MAPPING AQSHA 1

DPJP: dr. Masralena Siregar, Sp. PD

Sabtu/ 21 Juli 2018
Tim Jaga :dr. Indra/ dr. Lisa
DokterMuda :Fitri /shela/weny

ISO 1 ISO 2 ISO 3 ISO 4

SARAF Dokter : dr. Irhas Dokter : dr. Irhas ORTHOPEDI
COW : dr. Laura COW : dr. Laura
Nama : Nazaruddin
Usia :47 Tahun
Alamat: Pidie Jaya
Pekerjaan: PNS
CM: 0974219
Hari rawatan:2

Ass/
1. Pneumonia dd/
- TB paru infeksi sekunder
2. Gout Arthritis kronik
3. DM tipe 2 normoweight
4. Dispepsia tipe like ulcer dd
gastropati diabetikum

Th/
- Bedrest
- Diet DM 1700 kkal/hari
- O2 2-4 L/i
- IVFD Nacl 0,9% 20gtt/i
- IV Ceftriaxone 2gr/ 24 jam
- Omeprazole 40gr/24 jam
- Domperidon 3x10mg
- Flumucyl 3x200mg
- SC levemir 0-0-0-8 IU

Lab 20/07/2018
Kolesterol total : 155
HDL/LDL : 22/88
Trigliserida : 93
Urinalisis
Protein +1
Glukosa +1

Lab 18/7/2018
Hb/HT/E/L/T
10,7/31/4,2/7,1/561
MCV/MCH/MCHC
74/25/34
Diftel : 1/0/1/75/9/14
SGOT/SGPT: 37/34
Gds/Ur/Cr : 269/15/0,83
Na/K/Cl : 138/3,9/99

ISO 5 ISO6 ISO 7 ISO 8

dr. Saddam dr. Saddam ANAK ANAK
COW dr. Kudrah COW dr. Kudrah
Nama : Nama : Amiruddin
Usia : Usia :58 Tahun
Alamat: Alamat: Banda Aceh
Pekerjaan: Pekerjaan: Swasta
CM: CM: 0828192
Hari rawatan: Harirawatan: 5

Ass/
5. Obstruksi Joundice ec dd/
- Cholangio Ca
- Ca Caput Pankreas
6. DM tipe 2
7. HT stage II on terapi

Th/
- Bedrest
- Diet MB Hati 1700 kkal/hari
- IVFD aminoleban 1 fls/hr
- IV Cefaperazone sulbactam
1gr/12jam
- Amlodipin 1x10mg
- Glimepiride 2x2mg
- S.C Levemir 0-0-0-8 iu
 Lab 17/7/2018
PT/APTT : 1/1,2

Lab 17/7/2018
Hb/HT/E/L/T
14,7/42/4,9/9,5/251
MCV/MCH/MCHC
85/30/35
Diftel : 2/1/0/65/23/9
Bil. Indirect/SGOT/SGPT
4,37/129/164
Ur/Cr : 22/0,83
Na/K/Cl : 140/3,8/103

ISO 9 ISO 10 ISO 11 ISO 12

dr. Andri BK dr. Andri BK dr. Andri BK ANAK
COW : dr. Hendra COW : dr. Hendra COW dr. Hendra
Nama : Fajar Rotama
Usia :24 th
Alamat: BNA
Pekerjaan: Wiraswasta
CM: 1114373
Hari rawatan: 7

Ass/
1. Susp. Tonsilitis difteri dd/
- Tonsilitid Kronis eks akut
- Tonsilitis folikularis
2. Susp miokarditis RBBB
Th/
- Bedrest
- Diet MB TKTP
- IVFD Nacl 0,9% 20 gtt/i
- Penicillin Procain 1,2 juta
Unit/12 jam (H-6)
- PCT 3x500 mg
- Eritromisin 4x500 mg

Lab 16/7/2018
Hb/Ht/E/T/L
13,9/41/4,8/174/11,8
MCV/MCH/MCHC
85/29/34
Diftell : 4/0/0/76/9/11
Gds : 93
Ur/Cr : 35//0,97
Na/K/Cl : 142/3,6/104

