Mapping Aqsa 1 Senin 10 September.docx

MAPPING AQSHA 1 DPJP: dr. Masra Lena Siregar, Sp. PD Selasa, 11 September 2018 Tim Jaga Dokter Muda

: dr. Salwiyadi / dr. rizki : Gita / Thesa ISO 1

dr. Irhas COW: dr. laura DM : Jaja

ISO 2

dr. Daus COW : dr. Hendra DM : Inneke Nama : T Romy Maulana Afri Usia : 17-09-1992 (25 tahun) Alamat : Aceh Timur Pekerjaan : Mahasiswa CM : 1175778 Hari rawatan: 4 Ass/ 1. SIDA st III 2. DILI 3. Morbili dd/ 1. DHF 2. Drug Eruption 4. Candidiasis oral Th/ -Bedrest -Diet lunak 1700 kkal/hari -IVFD tutofusin 20gtt/i -IV OMZ 40mg/12jam -IV metochlorpramide 5mg/12j -PCT 3x500mg bila T≥37°C -N acetyl Cystein tab 3x200mg -curcuma tab 3x1 - Vit A 1x1 untuk 2 hari 1x200.000 IU - Liverprime 1x1 -laxadin syr 3xcI Lab 8/9/2018 Hb/Ht/E/L/T 14,9/40/5,0/4,2/122 MCV/MCH/MCHC: 80/30/37 Diftel: 3/1/0/85/7/4 SGOT/SGPT: 370/289 GDS: 144 Kalsium: 5,5 Ur/Cr : 20/0,78 Na/K/Cl: 132/4,6/87

ISO 3

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ISO 4

ISO 5 dr. Saddam COW : dr. Kudrah DM : Reza Nama : Zakir Zakaria Usia : 13-12-1937 (80 tahun) Alamat : Karo Pekerjaan: Wiraswasta CM: 1183882 Hari rawatan: 5

ISO 6 dr. Irhas COW : dr. Laura DM : Jaja Nama : Rohani Usia : 04-03-1948 (70 tahun) Alamat : Langsa Pekerjaan : IRT CM : 1171696 Hari rawatan : 7

Ass/ 1. Trombositopenia es dd: 1) MDS 2) ITP 3) TTP 2. Pneumonia (CAP) dd/ TB paru relaps dengan infeksi sekunder 3. PSMBA (Perbaikan) ec dd: - Gastritis erosif - Ulkus Gaster - Ulkus duodenum 4. Gout Arthritis akut dd septik arthritis

Ass/ 1. CML fase akselerasi 2. Ginggivitis dgn caries dentis 3. Selulitis a/r manus (D) 4. Dispepsia tipe like ulcer 5. Hipertensi stg 1

Th/ - Bed rest - Diet MB 1700 kkal/hari - IV Omeprazole 40 mg/12 jam - IV Ceftriaxone 2 g/24 jam (H5) - Sucralfat Syr 3xCI - Vectirin 3x1 tab - Transfusi trombosit jika trombosit <10.000 atau trombosit <20.000 dgn perdarahan - Azytromisin 1x500 mg(H1) - Metil prednisolone 3x8 mg - PCT 3x500 mg - Colcisin 2x0,6 mg Lab 8/9/2018 Anti HCV: negative HBsAg: negative Lab 8/9/2018 Hb/Ht/E/L/T : 9,0/27/3,2/14,7/12 MCV/MCH/MCHC : 84/28/34 Diftell : 0/0/5/90/3/2 Urinalisis 07/9/2018 Berat Jenis/pH: 1,010/6,5 Leu/pro/glu: (-)/(-)/(+2) Ketron/Nitrit: (-)/(-) Urobilinogen/Bilirubin:(-)/(-) Sedimen urin: Leuko/Erit/Epitel: 2-4/0-1/2-3

