Mapping

dr. Nur Astini, Sp.S(K)

MINA 1
SUBJEKTIF
NO KAMAR IDENTITAS DIAGNOSIS LABORATORIUM TERAPI PLANING
Keluhan GCS TD
K5/2 Ruslan bin rusli, Sesak nafas E4 Hemiparesis sinistra + paresis 2/11/2021 Amlodipin 1x10 mg Susul hasil head ct
lk, 48 th M6 NVII sinistra sentral ec dd 1. HB 14.5 Iv citicoline 500 mg/12 jam scan kontras
V5 stroke HCT 41 Iv ceftriaxone 1g/12 jam
2. metastasis proses Trombo 420 Curcuma 3x1
Tgl masuk Efusi pleura ec dd Malignansi Leuko 9,7 Iv omeprazole 40 mg/12 jam
2/11/21 GDS 145 N acetylsistein 3x200 mg
DPJP UR/CR Telmisartan 1x40 mg
PULMO 23/0.8
NA/K/CL
141/4,7/105
 Mapping
dr. Nur Astini, Sp.S(K)
MINA 2
SUBJEKTIF
NO KAMAR IDENTITAS DIAGNOSIS LABORATORIUM TERAPI PLANING
Keluhan GCS TD

K7B2 Nurmani, Pr, 56th Kelemahan E4 Tetraparese tipe UMN + 21/10/2021 21/10/2021 Rencana
anggota gerak M6 Retensio Urine ec HB;9,8 IV Mecobalamin 500mg/12jam laminektomi
V5 HT;29 IV Citicolin 500mg/12jam MRI (+)
Tanggal masuk ERI;3,5
DPJP IV Gabapentin 100mg/12jam
dr NA 20/10/21 TRO;446
LEO;9,6
IV Meytilprednisolon
GDS;100 125mg/12jam
Raber
UR/CR;25/0,60 IV Omeprazole 40mg/12jam
ortho
NA/K/CL;145/4,20/
113
 Mapping
dr. Nur Astini, Sp.S(K)

MINA 2

SUBJEKTIF
NO KAMAR IDENTITAS DIAGNOSIS LABORATORIUM TERAPI PLANING
Keluhan GCS TD
K5/4 Jalinar (Mrs. X), Penurunan E3 Dx: 2/11/2021 Iv citicoline 500 mg/12 jam
Pr, 40 tahun kesadaran M5 - Penurunan kesadaran ec HB 10,9 Drip PCT 1g/8 jam
V4 SAH Traumatik HCT 31 Drip Nimodipin 2,1 cc/jam
- Hematom ar facialis Trombo 367
Tanggal Masuk Leuko 12,7
2/11/2021 GDS 254
DPJP dr UR/CR
NA 27/0,50
NA/K/CL
145/3.4/107
 Mapping
dr. Nur Astini, Sp.S(K)

Raudah 3

SUBJEKTIF
NO KAMAR IDENTITAS DIAGNOSIS LABORATORIUM TERAPI PLANING
Keluhan GCS TD
K5/2 Eliani, pr, 23 th E4 Tetraparesis tipe UMN ec 3/11/2021 Iv ceftriaxone 1g/12 jam
M5 susp mielitis dd sol Medula HB 10,8 Iv omeprazole 40 mg/12 jam
VX spinalis HCT 31 Iv citicoline 500 mg/12 jam
Partial mechanical bowel Trombo 371.000 Iv mecobalamin 500 mcg/12 jam
DPJP obstruction Leuko 9,2
bedah Hipokalemia GDS 65 Drip Aalbumin 25%
Digestiv Hypoalbuminemia UR/CR Iv dexketoprofen 1 amp/8 jam
e 16/0,3
Raber NA/K/CL
dr NA 135/3,4/98
 Mapping
dr. Nur Astini, Sp.S(K)