Kelas 1 Kelas 2 Kelas 3 Kelas 4

dr. Andri BK dr. Andri BK dr. Irhas dr. Irhas
COW: dr.Hendra COW: dr. Hendra COW: dr.Laura COW :dr. Laura
Nama : Adnan Mahmud Nama : Zulhilmi Nama : Syamsuddin Mahmud Nama :Zachrial
Usia :67 Tahun Usia : 44 Tahun Usia :66 tahun Usia : 56 tahun
Alamat: Bireuen Alamat: Ulee Kareng Alamat : Bireun Alamat : Sabang
Pekerjaan: PNS Pekerjaan: PNS Pekerjaan :pensiunan Pekerjaan :Swasta
CM: 1177817 CM: 0935292 CM :1-17-83-46 CM : 1-17-82-81
Harirawatan:12 Harirawatan: 6 Hari rawatan: 7 Hari rawatan :2

Ass/ Ass/ Ass/ Ass/

1. Akut on CKD dd AKI stage III 1. Varises Esofagus grade III 1. Syok Sepsis (perbaikan) ec 1.CKD stage V ec dd/
post renal 2. Gastropati hipertensi portal dd - HN
2. Multiple nefrolitiasis sinistra+ 3. Sirosis hepatis std DC related - Urosepsis - PNC
DJ Stent Sinistra Hep.C - Pneumonia 2. Anemia sedang NN ec
3. Ureterolithiasis 1/3 distal D 4. Status hipokoagulasi 2. . CHF Fc NYHA II-II ec peny. Ginjal Kronik
4. Hidronefrosis berat D+ ringan 5. DM tipe 2 NW DCM 3. HT stage I
Sinistra 3. Cardiorenal syndrome 4. Ulkus diabetik a/r cruris
5. Hiperuresemia stage 1 dd acute on CKD sin
Th/ Th/ 4. CAP 5. DM tipe 2 normoweight
- Bedrest - Bedrest 5. Anemia sedang NN ec dd
- Diet ginjal 1700 kkal/hari+30gr - Diet hati MB 1700 kkal/hari - Penyakit Kronis Th/
protein/hari - Threeway - Perdarahan -Bed rest
- Threeway - IV vit. K 10 mg/8 j 6. DM tipe 2 Normoweight -Diet ginjal 1700 kkal+60 gr
- IV ceftriaxone 2 gr/ 24 jam (H8) - SC humalog kwikpen 12-12-12 7. Hipoglikemia (Perbaikan) protein
- Flumucyl 3x200 mg - Omeprazole 2x20 mg 8. Post cystotomy - IV ceftriaxone 2gr/24jam
- Bicnat 2x1 tab - Propanolol 2x 10 mg 9. Hiponatremia - IV Omeprazole 40mg/12jam
- Alloporinol 1x100mg - Curcuma 3x1 tab 10. dd/ - amlodipin 1x10mg
- Fossen Enema (k/p) 1.Ca prostat - betahistin 3x1
- Graphalac syr 3x cth II Lab 20/7/2018 2. BPH - asam folat 2x1
- Asam Folat 2x400 mg PT/APTT : 1,21/1,53 3.Striktur uretra - lenal ace 2x169mg
- Lenal ace 2x169 mg
Lab 17/7/2018 Th/ Lab 20/7/2018
Lab 19/7/2018 Hb/Ht/E/L/T - Bedrest Hb/Ht/E/L/T
Hb/Ht/E/T/L 11,3/33/3,7/4,4/103 - Kateter 9,0/26/2,9/10,4/164
8,4/24/2,9/374/8,3 MCV/MCH/MCHC - Diet MII 1700 kkal/hari MCH/MCV/MCHC
Mcv/Mch/Mchc 88/30/34 - O2 2-4 liter/i 89/31/35
84/30/35 Diftell : 15/2/0/47/24/12 - IVFD cairan 2:1 15 gtt/i Diftel : 2/0/0/83/5/10
Diftell: 9/1/0/61/18/11 PT/APTT : 1,51/1,75 - IV Meropenem 1 gr/12 Urinalisis
Ur/Cr : 106/4,24 jam (H7) Protein +1
Na/K/Cl : 142/3,7/98 - IV Omeprazole 40 mg/24 Glukosa +3
Asam Urat: 8,2 jam Darah +
- Drip NE 0,05 meq titrasi
Lab 16/7/2018 dosis via syringepump Lab 15/7/2018
Hb/Ht/E/T/L target MAP> 65 mmhg Na/K/Cl : 142/4,5/15
8,8/24/3,0/203/5,2 - Domperidon 3x10 mg
Mcv/Mch/Mchc - Flumucyl 3x200mg Lab 14/7/2018
82/30/36 - Bicnat 3x1 Hb/Ht/E/L/T
Diftell: 7/1/0/60/22/10 - IV. Furosemid 1 amp/8 5,2/15/1,7/13,0/288
Ur/Cr : 149/5,01 jam MCH/MCV/MCHC
Na/K/Cl : 140/4,0/107 - CPG 1x 75 mg 90/30/34
- Atorvastatin 1x 20 mg Diftel : 1/0/0/90/4/5
Lab 12/07/2018 - Spironolakton 2x100 mg Gds/Ur/Cr: 142/340/16,45
Ur/Cr: 168/8,23 - KSR 2x 600 mg Na/K/Cl: 143/6,2/119
- Nebule Combivent 1
Lab 11/07/2018 resp/8 jam
Urinalisis
Warna: kuning Lab 17/7/2018
Kejernihan: keruh Urinalisis
Berat jenis: 1,010 Lekosit +
pH: 6,5 Protein +1
Leukosit: Positif Darah +
Protein: Positif (+1)
Darah: Positif Lab 17/7/2018
Glu/Keton/Nitrit/ Hb/Ht/E/L/T
Urobilinogen/Bilirubin: Neg 9,9/30/3,5/40,3/82
Leukosit: 20-30 MCH/MCV/MCHC
Eritrosit: 30-40 84/28/33
Epitel: 8-10 Diftell :0/0/0/90/7/3
PSA total: 9,61
Lab 10/07/2018 Albumin: 2,87
Hb/Ht/E/L/Tr Kolestrol total:74
11,3/32/3,9/8,1/51 Kolestrol HDL: 4
MCV/MCH/MCHC Trigliserida: 108
81/29/36 Ca/Hb-a1c: 8,4/8,00
Diftel : 6/1/0/73/11/9 Ur/Cr : 145/5,26
PT/APTT: 0,8/1,2 Na/K/Cl : 151/6,3/115
Gds: 75 Urinalisis
Ur/cr: 160/8,81 Warna: kuning/Kejernihan:
Na/k/CI: 135/4,1/108 keruh/berat jenis: 1,010/PH:
6,5/leukosit: (+) /protein: (+)

