Mapping Aqsa 2 Minggu, 14 Februari 2021
K1B1
DPJP : dr.M.Fuad,
Sp.PD,KHOM
COW : dr. Indah Fajarini
Ruangan : dr. Fahmi
Nama : Lee Giman
TL : 15/09/1971
CM : 1179718
Tgl masuk : 11/02/2021
Ass/
1. Abdominal pain ec dd
Dyspepsia tipe dismotility
dd tipe mixed dengan
alarm sintom
2. Konstipasi
Th/
- bed rest
- diet lunak 1700 kkal/hari
- IVFD triofusin 2o gtt/i
- pasang NGT
- IV Lansoprazole 30
mg/12 j
- sucralfat 3xCI
- fosa enema k/p
-domperidone 3x10 mg
-lactulac syr 1xC1
Lab 11/2/21
Hb/Ht/L/T : 17,4/52/6/295
Diftel : 2/0/0/47/39/12
Bil total : 0,82
Bil Direct : 0,3
Bil Indirect : 0,52
SGOT/SGPT : 35/24
Albumin : 5
Ca : 10,4
KGDS : 93
Ur/Cr : 45/1
Na/K/Cl : 142/3,4/90
K1B2 K1B3 K1B4 K1B5
DPJP : dr. Abdullah DPJP: dr. Abdullah
Sp.PD,KGH Sp.PD,KGH
COW : Yudistira lianputra COW : Yudistira
Ruangan : dr. Murdia Ruangan : dr. Umar
Nama : Isno Mubardi Nama: Muh Nasir
Umur : 10/05/1951 TTL: 01/07/1980 (40th)
CM : 1264646 CM: 1264749
Tgl masuk : 04/02/2021 Tgl masuk : 04/02/2021
Ass/ Ass/
1. PSMBA ec dd 1. CKD stage V dgn
(perbaikan) uremic syndrome ec dd/
1. Ulkus peptikum - Diabetic nefropati
2. Ulkus Duodenale - HN
3. Gastritis erosive - PNC
2. Dm tipe 2 2. Anemia sedang NN
3. Hipertensi stage 2 3. DM tipe 2 NW
4. Post ambuted digiti 1 4.HHD
pedis dextra
Th/
Th/ - Bedrest
Inj. Ceftriaxone 2 gr/24 - O2 2-4lpm
jam (03/02/21) - IV Ceftriaxone 2gr/24j
Inj. Omeprazole 40 mg / (04/02)
12 jam - IV Omeprazole
Lantu 0-0-0-12 ui 40mg/12j
Herbesser cd 1x200 mg - IV Ondancentron
Valsartan 1x160 mg 4mg/8jam
Bisoprolol 1x5 mg - As folat 2x0,4mg
Clonidine 1x0,15 mg - Lenal ace 2x169mg
Domperidone 3x10 mg -Herbesser CD 1x200
Sucralfate 3xcII mg
Flumucyl 3x200mg -valsartan 1x40 mg
Bicnat 3x500 mg -ramipril 1x2,5 mg
Lab 05/02/2021 Lab 05/02/2021
Hb/Ht/Eri/L/T : Na/K/Cl : 138/5,8/104
10.8/32/3.9/9.5/473
MCV/MCH/MCHC: Urinalisa
82/28/34 Leu/Pro/Glu/Ket:
Diftel: 2/1/0/58/31/8 +/+1/+1/-
Ur/cr:28/2.00 Nit/Uro/Bil/Dar: -/-/-/+
Albumin : 2.60
Kolesterol total : 294 Lab 04/02/2021
Kolesterol HDL : 42 Hb/L/Tr: 5,7/13/391
Kolesterol LDL : 210 MCV/MCH: 74/26
Urinalisis: Diffcount:
Protein : +2 4/1/0/76//9/10
Glukosa : +1 HIV/Hbsag/Anti HIV:
Darah : positif Neg
Granulosit cast : positif Albumin: 3,10