Lab 6/9/2018 Hb/Ht/E/L/T : 10,5/31/3,8/8,1/1 MCV/MCH/MCHC: 83/28/34 E/B/NB/NS/L/M: 8/0/0/70/10/12

Th/ - Bedrest - Diet Lunak 1700 kkal/hr - IVFD NaCl 0,9% 20 gtt/i - Ciprofloxacin 2x500mg (H11) - Clindamysin 3x500mg (H3) - Paracetamol 3x500 mg - Lansoprazol 2x30mg - Sucralfat syr 3xCI - Amlodipin 1x10 mg - Sc leucogen 1 vial/24 jam jika ANC ≤ 1500 - IV Meticlopramid 1 amp/8jam Lab 10/9/2018 Hb/Ht/E//L/T : 9,3/27/3,2/1,4/7 MCV/MCH/MCHC : 85/29/35 Diftell : 0/1/0/7/88/4 Lab 9/9/2018 Hb/Ht/E//L/T : 9,3/28/3,2/0,9/20 MCV/MCH/MCHC : 83/29/36 Diftell : 0/1/0/15/79/5 Lab 07/09/2018 Hb/Ht/E/Tr/L : 10,8/31/3,6/4/0,8 MCV/MCH/MCHC : 80/30/35 Diftell : 0/0/0/5/94/1 MDT: Erit: normokrom normositer, anisositosis Trom: jumlah sangat sedikit, tersebar merata, giant – Leu: Limfositosis dengan atipik limfosit (+), blas (-) Lab 06/09/2018 Hb/Ht/E/Tr/L : 10,5/30/3,5/6/1,1 MCV/MCH/MCHC : 85/30/35 Diftell : 0/0/0/7/92/1 Lab 05/09/2018 Hb/Ht/E/Tr/L : 10,4/30/3,5/13/1,0 MCV/MCH/MCHC : 86/30/35 Diftell : 0/0/0/6/92/2 Lab 04/09/2018 Hb/Ht/E/L/T 8.9/25/2.9/0.9/22 MCV/MCH/MCHC: 86/31/36 LED: 120 Diftel: 0/0/0/10/86/4 Lab 31/8/2018 Hb/ht/E/L/Tr 10,3/29/3,4/0,3/6 mcv/mch/mchc 87/31/35 diftel 0/0/0/24/73/3

ISO 7 ANAK

ISO 8 dr. Eko COW: dr. Kudrah DM : Dwiky Nama : Nurparisi Abdul Jalil Usia : 25-01-1962 (56 tahun) Alamat : Banda Aceh Pekerjaan : IRT CM : 1177981 Hari rawatan : 5 Ass/ 1.PSMBA ec dd -Varises Esofagus bleeding -Varises Fundus bleeding -Gastropati Hipertensi portal 2.Sirosis Hepatitis stad. Decompensate related hep. B kronik chilpught B 3. DM type 2 obes grade 1 4.Anemia sedang NN ec pendarahan 5. Hipernatremia hiperosmolar Th/ - Bedrest, threeway - Diet hati II 6x200cc/hari (Via NGT) - IVFD NaCl 0,9% 20 gtt/i - IV Ceftriaxone 1gr/12jam (H4) - IV vit K 1 amp/8jam - IV Omeprazole 40 mg/12jam - IV ondasentron 4 mg/12 jam - Tf PRC s/d HB ≥10 gr/dl - Lactulac syr 3xcI - Fosen enema (extra) - Spironolakton 2x100 mg Lab 7/7/2018 PT/APTT : 1,39/1,35 Lab 06/09/2018 Hb/Ht/E/Tr/L : 8,3/26/3,4/133/6,7 MCV/MCH/MCHC : 75/24/32 Diftell : 1/0/0/79/14/6 SGOT/SGPT : 38/18 HbsAG ; + Bil total/inderect : 1,81/0,42 Protein total : 6,74 Alb/Glo :2,38/4,35 Ur/Cr 24/0,37 Na/ K/Cl: 150/4,1/111

