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  • MAPPING AQSA 1 (Zamzam) (Sabtu, 06 November 2021)

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    Fahmy Dekmy
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    The document provides patient mapping information for 16 patients across 6 rooms in the Aqsa 1 and Arafah 2 sections. It lists the attending physician, consulting physician, room physician, patient name, age, medical record number, admission date, diagnosis, and treatment plan for each patient. The patients have various conditions including pneumonia, sepsis, diabetes, anemia, and fractures. Their treatment plans involve bed rest, intravenous fluids and medications.

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    The document provides patient mapping information for 16 patients across 6 rooms in the Aqsa 1 and Arafah 2 sections. It lists the attending physician, consulting physician, room physician, patient name, age, medical record number, admission date, diagnosis, and treatment plan for each patient. The patients have various conditions including pneumonia, sepsis, diabetes, anemia, and fractures. Their treatment plans involve bed rest, intravenous fluids and medications.

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    24 views4 pages

    MAPPING AQSA 1 (Zamzam) (Sabtu, 06 November 2021)

    Uploaded by

    Fahmy Dekmy
    The document provides patient mapping information for 16 patients across 6 rooms in the Aqsa 1 and Arafah 2 sections. It lists the attending physician, consulting physician, room physician, patient name, age, medical record number, admission date, diagnosis, and treatment plan for each patient. The patients have various conditions including pneumonia, sepsis, diabetes, anemia, and fractures. Their treatment plans involve bed rest, intravenous fluids and medications.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    of 4

    MAPPING AQSA 1 (Zamzam)

    (Sabtu, 06 November 2021)


    Zamzam 4 K1 Raudha 1 K1B1 Zamzam 4 K12 Zamzam 4 K15

    DPJP : Dr. dr. Fauzi Yusuf Sp.PD Dpjp: dr. Fauzi Yusuf Sp.PD- DPJP: dr. Vera Abdullah, DPJP : Dr. dr. Fauzi Yusuf Sp.PD
    KGEH KGEH Sp.PD KPSi KGEH
    COW : dr. Saddam Cow : dr. Saddam COW: dr. Rizqi COW : dr. Saddam Emir Pratama
    Ruangan : dr. Julia Ruangan : dr. Julia
    Ruang : dr. Julia Ruangan: dr. Fathir

    Nama : Musalamah Nama : Ruhani Nama : Tjut Maneh Nama : Nanda putri Mawaddah
    CM : 1288429 Cm : 1290098 TTL : 69 tahun TTL : 27.05.1989
    TL : 10/02/1969 (52) Tl : 1/07/1961 (60 thn) NCM : 103-59-84 CM : 1095032
    TM : 16/10/21 Tm : 04/11/21
    TM : 25/10/2021
    Raber Divisi EMD, Geriatri