Analisi tinja : Ur/Cr: 227 / 17,4
Warna : kuning Na/K/Cl: 138/6,2/105
PT / APTT: 0.9 / 1.07
Lab 02/02/02
HB/l/t : 10,6/9,8/457
Mcv/mch/mchc : 83/28/34
Ur/cr : 48/2,2
Albumin : 2,6
Na/K/cl : 137/5.104
 K2B1 K2B2 K2B3 K2B4 K2B5
DPJP : dr. M. Fuad Sp. PD DPJP : DR. dr. M. Diah, DPJP : DR. dr. M. Diah, DPJP : dr. M. Fuad Sp. PD
KHOM Sp.PD ,KKV Sp.PD ,KKV KHOM
COW : dr. Indah COW : dr. Rizqi Aulia COW : dr. Rizqi Aulia COW : dr. Indah
dr. Ruangan : dr. Rossyta /dr. Ruangan : dr. Rina Ruangan : dr. Rina dr. Ruangan : dr.
Fahmi Rossyta /dr. Fahmi
Nama : Razali Hamid Nama : Firdaus bin Nama : Muhifudddin Nama : Muzakir Puteh
CM : 0970193 mahmud Umur : 47 tahun Umur :53th/ 2/2/68
TTL : 13/06/1963 (57) Umur : (53 thn) CM : 1116991 CM : 1265489
Tanggal masuk : 11/2/2021 CM : 1242575 Tgl masuk : 04/02/2021 Tgl masuk : 11/02/2021
Tgl masuk : 18.1.2021
Ass/ Ass/ Ass/ Ass/
1. Anemia berat Hipokrom 1. Edema Paru akut ec dd 1. Empiemaec DD 1. Pneumonia CHAP dd.
mikrositer ec dd/1. CHF fc nyha II-III 1. pleuropneumonia Pneumonia viral
Defisiensi besi 2. Penyakit (Perbaikan) 2.malignancy 2. Edema paru
kronik 2 .Penurunan kesadaran 3.pleuritis TB 3. DM tipe 2 normoweight
2. ISK (perbaikan) ec dd/ 2. Anemia Berat ec dd 4. Efusi Pleura bilateral
3. OA pedis bilateral - sepsis 1. defisiensi besi
4. HHD - imbalans elektrolit 2. penyakit kronik Th/
3. CHF NYHA II-III 2. Epilepsi - bed rest
Th/ (Perbaikan) ec dd 3. DM tipe 2 NW - diet MII 1700 kkal/hari
-bed rest 1. CAD - IVFD aminofluid 1
- diet MB 180 kkal/hari 2. HHD fls/hari
- drip levofloxacin 500 4. Sepsis ec dd/ Th/ - IV ceftriaxon 2gr/24j
mg /hari - ulkus diabetik - Bedrest, - IV omperazole 20 mg/12j
- IV lansoprazole 30 - pneumonia - O2 4 lpm nasal canule - acetyl sistein 3x200
mg/24j - ISK - IVFD Nacl 0,9% 20 gtt/i - IV furosemid 40 mg/8j
- curcuma 3x1 5. Pneumonia dgn - iv omeprazole 40 mg /24 - cetirizine 2x1
secondary infection jam
Lab 12/02/2021 6. Gastropati diabetium - IV Levofloxacin Lab 11/2/21
7. Post Amputasi digiti III 500mg/24j (05/02/2021) Hb /L/T :13/8,9/407
pedis sinistra - asam folat 3x0,4 mg Diftel : 3/1/0/66/22/8
Lab 4/2/21 8. retinopati diabetik - Fenitoin 3x100 mg Albumin : 3,5
Hb/ht/L/T : 4,1/15/25/700 9. OMI Inferior - Domperidone 3x10mg Na/K/Cl : 142/4,2/1