ISO 9 NEURO

ISO 10 BEDAH SARAF

ISO 11 ORTHOPEDI RABER ENDOKRIN Nama : Darmiati M Jafar Usia : 53 tahun Alamat : Aceh utara Pekerjaan : IRT CM : 1183837 Hari rawatan : 3 Ass/ 1. DM tipe 2 NW 2. Gangren Diabetik Pedis (S) 3. Anemia sedang Hiperkrom Mikrositer ec pen. Kronik 4. Hipoalbuminemia 5. sepsis ec gangrendiabetik Th/ - Diet DM 1700 kkal/hari - SC lantus 0-0-0-10 IU (22:00) Lab 9/9/2018 Hb/Ht/E/L/T : 12,9/39/4,8/31,3/427 MCV/MCH/MCHC : 81/27/34 Diftell : 0/0/1/92/4/3 Lab 6/9/2018 Hb/H/E/L/T : 7,8/25/3,2/33,2/758 MCV/MCH/MCHC : 79/25/31 Diftell : 0/0/0/89/7/4 GDS : 187 Ur/Cr : 132/0,76 Na/K/Cl : 151/3,9/109

ISO 12 KULIT KELAMIN

MAPPING AQSHA 1 DPJP: dr. Masra Lena Siregar, Sp. PD Selasa, 11 September 2018 Tim Jaga : dr. Salwiyadi / dr. rizki Dokter Muda : Gita / Thesa Kelas 1 ------

Kelas 2 PARU

Kelas 3 BEDAH PLASTIK RABER ENDOKRIN Nama : Fatimah M Daud Usia : 72 thn Alamat : Banda aceh Pekerjaan : IRT CM : 1184024 Hari rawatan : 3 Ass/ 1. DM tipe 2 2. Gangren Diabetikum ar Pedis dex 3. hipoalbuminemia (2,53) Th/ 1.Diet DM 1700 kkal/hari + ekstra putih telur 2. SC Aprida 8-8-8 IU 3. SC Lantus 10 IU (22.00) Lab 07/09/2018 Hb/Ht/E/L/T : 9,8/30/3,8/15,9/415 MCV/MCH/MCHC : 78/26/33 Diftell : 2/0/0/88/5/5 Alb : 2,53 GDS : 132 Ur/Cr : 33/0,61 Na/K/Cl : 129/4,6/93

Kelas 4 BEDAH DIGESTIVE

Kelas 5 dr. Lisa COW: dr. Laura DM : Ade Nama :Aslinawati Usia : 10-04-1953 (65 tahun) Alamat :Sabang Pekerjaan : PNS CM :0-89-50-62 Hari rawatan : 29 Ass/ 1. Pneumonia (HAP) 2. CKD stg V ec PNC on HD reguler 3. PSMBA(perbaikan) ec dd/ -stress ulcer -ulcus gaster -ulcus duodenum -uremic bleeding 4. massa intraabdomen ec dd/ - kista abdomen

Kelas 6 dr. Saddam COW : dr. Kudrah DM : Reza Nama: Ummi Kalsum

Usia : 24-07-1965 (53 tahun) Alamat : Aceh Besar Pekerjaan : IRT CM: 1065075 Hari rawatan :2 Ass/ 1. Syok Sepsis ec dd/ - Gangren diabetic - Pneumonia 2. Akut on CKD dd/ AKI stg I prerenal 3. Gangren diabetic a/r pedis

Kelas 7

NEURO

Kelas 8 dr. Eko COW : dr. Kudrah DM : Dwiky

-ca ovarium relaps 5. Gangguan Penyesuaian dd/ depresi 6.. Hidronefrosis grade I-II dengan hidroureter bilateral 7. post CABG 8. Anemia sedang HM ec dd/ -Penyakit ginjal kronis -def.besi 9. post AV shunt 10. OA genu sinistra 11. candidiasis oral Th/ - Bedrest - Diet sonde ginjal 6x200 cc - Threeway - IV Ceftazidine 1gr/48jam (H3) - IV Omeprazole 40 mg/12 jam - IV Furosemid 20mg / 12j - Asam folat 2x400mg - Lenal ace 2x169mg - N-Asetil Sistein 3x 200mg - Paracetamol 3x500mg - Curcuma 3x1 - Kalxetin 1x10 mg - Nebul NaCl 0,9 % 2cc/8jam - HD reguler dua kali seminggu (selasajumat) - Transfusi PRC 1 kolf - Sucralfat syr 3xCII (30AC) - Nystatin drop 4x2cc - Balance cairan seimbang Lab 09/09/2018 HbHt/E/L/T 12/34/4,5/8,9/91 MCV/MCH/MCHC: 75/27/36 DIFTELL: 2/0/0/85/6/7 Lab 04/09/2018 HbHt/E/L/T 8.9/26/3.4/6.8/123 MCV/MCH/MCHC: 77/26/34 DIFTELL: 1/0/0/85/10/4 Lab 3/8/2018 Ca/Na/K/Cl : 8,9/134/3,6/101 Lab 30/8/2018 Na/K/cl 142/2,7/99 Lab 27//8/2018 Hb/Leu/Tr/LED: 12,0/34/4,5/7,5128 MCV/MCH/MCHC: 75/27/35 Diftel: 0/0/1/80/13/6 CA 125: 5,86 Lab 24//8/2018 Hb/Leu/Tr: 10,3/5,0/144 MCV/MCH/MCHC: 76/27/36 Diftel: 0/1/0/74/9/16 Ur/Cr: 200/0.98 Na/K/Cl: 139/3,0/96