    Ass/ Ass/ Ass/ Ass/


    1. Pneumonia Ca ectosugmoid 1. KIPI
    2. Riwayat Piuria ec dd 1. ISK Th/ 1. Syok Sepsis (perbaikan) ec 2. Hipertiroid ec grave
    3. DM tipe 2 normoweight Bedrest Pneumonia + urosepsis disease
    4. Dispepsia tipe dismotility Diet dm 1700 kkal/hari 2. Pneumonia (CAP) 3. DM tipe 2 NW
    dd tipe mixed Iv lansoprazole 30 mg/12 jam 3. Urosepsis ec ISK 4. Susp SLE
    5. Anemia sedang HM ec dd Komplikata
    - Penyakit kronik Lab 4/11/21 4. CHF Stage C Fc NYHA II-III Th/
    - Defisiensi Fe Hb/l/t :11,1/6,7/453 ec dd 1. DCM, 2 IHD Bed rest
    6. Hipoglikemia ec dd Mcv/mch/mchc : 74/25/33 5. Anemia Berat HN ec Peny. O2 nasal canul 2l/i
    - Low intake Diftel : 4/0/0/43/46/7 IVFD NaCL 0.9%tpm
    Kronis
    - Drug induced Hbsag – Diet DM 1700 kkal /hari
    6. Dispepsia tipe mixed dd
    7. Hiponatremia Albumin 3,9 IV omeprazole 40mg/12jam
    Gastropati diabetic
    Kgds : 107 Sc Ryzodeg 10U/24jam
    Th/ Ur/cr : 13/07 7. Hiponatremia Domperidone 10mg/8jam
    Bedrest Na/k/cl : 144/4,4/111 hipoosmolar euvolemik Curcuma tab /8jam
    IVFD NaCl 0,9% 20 tpm Pt/aptt : 0,97/0.8 8. Hipokelemia sedang Tyrozol 2x5mg
    M II 1700kkal 9. Hipoalbuminemia sedang Propanolol 2x10mg
    IV Levofloxacin 500mg/24jam ec. low intake Glavus 2x50mg
    (24/10) 10.DM tipe 2 dgn obesitas Sistenol tab /8jam
    IV Omeprazol 40 mg/12 jam grade 2
    SC Lantus 12 unit 11.Geriatri problem (Inanisi, Lab 02/11/2021
    Domperidone 3x10mg Immobilisasi, Instabilitas Hb/L/T : 13,8/8,7/304
    Flumucyl 3x200mg dan jatuh) diftell : 2/0/0/51/41/6
    Curcuma 3x1 GDS : 410
    12.Visceral pain
    Ramipril 1x5mg Ca: 9,7
    13.Post ORIF a/r Humerus
    Ur/Cr : 20/0,4
    dextra Na/K/Cl : 138/4,50/105
    Lab 29/10/21
    Hb/Ht/L/T : 9,9/30/10/320
    Th/
    MCV.MCH/MCHC : 77/25/33
    Bedrest
    Diftel : 0/1/0/76/18/5
    NGT
    Alb : 3,0
    Folley cateter
    Ur/ Cr : 15/0,5
    Diet sonde DM 6x200cc
    Urinalisa 29/10/21
    IVFD Triofusin 1fls/24jam
    Makroskopis :
    IVFD Aminofluid 1fls/24jam
    Darah (+), glukosa (+1),
    IV Cefoperazone 2g/12jam
    leukosit (+)
    (02/10/2021)
    Mikroskopis : leukosit 25-50
    Drip NE mulai dosis 0.05
    LPB
    mEq/KgBB/jam, kec. 3.0
    Eritrosit 10- 25 LPB
    cc/jam
    Sel Ragi (+)
    Drip KCL 1 flacon dalam
    Lab 26/10/21 :
    500cc NaCl 0.9% 15 tpm
    Hb/Ht/L/T : 9,2/28/12,6/361
    IV Ca Gluconas 1 amp/12jam
    Diftel : 76/25/33
    IV Omeprazole 40mg/12jam
    Diftel : 1/0/1/77/18/3
    SC Heparin 5000 U/12 jam
    Urinalisa 25/10/21
    SC lantus 0-0-0-12 unit
    Makroskopis :Leukosit (+)
    Paracetamol 3x500mg
    Darah (+)
    Domperidone 3x10mg
    Mikroskopis : leukosit : 70-80
    Alprazolam 1x0.25mg
    LPB
    Synbio 2x1 tab
    Eritrosit 25-50
    Lactulac syr 3xCII
    Sel Ragi (+),bakter (+)
    Sukralfat 3xCII
    Urinalisa 25/10/21
    Sukralfat syr 3xCII
    Makrosopis : leukosit (+),
    KSR 2x600mg
    glukosa (+2), darah (+)
    Mikroskopis : leukosit 80 –
    Lab 31/10/2021
    100 LPB
    Eritrosit 25-50 LPB Hb/L/T : 8.8/14/397
    Sel ragi (+), bakteri (+) MCV/MCH : 76/29
    Lab 21/10/21 DiftelL 0/0/0/74/15/11
    Hb/ht/L/T ; 10/31/12,5/497 PT/APTT : 1.2/1.6
    MCV/MCH/MCHC : 76/25/33 D-dimer : 2260
    Diftel : 2/0/0/65/28/5 Albumin : 2.9
    Urinalisa 22/10/21 Ur/Cr : 34/3.9
    Makro : leukosit (+) darah (+) Na/K/Cl : 128/2.5/91
    Mikro : sedimen urin
    leukosit : 100-150 LPB Lab 28/10/2021
    Eritrosit : 25-50LPB Hb/L/Tro : 8.9/8.8/444
    Sel ragi (+) bakteri (+) Difftel : 5/1/0/61/23/10