MCV/MCH/MCHC : 10. DM Tipe 2 obese gr II - Lactulax syr 3xCI
53/15/28 11. Hipoalbumin - IV Paracetamol drip 1
Diftel : 0/0/1/89/7/3 gr/8 jam
CRP kualitatif : postif Th/ - Asam folat 3x1
Faktor reumatuid : neg - Bedrest,
Asam urat :5,6 - O2 4lpm nasal canule Lab 11/2/21
Kol total : 100 - Diet DM 1700 kkal/hari hb/ht/T/L
HDL : 37 - IVFD NaCl 0.9% 10gtt 7,3/23/280/11,1
LDL : 62 - Inj Furosemid 40 mg/8j Na/K/Cl/Ca
TG : 72 - Inj Lansoprazole 140/2,9/100/7,8
KGDS : 95 30mg/24j mcv/mch/mchc
Ur/Cr : 20/0,9 - Inf Paracetamol 1gr/8j 80/26/23
Na/K/139/4,0/107 - Cilostazole 1x100mg diftel3/021/7/1/68
- Valsartan 1x80mg led/albumin
- Domperidone 3x10mg 130/2,50
- Gabapentin 1x100mg ur/cr
- Atovarstatin 1x20 mg 21/1,09
- SC humalog 25-0-25 IU
- Flumucyl 3x200 mg Lab 8/2/2021
- Amlodipine 1x 10 mg Hb/Ht/T/L
- Cendo lyteers 4x1tts 6,6/20/303/12,1
- Simarc 1x2 mg MCV/MCH/MCHC
- iv meropenem 500mg/12 77/26/33
jam Diftell 4/0/0/75/16/5
- Lactulac sirup 3xCII Protein total 5,86
Albumin 2,17
Lab 11/02/2021 Globulin 3,69
Hb/Ht/L/T : 8,3/26/11,2/530 Ca 8,0
Mcv/mch/mchc : 77/25/32 Ur/cr 23/0,92
Diftel : 4/1/0/57/30/8 Asam urat 3,0
Pt/apt : 1,5/1,2 Na/K/CL 142/3,50/108
Albumin : 2,6
Ur/cr: 68/2,28 Feses 8/2/2021
Na/k/cl/ca : 142/3,5/103/7,7 Tidfak Ada kelainan
Lab 05/02/2021
TIBC/SI/Ferritin:138/16/3
66
Lab 8/2/2021 Kol Tot/HDL/LDL:
Hb/Ht/T/L 8,7/27/557/12,7 63/16/36 , TG 64
MCV/MCH/MCHC Urinalisa
78/25/33 Darah +, eri 25-50
Diftell 1/1/0/72/18/8 Nit: +, Prot/Uro/Bil: -/+/-
PT/APPT 1,58/1,33 Leu +, leu 25-50
Alb 2,8 Lab 04/01/2021
Ca 8,2 Hb//L/T : 6,5/7,4/29
Ur/cr 66/2,3 Mcv/mch/mchc :
Na/K/CL 141/4,2/104 77/26/34
Lab 4/2/2021 Diftel : 0/1/0/67/21/11
Hb/Ht/L/T KGDS : 224 mg/dl
8,8/26/3,5/11,9/572 Bil.total.direct/indirect :
MCV/MCH/MCHC 0,51/0,27/0,24
75/25/34 SGOT/SGPT : 45/27
Diftell 1/1/0/61/26/11 UR./CR : 35/0,9
PT/APPT 1,5/1,5 Na/K/cl : 1335/4,3/103
Ddimer 1850, Alb 2,54
Ca 8,2,,,Ur/cr 80/2,96
Na/K/CL 136/4,10/100
Urinalisa 05/02/2021
Darah +, eri 25-50
Glu/Ket/Nit: -/+/-
K3B1 K3B2 K3B3 K3B4 K3B5
DPJP : Prof. Dr. dr.
Kurnia F. Jamil Sp. PD
KPTI
COW : dr. Rizqi
Dr. ruangan : dr. Jupri
Ependi
Nama : Zamzami Yacob
TL : 31/12/1946
CM : 0850343
Tgl masuk : 11/02/2021

