MAPPING SHAFA 17 MEI

K1B1 K2B2 K4B4 k6b2

DPJP : dr. Ferry Dwi K, Sp.P (K) DPJP dr. Budi Yanti DPJP:dr. Herry Priyanto, Sp.P(K() DPJP : dr T Zulfikar Sp. P (K)
PPDS: dr afif PPDS: dr Afif PPDS: dr. Afif
SYUHADA M ASYEK IRWANDI BIN TARMUDI ADNEN ZULFAHMI
CM: 1-29-71-11 CM: 1-30-55-83 CM: 1306601 CM : 1305542
TTL: 15-6-1974 TTL: 25-10-1989 TTL:31/12/1957 TTL :17101965
MRS: 09-05-2022 MRS 16-05-2022 MRS:13-05-22 MRS: 13/05/2022
S/ sesak napas S/ Sesak napas Dx : S/
Nyeri dada - Nyeri dada -efusi pleura dextra dd/ malignancy Nyeri dada kanan (+)
diare - Demam -ppok eksaserbasi akut Batuk sesekali
-susp massa paru kanan Sesak napas
Dx/ Dx/ Hipoalbumin
- Efusi pleura bilateral on Pigtail - Tumor Mediastinum Dx/
hemithorax Kanan ec DD 1. Malignancy 2. - Efusi pleura dextra ec Malignancy TH/ - Efusi pleura dextra on wsd ec
Pleuropneumonia
- SVKS -Iv omeprazole 40 mg/24 j Malignancy
- Susp Proses metastasis paru
- Cancer pain NRS 7-8 -Iv methylprednisolone 125 mg/12j (STOP) -low intake
- Ca ovarium Stadium II C
- Cancer pain NRS 4-5
-pulmicort nebule / 12 j
- Anemia (7,8) Th/ -ventolin nebule 1 resp/8 j Th/
- Hipoalbuminemia Berat (1.86) - IV Omeprazole 40mg/24jam -fluimucyl syr 3 x c2 -inj. Ceftriaxone 1 gr/12 jam
- Hipokalemi (2.60) - IV Furosemide 20mg/24jam -curcuma 3 x1 (14/05/2022(H3)
- Diare Akut - IV Dexamethasone 5mg/24j (16/5) H2 -iv levofloxacine 750 mg/24 j (mulai -inj. Omeprazole 40 mg/24 jam
- MST 2x10 mg PO 13/5/22) Curcuma 3x1
- Codei 3x10mg PO -drip plasbumin 1 fls/24 j (13/5) Vitamin d 3x1
Th/
- O2 2lpm - Tracetate 160mg/12jam PO
- Diet extra putih telur P/ p/
- Three way -foto thorax (13/5/22) : susul hasil
P/ cek lab 13/05/2022
- IV omeprazole 40mg/24jam -usg thorax (+) efusi pleura dekstra
- Evaluasi KU dan Saturasi foto thorax(13/05/2022
- IV Ketorolac 1 amp/8jam -toracosintesis (14/5/22) (+) jumlah cairan
- Vastral 1x1 PO - USG thorax usg thorax
- Thoracosintesis 990 cc rencana kemoterapi
- Curcuma 3x1 PO -Sitologi CP,Kultur CP,Analisa CP (14/5/22)
- Plasbumin 25% 1flash/24 jam - Susul Hasil : Sitologi BAL, FNAB konsul neuologi
(+) Susul hasil konsul Cradio untuk bc (+)
- Paracetamol 1gr/12jam DRIP
-CT scan Thorax K/NK, Daftar (+)
- Attapulgit 2 tab/BAB, max 8tab/24jam Lab 16-05-2022
- Synbio 3x1 PO Hb/Ht/L/T 11.7/34/14.34/507 LAB 13/05/2022
- KSR 3x600mg PO
E/B/NB/NS/L/M 0/0/0/83/7/10 Lab 13-06-2022 HB/HT/L/T
- Domperidone 10mg 3x1 PO Hb/Ht/l/T : 13,3/41/23,45/278
PT/APTT 13.90/34.60 12,9/38/12,68/245
- loperamide 1tab/8jam PO E/B/NB/NS/L/M 0/0/0/89/3/8
Alb 3.30 Sgot/sgpt : 19/23
Ur/Cr 32/0.70 PT/APTT 11,10/24,20 Na/k/cl : 139/3,20/104
P/ Na/K/Cl 136/4.90/100 SGOT/SGPT 33/ Ur/cr : 13/0.56
- Evaluasi KU dan saturasi KGDS 106 Alb : 2,30
- USG thorax (+) 09/05/2022 Ur/Cr 24/0,5
- Cek Lab lengkap Na/K/Cl 140/4/103
- Pleurodesis ditunda hingga KU baik ALB : 2,6
- Koreksi albumin, cek ulang albumin
(12/5)
- TransFusi PRC s/d Hb 10
- Konsul IPD GEH (+) Diare akut

Lab 09-05-2022
Hb/Ht/E/L/T 7.8/23/7.31/399
Alb 1.86
Globulin 3.16
Protein total 5.02
SGOT/SGPT 17/5
Na/K/Cl 131/2.60/91

Lab 14-05-2022
Na/K/Cl : 126/3,90/100
Albumin : 1,80
Sgot Sgpt : 49/14\