    EGD 22/10/21
    Ulkus ar antrum gaster Lab 22/10/2021
    Na/K/Cl : 15/0.7
    Kultur urin 17/10/21
    Sphigomonas pauchimobilis Lab 16/10/2021
    Jumlah koloni>105 CFU/mL Hb/L/T : 11.8/9.2/129
    diftelL 2/0/0/73/23//2
    Lab 19/10/21 PT/APTT : 1.0/0.75
    Hb/L/T : 9,8/11,1/330 Fibrinogen : 517
    LED : 130 D-dimer : 5860
    Diftel : 2/0/0/66/23/9 SGOT/SGPT : 35/10
    Bil T/D/I : 0,29/0,1/0,19 Bil T/D/I : 1,04/0.53/0.51
    SGOT/SGPT : 18/28
    ALP : 434
    Alb : 2,58
    Na/K/Cl : 134/4,2/96

    Lab16/10/21
    Hb/L/T : 9,0/13,7/343
    MCV/MCH/MCHC : 72/25/35
    Diftel : 0/0/1/82/11/6
    PT/APTT : 0,94/1,2
    Ddimer : 1070
    SGOT/SGPT : 87/59
    Albumin 2,5
    GDS : 190
    Na/K/Cl/Ca : 120/3,4/84/7,1
    Arafah 2 KISO2 Arafah 2 K6B1

    DPJP : dr. Hendra Jufry SpPD DPJP : Dr. dr. Fauzi Yusuf Sp.PD
    KEMD KGEH
    COW : dr. Rizki Aulia O COW : dr. Saddam
    Ruangan : dr. Putra basmayus Ruangan : dr. Julia

    Nama : Halimatun Nama : Halimah Abu Bakar


    TTL : 01/12/1946 (74) TL : 1/7/1955
    CM : 090328 CM : 1289284
    Tgl masuk : 29/10/2021

    Ass/ Ass/
    1. Pneumonia ec dd infeksi
    paru spesifik 1. Susp. HCC
    2. Odem etermias 2. Asites ec dd 1) malinancy
    3. Susp Ca endometriosi 2) hipoalnuminemia
    4. Tumor ovarim kakan 3. HT stage II
    5. Hipertiroid
    Th/
    Th/ Bed Rest
    Bed rest Diet hati 1700 kkal/hari
    IVFD NaCL 0.9%tpm IVFD Comafusin hepar 1
    Diet DM 1700 kkal /hari fls/24 jam
    IV Ceftriaxone  2gr/24 jam iv. cefoperazone 1 gram/8
    IV Omeprazole 30mg/12 jam jam
    Fluimucil 200mg/8jam IV. Omeprazole 40 mg/ 12
    Paracetamol 500mg /8jam jam
    IV metoclopramid 1/2amp Lactulac syr 3 x 30 cc
    /8jam Sukralfat 3 x cII
    Valsartan 1 x 80 mg
    Lab 31/10/2021 Curcuma 3 x 1 tab
    Hb/L/T : 12,2/4,5/223
    diftell : 2/0/0/44/30/24 Lab 27/10/21
    GDS : 234 Hb/Ht/L /T :
    Ca : 8,8 11,8/34/20,3/220
    Ur/Cr : 4,2/0,3 MCV/MC/MCHC : 88/30/34
    Na/K/Cl : 136/3,5/105 Diftel : 1/1/0/81/11/6
    CT/BT : 2/7
    Anti HCV/HbsAg :
    Negatif/Non reaktif
    Biltot/BilDir/Bil Indir :
    1,3/0,82/0,48
    SGOT/SGPT : 106/44
    ALP : 210
    Alb /Glob: 2,96/ 4,53

    USG A bdomen :
    Mengarah pada Carcinoma
    Hepatomegaly, colesistitis ,
    asites
    Saat ini pankreas/lien/ginjal
    kaan kiri/buli/prostat tak
    tampak kelainan
    Zamzam 3 K3 Zamzam 4 K10 Zam zam 1 K16 Raudhah 1 K6B5

    Dpjp: dr. Fauzi Yusuf Sp.PD- Dpjp : dr. Azhari Gani Sp.PD- Dpjp : dr. T. Mamfaluti, Sp.PD Dpjp : dr. Azhari Gani Sp.PD-
    KGEH KKV Cow : dr. Saddam KKV
    Cow : dr. Saddam Cow : dr. Saddam Ruangan : dr. Aidil Cow : dr. Saddam
    Ruang : dr. Julia Ruang : dr. Murdia Ruang : dr. Murdia

    Nama : Amiruddin bin Nama : Nazaruddin bin Nama : Husnawati Nama : Jauhri
    Mahmud Muslim Tl : 03/12/1973 Cm: 1285487
    NRM : 1-25-50-47 NRM : 1-27-82-54 Cm : 0909536 Tl: 01/01/1964 (57 thn)
    TL : 14/05/1982 TTL : 16-06-1983 Tm : 31/10/21 Tm : 04/11/21
    MRS : 31/10/2021 MRS : 31/10/2021 Raber: EMD, Neurologi,
    Psikosomatis, Rehab medik