Ass/
1. Odema paru akut
2. CKD Stg V on HD
regular
3. Anemia Berat ec dd
1. Penyakit Kronis
2. Perdarahan
4. Hipertensi
5. Hipoalbumin ec dd
1. Renal loss
2. Low intake

Th/
- Bedrest
- Diet ginjal 1900 kkal +
50 gr protein /hari
- threeway
- Nitrogliserin 10 mg
dalam 50 cc Nacl 0,9 %
(titrasi dosis):titrasi
- Asam folat 2x04 mg
- Lenal Ace 1x169 mg
- Bicnat 2x500 mg
-amlodipine 1x5mg

Lab 11/2/21
Hb/ht/T/L
9,9/29/14/22,3
mcv/mch/mchc
81/28/34
diftel
0/0/93/0/1/6

Lab 12/02/2021
Hb/ht//t : 6,5/20/5,3/93
Mcv/mch/mchc :
87/29/33/16,8/11,1/14,8
Diftel : 0/0/1/80/14/5

Lab 11/02/2021
Hb/ht/l/t : 6,2/19/5,8/89
Mcv/mch/mchc : 88/29/33
Diftel : 4/1/0/70/20/5
Albumin : 2,4
Ur/cr : 58/4,2
Na/k/cl : 142/3,1/106
 K4B1 K4B2 K4B3 K4B4 K4B5
DPJP : dr.M.Fuad, DPJP : dr.M.Fuad,
Sp.PD,KHOM Sp.PD,KHOM
COW : dr. Indah Fajarini COW : dr. Indah
Ruangan : dr. Rossyta Fajarini
Ruangan : dr. Rossyta
Nama : Rusdi daud Nama : Saiful Bahri
TTL: 04/06/1951 (27th) TTL : 12/12/65
CM: 1251359 CM: 1265487
Tgl Masuk: 09/02/2021 Tgl Masuk: 11/02/2021
Ass/ Ass/
1.penurunan keasadaran 1. dd 1/ hepatoma
(perbaikan) ec.hipoglikemia 2/ kista hepar
2.hipoglikemia ec.dd: 3/ massa intra abd
-drug induced 4. ileus paralitik
-low intake 2. asites ec dd : 1.
3.DM tipe 2 hipoalbuminemia, 2.
4.Ht stage I sirosis hepatis
3. kosntipasi
Th/
-bed rest Ass/
-IVFD D 10% 20tpm -. bed rsst
-bolus D40% 1flacon - diet hati 1700kkal
-curcuma 3x1 - three way
-N.asetilcystein 2x1tab - IV cefperazone 1gr/8j
- Drip NTG 10 mg dalam 50 - IV omeprazole
cc nacl 0,9 % 1,5 cc/jam 40mg/12j
(titrasi dosis) - furosemid 1x40 mg
- Drip Furosemide 1 cc/jam - spironolakton 2x100
- lactulac 3xC1
lab 13/02/21 - curcma 3x1
hb/ht/T/L
12,2/35/132/19 Lab 12/12/2021
mcv/mch/mchc PT/APTT: 1,13/1,07
85/30/35 D-dimer : 1470
diftel
1/0/6,3/6/-1/75 Lab 11/2/21
gds Hb/L/T : 9,1/7,7/193
202 MCV/MCH/MCHC :
ur/cr 64/21/34
136/6,2 Diftel : 0/0/1/79/13/7
Na/K/Cl
131/4,0/103 Anti HCV : negatif
HbsAg : reaktif
Foto thorax PA 13/2/21
jantung membesar Bil Total : 1,2
tampak infiltrat di paru Bil Direct : 0,63
kanan kiri Bil Indirect : 0,57
sinus phrenicocostalis kanan OT/PT : 38/12
kiri tidk tervisualisai KGDS : 115
kesmpilan : kardiomegali, Albumin : 2,5
pneumonia Ur/Cr : 15/0,7
Na/K/Cl : 137/3,2/ 105
Lab 09/02/2021
HB/L/T : 10,8/7,4/154
Ur/cr: 68/4,10
MCV/MCH/MCHC:
90/30/34
Diftel: 0/0/1/87/4/8