sinistra 4. DM tipe 2 normoweight 5. CAD 6. Hiperkalemia (perbaikan) 8.Anemia normokrom normositer ec dd/ - penyakit kronis (CKD) - perdarahan 9. Hipoalbuminemia 10. Pneumonia Th/ -Bedrest -diet ginjal 1900kkal/hari+60 gr protein/hari - threeway IVFD NaCl 0,9% 20 gtt/i -IV meropenem 1 gr/8 j (H10) -Drip Norepinefrin 0,1 meq/kgBB/jam , target TDS >100 mmHg atau MAP >6,5 -IV Omeprazole 40 mg/12 jam - Concor 1x2,5 mg - CPG 1x75 mg - Nitronaf retrad 1x2,5 mg - flumucyl 3x200 mg - kalitake sachet 3x1 - Nystatin drop 4x2 mg - cendolyters 4xgtt/i ODS - BC/Hari - Drip Human Albumin 20% 100 cc 1 fls/hr - SC Novorapid 8-8-8 IU - SC Lantus 0-0-0-14 IU Lab 04-09-2018 Ca/Mg : 9,3/1,9 Ur/Cr : 105/1,95 Na/K/Cl : 138/5,8/102 Lab 03-09-2018 Hb/Ht/E/Tr/Leu 9,5/29/3,6/313/40,0 MCV/MCH/MCHC 80/26/33 Diftell : 1/0/0/89/5/5 PT/APTT: 0,94/0,81 HBsAg: negative SGOT/SGPT: 27/10 GDS: 391 Ur/Cr: 185/3,30 Na/K/CL : 142/6,0/106 Lab 01-09-2018 Anti HCV: negative 1.

Urinalisis 16/8/2018 Berat Jenis/pH: 1,010 / 6,5 Leukosit: positif Protein: (+1) Sedimen urin:Leuko/Erit/Epitel 10-15/6-8/3-5

Kelas 9 dr. Lisa COW: dr. Laura DM : Ade

A c d s v

2.

Kelas 10 NEURO

Kelas 11 dr. Muchsin COW: dr. Hendra DM : Jaja/Dwiky

Kelas 12 dr. Muchsin COW: dr. Hendra DM : Jaja/Dwiky

Nama : Cut Suryati Usia :06-09-1964 (53 tahun) Alamat : Aceh Jaya Pekerjaan : IRT CM : 1-17-76-20 Hari rawatan : 4

Nama : Yadi Jufri Usia : 27-11-1965 (52 tahun) Alamat : Aceh Besar Pekerjaan : Dosen CM : 1-15-31-18 Hari Rawatan : 3

Nama : S iti Merak Usia: 27-10-1941 Alamat : Banda Aceh Pekerjaan : Purnawirawan CM : 1-15-93-16 Hari Rawatan : 10

Ass/ 1. CKD stage 5 ec PNC dengan uremic syndrom (perbaikan) 2. DM type 2 NW 3. HT on terapy 4. Post PSMBA (perbaikan) ec dd - uremic bleeding - stress ulcer -ulcus gaster 5. ISK asymptomatik 6. Anemia berat NN ec peny. Ginjal kronik 7. diare akut (perbaikan)

Ass/ 1. Selulitis ar cruris dextra dd/ - DVT - PAD 2. Obesitas 3. Hipertensi stage 1