Raudah 3
SUBJEKTIF
NO KAMAR IDENTITAS DIAGNOSIS LABORATORIUM TERAPI PLANING
Keluhan GCS TD

K5/1 Hidayani, pr, 38 Penurunan E Penurunan kesadaran + 26/10/2021 22/10/2021

th kesadaran M hemiparesis sinistra ec ICH Hb : 9.4 g/dl IV Citicolin 500mg/12jam
V Ht : 28 % IV Paracetamol 1g/8jam
DPJP Tanggal masuk Post Craniotemi evakuasi ICH Leu : 8.1 /mm3 IV Omeprazole 40 mg/12jam
dr NA 22/10/21 Trombo:218/mm3 Drip flukonazol 100 mg/12jam
GDS : mg/dl Iv ceftriaxone 1g/12 jam
Ur: mg/dl
Cr: mg/dl
Na: 144 mmol/L
K: 3.5 mmol/L
Cl: 106 mmol/L 
 Mapping
dr. Nur Astini, Sp.S(K)
RAUDAH 4
SUBJEKTIF
NO KAMAR IDENTITAS DIAGNOSIS LABORATORIUM TERAPI PLANING
Keluhan GCS TD
K7/4 Tambuk Kejang sejak Dx: 2/11/2021 Fenitoin 3x100 mg
Panjaitan, Lk, 38 usia 2 bulan - Riwayat bangkitan epileptik HB 10,5
tahun tipe general onset motor HCT 31
seizure tonic clonic Trombo 219.000
- Open defect ar left elbow Leuko 7,1
TGL MASUK GDS 185
2/11/2021 UR/CR
DPJP 35/1,2
BEDAH NA/K/CL
PLASTI 145/3.1/109
K

ICU2
 Mapping
dr. Nur Astini, Sp.S(K)
SUBJEKTIF
NO KAMAR IDENTITAS DIAGNOSIS LABORATORIUM TERAPI PLANING
Keluhan GCS TD
BED 3 Racidah, pr, 61 Penurunan E2 DX penurunan kesadaran 2/11/2021 Iv citicoline 500 mg/12 jam Pasien menolak
th kesadaran M5 +hemiparesis sinistra ec HB 16,6 Drip paracetamol 1g/8 jam Tindakan vp shunt
sejak 3 hari V2 stroke Hemoragik (ICH a/r HCT 49% Drip Nimodipin 2,1 cc/jam
DPJP SMRS ganglia basalis dextra+IVH) Trombo 402.000 Iv omeprazole 40 mg/12 jam
Bedah Leuko 19,0 Amlodipine 1x10 mg
Saraf Tgl masuk GDS 140
2/11/21 UR/CR 53/1,3
NA/K/CL
147/4,5/107

AQSA 1
 Mapping
dr. Nur Astini, Sp.S(K)
SUBJEKTIF
NO KAMAR IDENTITAS DIAGNOSIS LABORATORIUM TERAPI PLANING
Keluhan GCS TD

ISO 5 Muhibbudin, lk, kelemahan E4 - Hemiplegi sinistra ec susp Hasil laboratorium - IV Lansopleaze 30mg/12j Rencana LP
33thn anggota gerak M6 Toxoplasma Cerebri 21/10/2021 - PO Cotrimoxazole 960mg/24 j
kiri V5 - SIDA stadium 4 Hb : 13,2 g/dl - PO Sulfadiazin 1 g/6j
DPJP Tanggal masuk - Candidiasis Oral Leu : 4.700 /mm3 - PO Pirimetamin 200 mg/24j
IPD 21/10/21 Trombo : - Nystatn drop 2cc/6j
180.000/mm3 - paracetamol 3x500 mg
Raber GDS : 110 mg/dl - drp novalgin 1 amp/12 jam
dr NA Na: 142 mmol/L - itraconazole 2x1
K: 4,2 mmol/L - iv buscopan 1amp/8 jam
Cl: 108 mmol/L
Ca: 8,0 TX NEURO
Alb: 3,6 - iv citicoline 500 mg/12 jam
PT: 0,78
APTT: 1,17