MAPING dr.NASRUL MUSADIR, Sp.

S FINA, 5/3/2021
MINA 1

NO. KAMAR IDENTITAS SUBJEKTIF DIAGNOSIS LABORATORIUM TERAPI PLANING

1 K5B4 Nasrul Belawan, lk, 63 Sulit bicara Penurunan kesadaran + Lab tgl 13/2/21 iv.citicoline 500mg/12j Konsul bedah
Tgl masuk: thn Nyeri kepala hemiparesis dextra + Hb: 16,2 iv. omeprazole 40mg/12j urologi rencana
13/2/21 Kelemahan anggota paresisi N.VII, XII dextra Ht: 47 Drip PCT 1gr/8j USG Urologi
H19 gerak kanan sentral ec Stroke Leu: 11.500 ciprofloxacin 2x500mg 23/2/21 (tunda
Dr. Gunawan Mata kiri bengkak Hemoragik (ICH ar Trom: 223.000 fluimucyl 3xcth 1 sementara)
frontotemporal) GDS:119 mg/dl Valproat 2x250mg
TD: 189/110 mmHg + Hipertensi Ur/cr: 81/1,50 Concor 1x 5mg
Raber cardio GCS: E3M5Vafasia + CAD Na/K/Cl: 145/4,6/104 Furosemid 1x20mg Fisioterapi (+)
Motorik: kesan + CHF FC NYHA II HbsAg: Non reaktif Valsartan 2x160 mg
dr.Nasrul Musadir, Sp.S hemiparesis dextra PT/APTT: 13,90/29,00 Laxadyn syrup 2x Cth 1 Konsul gizi klinik
FINA Skala Nyeri: 2 Rflacc Lab tgl 16/2/21 Atorvastatin 1x20mg (dr.iflan, Sp.GK) (+)
SS: 5 Ur: 41 mg/dl Clobazam 1x10mg (mlm)
Cr: 1,17 mg/dl Amlodipin 1x10mg (pagi) lab DR, ur/cr,
ISDN 3x5mg elektrolit hari ini->
Lab tgl 22/2/21 Synbio 2x1 caps hasil (-)
Hb: 14,1 Spironolacton 1x50mg
Ht: 41 Hytrin 1x2mg
Leu: 10,400 Corolan 2x7,5mg
Trom: 295.000
GDS:119 mg/dl
Ur/cr: 52/0,80

Lab tgl 1/3/21

Hb: 15,2
Ht: 42
Leu: 16.600
Trom: 428.000
GDS:178 mg/dl
Ur/cr: 29/0,81
Kol Total:149 mg/dl
HDL/LDL/TG: 41/99/81
Na/K/Cl: 133/ 3,90/ 94

2 K7B5 Syafii bin Yunus,lk, Nyeri pinggang LBP dengan radicular pain Lab tgl 13/2/21 Gabapentin 3x300mg MRI LS (+) hasil
60thn bawah (+) mulai ec Faset arthropathy Hb: 12,3 Mecobalamine 3x500mcg (+)
Tgl konsul : berkurang + hidronefrosis bilateral Ht: 35 Eperison HCl 2x50mg EMG (+)
16/2/21 + DM type 2 Leu: 8.300 clobazam 1x10mg mlm
H16 dr.Nasrul Musadir, Sp.S TD: 140/80 mmHg + pneumonia Trom: 144.000 Drip Paracetamol 1gr/8j Bladder training (+)
FINA GCS: E4M6V5 PT/APTT: 14.30/33,40 Sc novomix 16-0-16
Dr. Dino Motorik: 5555/5555 INR: 0,99 Seretide discus 3x300mg Ro thorax
5555/5555 Na/K/CL: 145/3,7/106 Silostazole 1x1 tab 25/2/21
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MAPING dr.NASRUL MUSADIR, Sp.S FINA, 5/3/2021
Skala Nyeri: D dimer: 1660 Nutriflam 1x1 tab Pneumonia
S: Alb: 2,9 Sintram 2x1 tab
D: Ca: 8,6 Etericoxib 1x1 tab USG Abdomen +
SS : Ur/cr: 28/0,9 Tramadol 2x25mg USG Urologi
iv. Metil prednisolon menunggu hasil
Lab tgl 16/2/21 125mg/12j
HbA1c/GDP:
9,90/177mg/dl
Kol total: 171
HDL/LDL/TG: 23/122/162

Lab tgl 22/2/21

Hb: 12,5
Ht: 35
Leu: 9,200
Trom: 170.000
PSA total: 0,99
Ur/cr: 14/ 0,83
Na/K/CL: 145/4,0/111
Alb: 3,21
LANTAI 1

NO KAMAR IDENTITAS KELUHAN DIAGNOSIS LABORATORIUM TERAPI PLANNING

1 AQSA 3 Rina Binti Cut Penurunan kesadaran Penurunan kesadaran ec Lab tgl 17/2/21 iv.citicoline 500mg/12j Hasil CT Scan Kepala
K2B4 Rahmi, pr, 57 thn Bengkak di ekstremitas dd 1.sepsis, 2.Imbalance Hb: 8,8  brain atrofi
Sesak napas (+) elektrolit, 3. Stroke dd Ht: 27 terapi TS IPD:
Dr. Cut Sri meningitis Leu: 3.900 iv.OMZ 40mg/12j Rehabilitasi medik
TD: 105/60 mmHg 2.ISK Trom: 232.000 iv.meropenem 1gr/8j (+)
Tgl konsul : dr.Nasrul Musadir, GCS: E3M5V2 3. Sellulitis, dd artritis TB Na/K/Cl: 148 Curcuma 3x1 tab
15/1/21 Sp.S FINA Motorik: kesan Ur/cr: 27/0,80 vit Bcomp 1x1 tab
H16 lateralisasi (-) Ca/Mg: 8,6/1,6 N asetil sistein 3x200mg
Skala Nyeri: 2 rflacc Alb: 3,00 Nebule ventoline 1 resp/8j
SS PT/APTT: 15,5/33,9 Nebule flexotide 1 resp/12j
D-Dimer: 1310,00 Sistenol 3x1 tab
Burnazin zalf
Lab tgl 22/2/21 Drip PCT 1 gr (k/p)
Hb: 7,7 Novalgin drip /8j
Ht: 25 Fluconazole 1x200mg
Leu: 7,700 Albumin 1 fls/hari
Trom: 304.000 Hidronat drip
Na/K/Cl: 151/2,60/109 Vascon drip (standby)
Ur/cr: 71/1,23 iv. furosemid 1 amp/8j
Ca: 8,4
SGOT/SGPT: 50/18
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MAPING dr.NASRUL MUSADIR, Sp.S FINA, 5/3/2021
Bil.total/direct/indirect:
0,55/ 0,32/ 0,23

Lab tgl 25/2/21

Hb: 6,8
Ht: 21
Leu: 12.300
Trom: 194.000
Alb: 2,10
Ur/cr: 110/4,18

Lab tgl 28/2/21

bil total: 1,42
direct/indirect: 0,88/0,54
SGOT/SGPT: 66/8
Alb: 2,70
Ca: 7,7
Na/K/Cl: 143/2,70/108
Ur/cr: 107/4,0
JUMLAH PASIEN: 3 pasien

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MAPING dr.NASRUL MUSADIR, Sp.S FINA, 5/3/2021