Ass/ 1. Ulkus decubitus grade III a/r sacrum 2. Anemia sedang Hipokrom Mikrositer ec dd/ - def. Fe - peny. Kronik 3. HIponatremia hipoosmolar hipovolemik 4. sarkopenia 5. demensia 6. DM tipe 2 UW 7. Immobilisasi 8. High Risk Trombosis (Padua score:7)

Th/ - Bedrest - Diet sonde ginjal 6x200cc/hari via NGT - Threeway - Kateter urine dan NGT terpasang - IV Ceftriaxone 2 g/24 jam (H9) - IV Omeprazol 40mg/12 jam - IV ondasentron 4mg/12jam -SC lantus 0-0-0-16 IU jam 22.00 -SC apidra 5-3-5-3-5-3 sebelum sonde -Asam folat 2x400mg -Lenal Ace 2x169mg -Amlodipin 1x10mg -PCT 3x500mg -Ramipril 1x2,5mg -HD 3xseminggu -Balance cairan -Trf PRC 1 kolf hari ini - fluconazole 1x200 mg (H1)

Lab 09-09-2018 Hb/Ht/E/L/T 6,2/19/2,2/19,4/147 MCV/MCH/MCHC 84/28/34 Diftell 9/0/0/73/10/8 Lab 05-09-2018 Hb/Ht/Er/Leu/Tro 7,9/22/2,7/121/13,7 MCV/MCH/MCHC 81/29/35 LED: 132 Diftell 0/0/0/87/7/6 Ur/Cr: 304/15,37 Na/K/Cl: 142/3,5/111 Urinalisis 05-09-2018 Warna, jernih: kuning, keruh BJ/PH: 1,015/7,5 Leu/prot/glu: +/+2/+2 Ket/Nit/Uro/Bil/Darah: -/-/-/-/+ Sedimen urin: leu/erit/epi 30-40/15-20/4-6 Sel ragi: positif

Th/ - Bedrest - Diet MB 1800 kkal/hari (rendah garam) - IVFD Nacl 0,9% 20gtt/i - IV ceftriaxone 2 gr/24 jam(H3) - Clindamisin (3x600 mg) (H3) - PCT tab 500 mg(k/p) - Kompress luka dgn NaCl 0,9% - SC Lovenox 1x0,6 mg (22.00) (H2) - Valsartan 1x80 mg Lab 07-09-2018 PT/APTT: 0,99/1,35 D-dimer: 1348,38 Lab 07-09-2018 Hb/Ht/E/T/L : 14,9/44/4,9/177/28,9 MCV/MCH/MCHC: 90/31/34 Diftell : 0/0/0/91/5/4 GDS : 192 Ur/Cr : 49/1,75 Na/K/Cl : 142/3,8/97

Th/ - bedrest, head up 30°, kasur decubitus - diet sonde 6x200cc@200 kkal - IVFD NaCl 0,9% 20 gtt/i - IVFD Clinimix+ clinoleic 1 fls/hr - IV Ceftriaxone 2gr/2j (H8) - IV OMZ 40 mg/12 jam - Clindamisin 3x300 mg (H8) - PCT tab 3x500 mg - Ostriol tab 2x1 - Rawat luka dengan NaCl 0,9% - Transfusi PRC s.d Hb≥10 gr/dL - Cetirizin 1x10 mg (malam) - Pradaxa 1x75 mg (pagi) - Drip Albuminar 25% 1 fls/hr (H1) Lab 05-09-2018 Hb/Ht/E/T/L : 8,3/25/3,3/358/17,0 MCV/MCH/MCHC: 76/25/33 Diftell : 1/0/1/38/5/5 GDS : 137 Na/K/Cl : 127/4,3/102 Lab 04-09-2018 Alb: 1,83 Lab 03-09-2018 HbA1c: 6,30 Lab 02-09-2018 Hb/Ht/E/T/L : 9,9/29/3,9/388/27,3 MCV/MCH/MCHC: 74/25/34 Diftell : 0/0/0/94/2/4 GDS : 279 Ur/Cr: 13/0,25 Na/K/Cl : 132/3,1/95