Lab 15/7/2018
Hb/Ht/E/L/T
9,6/28/3,4/42,8/149
MCH/MCV/MCHC
83/28/34
Diftell :0/0/0/94/3/3
Gds : 50
Ur/Cr : 81/4,28
Na/K/Cl : 138/4,9/110

Kelas 5 Kelas 6 Kelas 7 Kelas 8

dr. Saddam dr. Saddam dr. Andri dr. Saddam
COW: dr. Kudrah COW: dr. Kudrah COW: dr. Hendra COW: dr. Kudrah

Nama:Usman Nurdin Nama:Usman Anshari Nama:Fuadi Nama: Sabirin

Usia: 46 tahun Usia: 57 tahun Usia: 45 tahun Usia: 32 tahun
Alamat: bireun Alamat: Aceh Utara Alamat: Lhoksemawe Alamat: Aceh Besar
Pekerjaan: Swasta Pekerjaan: PNS Pekerjaan: PNS Pekerjaan: Karyawan Swasta
CM: 0-93-63-93 CM: 1-17-80-06 CM: 1062909 CM: 1-14-21-22
HariRawatan: 8 HariRawatan: 9 HariRawatan: 4 HariRawatan: 3

Ass/ Ass/ A/ Ass/

1. Efusi pleura bilateral e.c dd 1. CHF FC NYHA II ec HHD 1. PSMBA (perbaikan) ec dd/ 1. Edema anasarka ec dd/
- Pleuritis TB 2. Pneumonia (HAP) perbaikan - Ca gaster - Sindroma nefrotik
 - Pleuropneumonia 3.Partial MBO perbaikan ec dd/ - limfoma malignan recurrent - Sindroma nefritik
2. TB Milier - TB Peritoneal - GIST - IGA nefropati
3. HHD - Malignancy 2. Anemia sedang HM ec dd/ 2. Anemia sedang NN ec dd/
4. Hipoalbumin 4. Trombositopenia perbaikan - def. Besi - peny. Kronik
5. CKD stage V on HD reguler e.c dd 5. Cardiorenal syndrome tipe 1 - peny. Kronik - perdarahan
1) PNC 6. Hidrokel
2) HN 7. Tinea korporis Th/ Th/
3) PGOI -bedrest - Bedrest
1. Hemoroid grade II Th/ -Diet MII 1700 kkal/hr - Diet ginjal 1700 kkal + ekstra putih
- Bedrest -IVFD RL 10 gtt/i telur
Th/ - O2 2 L/i via NK -IV omeprazol 40 mg/12 j - Iv. Furosemid 1 amp/ 8 jam
-Tirah baring - Diet MII 1700 kkal/hr -IV ketorolac (K/P) - Valsartan 80 mg 1x1/2 tab
- O2 2-4 L/I nasalkanul - IV Cefriaxone 2 gr/24 jam -domperidon 3x10 mg - Simvastatin 1x20 mg
-Diet sonde 1500 kkal + 60 gr (H10)
protein/hari - IV Omeprazole 40 mg/12 jam Lab 18-07-2018 Lab 20/07/2018
- Threeway - Sucralfat 3xCII Hb/Ht/E/Tr/L Hb/Ht/E/Tr/L
-Lenal ace 2x169 mg - Flumcyl Syr 3xCI 9,2/27/3,5/194/4,4 6,5/19/2,2/620/13,4