    Ass/ ss/ Ass/ Ass/


    1. Atypical Chest Pain ec dd/ 1. Anemia berat NN ec dd/ 1. Struma Nodusa Non Toksik 1. CHF FC NYHA III-IV ec dd
    UAP - AIHA 2. DM tipe 2 1. HAD
    2. Dispepsia tipe like ulcer - penyakit kronik 3. Hipertensi stage 2 2. IHD
    3. GERD - perdarahan 4.Hemiparese dextra , parese 3. DCM
    2. Dispepsia like dismotiliti VII + XII, Parese N.IX & N.X 2. Colic abdomen
    Th/ dd/ tipe mixed ec susp.stroke batang otak
    Th/
    - O2 nasal canule 4lpm Th/
    Bedrest
    - diet jantung 1700 kkal Th/ Bedrest semifowler
    O2 2 liter/i (k/p)
    - iv lansoprazole 30mg/12jam - ivfd nacl 0.9% 20tpm Ivfd rl 10 gtt/i
    IVFD RL 20 tpm
    - alprazolam 1x0,5mg - iv omeprazole 40mg/12jam IV Levofloxacin 500 mg/24 j Diet jantung 1700 kkal/hari
    - roxithromicyn 1x300mg - iv ondansentron 4mg/8jam IV Citicolin 1 gram/12 j Iv ceftriaxone 2 g/24 jam
    - amoxicillin 3x500mg - transfusi PRC sd hb 10 g/dl IV Mecobalamin 1 gram/12 j Iv furosemide 20 mg/8 jam
    - vomitas fdc 3x10 mg (bloodset leukodepleted, IV Ondansetron amp/8 j Isdn 3x8mg
    premed dexamethasone) IV Novalgin amp/ 8 j Cpg 1x75 mg
    Lab 31/10/2021 Novorapid 6-6-6 Simvasatatin 1x20mg
    Hb/L/Tr: susul hasil (darah Lab 31/10/2021 SC levemir 0-0-0-20 Sucralfate 3x1c
    beku) Coomb’s test : Valsartan 1x80 mg Salbutamol 3x8 mg
    Diftel : susul hasil (darah Hb/L/Tr: 6,8/4,8 Amlodipin 1x10 mg
    beku) Mcv/mch : 90/52 Bisoprolol 1x2,5 mg Lab. 04/11/2021
    Mcv/mch : susul hasil (darah Diftel: 3/0/0/53/28/16 Flumusyl 3 x 200 mg Hb/l/t: 13,4/9,6/309
    beku) PT/APTT: 1,07/0,9 Mcv/mch/mchc: 84/29/34
    PT/APTT: 0,92/0,93 Sgot/sgpt: 25/13 P/ Cek ulang Diftel : 5/1/0/48/38/8
    Hbsag/antiHCV: negatif Bil total: 2,32 (Minggu,7/11/21) Hbsag : non reaktif
    D/R, Elektrolit, Ca,Albumin,
    Albumin : 4,3 Bil dir/ind: 0,33/1,99 Albumin: 3,6
    Ur/Cr, PT/Aptt, D-dimer,GDS
    Troponin : < 0.04 Na/K/Cl: 142/4,3/110 Ckmb: 16
    Ckmb : 17 Ur/cr: 16/1,1 4/11/2021 Na/k/ l/ca: 144/3,7/112/8,3
    Na/K/Cl: 145/4,1/110 GDS: 147 Hb/L/T : 12,0/10,3/274 Ur/cr: 15/1.1
    Ca : 9,5 MDT : (susul hasil) Diftel :0/0/0/85/9/6 Kgds:107
    Ur/cr: 18/1,30 PT/Aptt : 0,95/ 0,80
    GDS : 113 Ddimer : : 470

    3/11/2021
    CT Scan kepala: Infark di
    basal ganglia kiri, kapsula
    interna kiri, korona radiasi kiri,
    sentrumsemivoule kanan

    Lab 31/10/2021
    Hb/l/t: 13/10,2/335
    Mcv/mch/mchc : 72/24/33
    Diftel : 1/0/0/72/22/5
    Kgds: 485
    Ur/cr : 36/1
    Na/k/cl/Ca: 140/4,4/104/9,2

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