Albumin 3,0
Ca 7,8
GDS 203
Ur/cr: 68/4,1
Na/k/cl:133/4,3/105
 K5B2 K5B3 K5B4 K5B5
DPJP : dr. Mahriani DPJP : dr. Abdullah Sp.PD DPJP : Dr.dr.Kurnia F
Sylvawani Sp.PD-KR KGH, Jamil, Sp.PD,KPTI,
COW : dr. Indah Fajarini COW : dr. Yudistira FINASIM
Ruangan : dr. Rossyta F Ruangan : dr. Umar COW : dr.Rizqi
Ruangan : dr. Julia
Nama : Wahidin bin Abu Nama : M. Jamil A Nama : Jumaidi bin A.
bakar TL : 57 Ajid
TTL : 06/ 04/ 1988 CM : 1216114 TTL : 11/06/1972
CM : 1259485 Tanggal Masuk : 04/2/2021 CM : 0952651
Tgl Masuk : 3/ 2/ 2021 Tgl masuk: 2/2/2021
Ass/ Ass/ Ass/
1.CKD stage 5 ec dd : 1. 1. Bisitopenia ec dd 1.CKD stageV dengan
PGOI 2. HN on HD 1. Related NHL uremic syndrom dd/
regular dengan edem Paru 2. Induced Kemoterapi 1.PGOI 2. HN 3. PNC
akut 2. NHL stg 3 pro kemoterapi 2. Anemia berat ec dd/
2. Anemia Berat NN ec siklus V regimen (ICE - PGK
MESNA ) Karnofsky 80 %
Penyakit Kronik - Perdarahan (ISK)
3. HT on theraphy
Th/
Th - Bedrest
4. Hiperkalemia
-Bedrest - Diet MB 5.ISK
-O2 simple mask 7liter - IVFD NaCl 0.9% 20gtt/i 6.Hiperurisemia
permeit - curcuma 3x1
-Threeway - mecobalamin 3x1 Th/
-IV Levofloxacin 500mg/ - Bedrest
24jam Lab 05/02/2021 - Diet Ginjal
- Drip NTG 1A dlm 50cc SGOT/ SGPT :31/41 1700kkal/hari+ 0,8
NaCl 0,9 %  titrasi Ur/cr : 30/0,8 kalori/kgBB/hari
dosis Na/K/Cl : 145/4/113 - Thereway
- Diovan 1x160 mg - IV Omeprazole 40
- Ramipril 1x5 mg mg/12 jam
Lab 02/02/2021 - IV Ondansetron
lab 10/2/21 Hb/l/t : 7,3/ 10,1/13 4mg/8jam
Mcv/mch/mchc : 78/28/34
HB/HT/T/L - IV ceftriaxone 2
Diftel : 1/0/0/9/85/6
7,4/21/140/8,0 gram/24 jam (4/2/2021)
mcv/mch/mchc H3
73/25/35 - Lenal ace 2x169 mg
Diftel - As. Folat 2x0,4 mg
5/1/8/3/0/83 - Bicnat 3x500 mg
na/k/cl/ca - Flumucyl 3x200mg
141/5,1/106/8,6 - Amlodipine 1x 5 mg
D-dimer : >4000 - Cendo lyteers
Albumin : 2,6 -Allupurinol 1x100mg

lab 10/2/21
Lab 5/ 02/ 2021 hb/ht/T/L
Hb/ Ht/ L/ Tr : 6,5/ 19/ 9,2/27/264/11,7
16.100/ mcv/mch/mchc
Diftel : 3/0/0/88/4/5 84/29/34
LED : 16 led : 58
Na/ K/ Cl : 142/ 5/ 102 diftel
CA : 10 6/1/7/14/0/72
Cr: 14,99 na/k/cl/ca
 142/3,5/104/7,4
Lab (3/2/2021) albumin : 3,1
Hb / L/ Tr : 6,6/ 17 700/ ur/cr : 104/7,25
172000
Diftel : 3/1/0/86/6/4 FEses:
Na/K /Cl : 144/ 5,6/ 105 bau/konsitensi/warna:
Ca : 9,7 khas/lunak/kuning
HbsAg : non reaktif eritrosit/leukosit/parasit/te
Albumin : 3,3 lurcacing : negatif
GDS : 111
Ur/ Cr : 295/ 18,3