-As.folat 2x400 mcg - Nebule combivent 1 resp/8 jam MCV/MCH/MCHC MCV/MCH/MCHC
- Amlodipin 1x10 mg - Domperidone 3x10 mg 77/26/34 89/30/34
- Paracetamol 3x500 mg - Ceterizin 2x 10 mg Diftell: 2/1/0/57/29/11 Diftell: 2/0/0/50/38/10
- anti hemorrhoid supp 1x1 - Ketokonazolecr (Sue malam) HbsAg/anti HCV: Negatif/neg Retikulosit : 7,2
- lactulac syr 3xc1 - Asamsalisilat 3% + mikonazol Bil.total : 0,35 MDT
- iv aminofusin 250 mg post HD - Graphalac syr 3 CII Bil. Direl/indirek : 0,15/0,2 Eritosit : normokrom anisositosis
- antihemoroid supp 1x1 - SC lantus 0-0-0-10 SGOT/SGPT : 22/6 Lekosit : leukositosis
- IM streptomisin 1000 mg/hari (H8) GDS : 112 Trombosit : jumlah meningkat, bentuk
- pro TB 2 FDC 1x3 tab Lab 16/07/2018 Ur/Cr: 19/0,94 nomal
- Etambutol 1x1000 (post HD) Hb/Ht/E/Tr/L Na/k/CI: 142/4,0/107 Kesimpulan : anemia NN dg
- Pirazinamid 1x2000 (post HD) 12,7/34/4,5/22,5/101 trombositopenia
- curcuma 3x1 MCV/MCH/MCHC
- piridoksin 2x1 77/28/37 Lab 18/07/2018
-HD 3 x (senin, Rabu,Jum’at) Diftell: 7/0/0/73/8/12 Hb/Ht/E/Tr/L
Ur/Cr: 193/2,89 7,6/22/2,6/665/26,6
Lab 18/07/2018 SGOT/SGPT/ bil total: 47/118/0,89 MCV/MCH/MCHC
Hb/Ht/E/Tr/L 85/29/34
9,5/29/3,6/336/18,1 Lab 15/07/2018 Diftell: 0/0/1/88/10/1
MCV/MCH/MCHC Ur/cr HbsAg: Negatif
80/26/33 210/ 3,74 Albumin/GDS: 1,42/163
Diftell: 4/0/0/78/7/11 Lab 13/07/2018 Ur/Cr: 59/0,94
Ur/Cr: 143/10,33 Hb/Ht/E/L/T Na/k/CI: 135/4,2/111
Na/K/Cl: 135/4,2/99 12,2/33/4,3/23,9/58
Ca : 13,1 MCV/MCH/MCHC
SGOT/SGPT : 72/9 Albumin: 3,34
Ur/Cr: 219/5,54
Lab 13/07/2018 HbA1C: 7,8
Hb/Ht/E/Tr/L LED: 110
10,2/31/4/253/16,4 Anti HCV: Negatif
MCV/MCH/MCHC
78/25/33
Diftell: 0/1/0/86/3/10
Ur/Cr: 87/7,87
Na/K/Cl: 133/4,3/99
SGOT/SGPT/ alb/ bilind/ bildir
34/ 5/ 2,99/ 0,33/0,99

Lab 11/07/2018
Hb/Ht/E/Tr/L
8,4/27/3,4/268/11,9
MCV/MCH/MCHC
79/25/32
LED : 75
Diftell: 1/1/0/82/5/11
Ur/Cr: 104/9,72
Na/K/Cl: 137/5,9/91

Lab 9/7/2018
Asam Urat : 8,5
 Kelas 9 Kelas 10 Kelas 11 Kelas 12
dr. Andri BK dr. Irhas BTKV dr. Irhas
COW :dr. Hendra COW : dr. Hasna Laura Raber EMD COW : dr. Hasna Laura

