol 1 g/8 jam Bedah Saraf  craniotomi
thn M5 kesadaran + Hb : 12,9 IV. Citicoline 500 mg/12 jam evakuasi ICH  keluarga
Amlodipine 1x5mg menolak
V3 Hemiparesis sinistra Ht : 38
Tanggal ec. Stroke Hemoragik
Tr : 208
Masuk : (ICH ar
6/11/21 temporoparietal Leu : 11,8
sinistra) GDS : 136

Hipertensi stage 1 Ur/Cr : 60/0,9

Na/K/Cl :

147/3,5/111
 IGD  MINA 2
SUBJEKTIF
NO. KAMAR IDENTITAS DIAGNOSIS LABORATORIUM TERAPI PLANING
Keluhan GCS TD
RCC Sri Mulyanti, Pusing E4 135/92 Dx. Vertigo perifer 06/11/2021 IV. Omeprazole 40 mg/ 12 jam
Pr, 44 Thn berputar M6 - Hipertensi stage 2 Hb : 12,5 Betahistin 3x6 mg
Flunarizin 2x5 mg
V5 Ht : 37 Amlodipine 1x10mg
Diovan 1x80mg
Tr : 384
Tanggal Domperidone 3x10mg
Masuk : Leu : 8,9
6/11/21 GDS :118
Ur/Cr : 23/0,60
Na/K/Cl :
143/4,3/107
 MINA 1
SUBJEKTIF
NO. KAMAR IDENTITAS DIAGNOSIS LABORATORIUM TERAPI PLANING
Keluhan GCS TD
K4B1 Chairuddin, Ganggua E4 138/83 Dx: Gangguan kognitif 06/11/2021 IV. Citicoline 500mg/12jam
lk, 47 thn n M6 ec Stroke Hemoragik Hb : 14,6 IV. Mecobalamin 500 nmg/12jam
perilaku V5 Ht : 43
Tanggal
Tr : 214
Masuk : Bicara
6/11/21 terbalik Leu : 10,3
balik GDS : 136
Ur/Cr : 61/1,8
Na/K/Cl :
144/4,5/112
 IGD
SUBJEKTIF
NO. KAMAR IDENTITAS DIAGNOSIS LABORATORIUM TERAPI PLANING
Keluhan GCS TD
K1Ki Riska Kelemah E4 170/90 Dx. Hemiplegia 06/11/2021 IV. Citicoline 500mg/12jam
Arachmad, lk, an M6 sinistra + paresis N. N Hb : 16,9 IV. Paracetamol 1g/8jam
Amlodipine 1x 10mg
43 thn anggota V5 VII XII dextra sentra + Ht : 47 Clopidogrel 1x75 mg
gerak paresis n. III IV VI
Tr : 287
Tanggal kanan sinistra ec stroke
Masuk : iskemik Leu : 11,7
6/11/21 GDS : 129
Ur/Cr : 11/0,8
Na/K/Cl :
144/3,6/108
 IGD
SUBJEKTIF
NO. KAMAR IDENTITAS DIAGNOSIS LABORATORIUM TERAPI PLANING
Keluhan GCS TD
K1Ka Dwi Kelemah E4 122/58 Dx. Edema Cerebri 06/11/2021 IV. Citicoline 500mg/12jam
Syahputra, lk, an M6 Hb : 14,6 IV. Paracetamol 1g/8jam
IV. Ceftriaxone 1 g/ 12 jam
18thn anggota V5 Ht : 43
gerak
Tr : 214
Tanggal kanan
Masuk : Leu : 10,3
6/11/21 GDS : 136
Ur/Cr : 61/1,8
Na/K/Cl :
144/112/4,5

PINERE
 SUBJEKTIF
NO. KAMAR IDENTITAS DIAGNOSIS LABORATORIUM TERAPI PLANING
Keluhan GCS TD
Daratul Laila, Penurun Dx. 06/11/2021
Pr, 42 Tahun an - Pneumonia ec. Hb :
Kesadara Probable Covid-19 Ht :
Tanggal n - Penurunan
Tr :
Masuk : Kesadaran +
Raber 6/11/21 Hemiparesis Dextra Leu :
Pulmon Ec. Susp.Brain GDS :
ologi Metastasis
- Ca.Mammae Dextra Ur/Cr :
Na/K/Cl :