Urinalsisa 8/2/2021
Lekosit +
Protein + 1
Darah +
Leukosit 25-50
Eritrosit 500-600
Epitel 0-1
Sel ragi +
Bakteri +

Lab 7/2/2021
Hb/Ht/L/Tr : 10/29/9,9/84
MCV/MCH/MCHC:
84/29/34
Diftel : 10/1/0/0/73/8/8
Na/K/Cl/Ca:
140/3,10/103
Ur/Cr : 330/10,50
Alb 3,1
Ca 8,2

Lab 5/01/2021
As urat : 11,6

Lab 4/2/2021
Hb/Ht/L/Tr :
7,4/21/8,5/304
MCV/MCH/MCHC:
79/28/35
Diftel 3/0/0/84/6/7
Na/K/Cl/Ca:
140/3,80/103/91
Ur/Cr : 287/13,77
Albumin 3,33

Eco 4/2/2021
EF 52% LA , AO dan LV
dilatasi
MR,AR severe,TR
moderate PH dan PR mild
LVH konsentrik disfungsi
diastolic
Sesuai HHD dan CAD

Lab 2/2/2021
Hb/Ht/Eri/L/T :
5,2/15/1,8/6,2/369
MCV/MCH/MCHC :
83/29/35
Diftel : 5/1/0/72/15/7
AntiHCV : negative
HbsAg : non reaktif
Albumin : 3,4
Ur/Cr : 455/20,10
Na/K/Cl/Ca :
138/5,80/103/8,1
 Nabawi Mina 1 K5B3

DPJP : dr. Abdullah DPJP : dr.M.Fuad,

Sp.PD,KGH Sp.PD,KHOM
COW : Yudistira COW : dr. Indah
lianputra Fajarini
Ruangan : dr. Murdia Ruangan : dr. Fahmi
Nama : juweiriah Nama : Sarudin
TL : 25/8/60 Kauding
CM : 1152035 TTL : 07-05-1967 (54)
Tgl masuk : 11/2/21 CM : 1264724
Tgl masuk : 03/2/2021

Ass/ Ass/
1. Sirosis stadium DC 1.PSMBA dd :
Childpugh B 1. ulkus gaster
2. Anemia berat HM ec 2. ulkus duodenum
dd/ 1. Perdarahan 3. gastritis erosif
2. penyakit kronis 4. drug induced
. def besi 2. hemiparese sinistra +
3. dd/1. Selulitis parese VI ,Xii
2. DVT Sinistra sentral ec
a/r pedis dextra stroke iskemik
4. hipokalemia ringan 3.Dm type 2
5. hipoalbumnemia 4.OMI inferior anterior
5.HT Stage II dg therapi
Th/
- bed rest Th/
- 02 2L/i -Bedrest
- diet hati 1700 kkal -NGT
- IVFD aminofusin -Drip lansoprazole 60
- lasix 20mg/12j mg dalam
- spironolakton 2x200 nacl 0,9 dg
- IV cefperazon 1gr/12j kecepatan 5 cc/ jam
- Sucralfat syrp 3 x
Lab 10/2/21 30 cc
Hb/L/T L 3,9/3,1/100 -Domperidone 3 x 10
Diftel : 4/0/1/64/21/10 mg
MCV/MCH/MCHC : -lactulac syrp 3 x 30
75/22/30 mg
KGDS : 202
Ur/Cr : 24/ 1. Lab 03/02/2021
Hb/Ht/Eri/L/T :
18.8/52/6.5/14.4/362
MCV/MCH/MCHC:
81/29/36
Diftel: 4/0/0/66/22/8
Ur/cr:44/1.10
Na/K/cl 146/4.60/103
GDS : 118