Nama:Syamsul Bahri Nama: A. Bakar Yus Nama : A. gani said

Usia:58 tahun Usia: 73 tahun Usia : 64 tahun
Alamat: Pidie Alamat: Geuceu Alamat : Indra jaya
Pekerjaan: Guru Pekerjaan: pensiunan Pekerjaan : pensiunan
CM: 1-14-16-05 CM: 1161973 CM: 1091722
HariRawatan :24 HariRawatan :7 Hari rawatan : 7

Ass/ A/ Ass/
1. CKD stage V e.c PGOI 1. Adenokarsinoma recti 1. Penurunan kesadaran ec dd/
2. Hipertensi on terapi 2. cholelitiasis - HHS
3. ISK 3. DM tipe 2 NW - imbalance elektrolit
4. Anemia ringanHipokrom 4. Hipertensi terkontrol - sepsis
Mikrositerec PGK 2. Sepsis ec dd/
5. Hidronefrosis bilateral post Th/ - peumonia
nefrostomi -bedrest - urosepsis
Th/ -IVFD NaCl 0,9% 20 gtt/i 3. DM tipe 2 normoweight dengan critical ill
- Tirah baring -graphalac syr 4. Ulkus dekubitus grade II
- Diet Ginjal 1700 kkal + 40 gr - amlodipin 1x10 mg 5. CAD
protein/harivia oral - omeprazol 1x1
- Threeway - IV ceftriaxone 2 gr/24 jam Th/
- IVLansoprazole 30 mg/12 jam - glimeprid 1x1 -bed rest
- Cefixime 2x100 mg - metformin 2x500 mg - O2 2-4 liter via nasal kanul
- Amlodipin 1x10 mg - Diet sonde DM 6x200 kkal/hari
- Lenal Ace 2x169 mg Lab 15/07/2018 - IVFD Nacl 0,9% 20 gtt/i
- As.Folat 2x 400 mcg Hb/Ht/E/Tr/L - Drip insulin novorapid 50 cc ( 0,5 cc/jam)
- Valsartan 1x80 mg 11,5/32/4,0/229/8,5 Titrasi dosis target 140-180
- Fluimucyl 3x200 mg MCV/MCH/MCHC - IV meropenem 1 gr/8 jam (H7)
- Herbesser 3x200 mg 81/29/36 - Iv omeprazole 40 mg/12 jam
- HD 2x seminggu Diftell: 6/1/0/48/38/7 - Drip PCT 1 gr/8jam
PT/APTT : 0,8/1,1 - SC heparin 2x500 mg
Lab 13/7/2018 GDS : 183
Hb/Ht/E/T/L Ur/Cr: 36/1,15 Lab 19-07-2018
10,1/31/3,6/266/8,9 Na/K/Cl: 142/3,6/108 Ca/ Mg : 8,5/1,9
Mcv/mch/mchc Na/K/Cl : 150/4,2/116
86/28/32
Diftell ; 1/2/0/71/13/13 Lab 18-07-2018
Ca : 8,9 Ca/Mg : 8,1/1,2
Ur/Cr : 37/4,52 Na/K/Cl : 154/3,5/122
Na/K/Cl : 141/4,1/108
Lab 16/7/2018
Lab 9/7/2018 D-dimer >10000
Hb/ht/E/T/L Ca/Mg : 7,5/2,1
9,4/28/3,4/328/21,0 Ur/cr : 104/2,09
MCV/MCH/MCHC Na/K/ : 168/3,4
83/28/33
Diftel: 0/0/0/97/2/1 Lab 15/7/2018
Ur/Cr: 48/5,58 Hb/ht/E/T/L
Na/K/Cl/Ca: 138/3,9/101/10,5 14,7/46/5,0/343/14,8
MCV/MCH/MCHC
Lab 6/7/2018 91/29/32
HB/HT/E/T/L Diftel: 0/0/1/85/8/6
10,6/32/3,8/259/12,6 PT/APTT : 0,8/4,2
MCV/MCH/MCHC/MPV HbsAg : negatif
84/28/33/11,4 GDS : 572
Diftell : 3/1/0/81/9/6 Ur/Cr: 110/2,2
Albumin: 2,95 Na/K/Cl/Ca: 170/4,0/131
Ur/cr : 102/9,71
Na/k/cl : 138/4,9/99

Lab 02/07/2018
Ur/cr: 177/14,07
HbA1c :6,00%