MAPPING MINA 1 (01/11/2021)

SUBJEKTIF
NO KAMAR IDENTITAS DIAGNOSIS LABORATORIUM TERAPI PLANING
Keluhan GCS TD

K6B1

Tgl mrs :

TITIPAN
IPD

DPJP :

RABER :

PPDS :

1
 SUBJEKTIF
NO KAMAR IDENTITAS DIAGNOSIS LABORATORIUM TERAPI PLANING
Keluhan GCS TD

K6B2 Afwandi bin T M. Nyeri E4 120/80 Cephalgia kronik progresif + 26/10/21 26/10/21 27/10/21
Ali, Lk, 39 th kepala M6 paresis N.VII sinistra sentral Hb : 16,1 Iv paracetamol 1gr/8jam Head ct scan kontras
(berkurang V5 ec SOL intracranial fossa Ht : 45 Iv citicolin 500mg/12jam (5/11)
) posterior Tr: 319 Iv omeprazole 40mg/12jam
Tgl Masuk: Leu : 9,5 Iv dexametason 5mg/8jam
26/11/2021 Gds : 127
Ur/cr : 29/0,8 30/10/21
Na/k/cl : 143/4,7/109 Clobazam 1x10mg

DPJP :
Dr.NM

RABER :

Ppds :
Dr. zefri

2
 SUBJEKTIF
KAMAR IDENTITAS DIAGNOSIS LABORATORIUM TERAPI PLANING
Keluhan GCS TD
K6B3 Zakaria Idrus, Sulit E4 90/60 Paresis N.VI bilateral, N. VII XII 26/10/21 26/10/21 27/10/21
Lk, 53 th menelan M6 sinistra sentral, N. IX X ec SOL Hb : 15,0 Iv paracetamol 1gr/8jam Konsul THT
BAB cair V5 intracranial Ht : 43 Iv omeprazole 40mg/12jam (tidak ACC
Tgl Masuk: kehitaman Susp. Massa nasofaring dd Tr : 425 (stop 29/10) raber)
25/10/21 tumor nasofaring Leu : 18,3 Iv ciicolin 500mg/12jam Konsul gizi klinik
Malnutrisi berat Gds : 114 Mestinon 3x30mg (+)
Ur/cr : 121/1,3 Iv mecobalamin 500mg/12jam
Na/k/cl : 147/4,7/108 Iv ceftriaxone 5mg/8jam (stop 29/10
DPJP : 29/10) Ct scan
Dr. NM 29/10/21 Iv aminofluid 1 fls/24jam (stop nasofaring K/NK
Hb : 14,2 29/10) (10/11)
Ht : 40 Attapulgit 2tab/diare (stop
RABER : Tr : 309 29/10) 1/11/21
IPD-GEH Leu : 14,1 Kultur sputum
29/10 besok
30/10/21 Iv aminofluid (selang seling) Iv
Pt/aptt: 1,0/0,7 triovusin 1 fls/24jam
Iv lansoprazole 30mg/12jam
Ppds : (stop 30/10)
Dr. zefri Sucralfat syr 3xC2

30/10
Drip pantoprazole 2 amp dalam
50cc nacl, kec 5cc/jam
Vit k 1 amp/8jam
Gabapentin 3x100mg

3
 SUBJEKTIF
KAMAR IDENTITAS DIAGNOSIS LABORATORIUM TERAPI PLANING
Keluhan GCS TD
K6B4

Tgl masuk :
TITIPAN
IPD
DPJP :

RABER :

Ppds :

4
 SUBJEKTIF
KAMAR IDENTITAS DIAGNOSIS LABORATORIUM TERAPI PLANING
Keluhan GCS TD
K6B5 Arsan bin Kelemahan E4 160/80 Hemiparese sinistra + paresis 31/10 31/10
musaluddin, lk, anggota M6 N.VII sinistra sentral ec stroke Hb : 13,1 Iv citicolin 500mg/12jam
57 th gerak kiri V5 iskemik Ht : 36 Iv mecobalamin 500mg/12jam
Hipertensi stage 2 Tr : 223 Amlodipin 1x5mg
Leu : 13,0 Sc lovenox 1x5mg
Tgl masuk : Gds : 214
31/10/21 Ur/cr : 37/116
Na/k/cl : 142/3,8/107
DPJP :
Dr. IK

Raber :

Ppds :
Dr. kahfi/dr.
aidil

5
 SUBJEKTIF
KAMAR IDENTITAS DIAGNOSIS LABORATORIUM TERAPI PLANING
Keluhan GCS TD
K6B6

Tgl masuk :

DPJP :

RABER:

Ppds :

6
 SUBJEKTIF
NO. KAMAR IDENTITAS DIAGNOSIS LABORATORIUM TERAPI PLANING
Keluhan GCS TD
4 K7B1 Usman Ramli, lk, Kelemahan E4 126/57 1. Obs seizure + 29/10 30/10
58 th anggota M6 hemiparesis dextra + ec dd Hb : 13,6 Iv paracetamol 1gr/8jam
gerak V5 stroke iskemik Ht : 40 Iv citicolin 500mg/12jam
Tanggal Masuk 2. sepsis ec severe Tr : 316 Iv meropenem 1gr/8jam
29/10/21 pneumonia Leu : 24,3 Iv omeprazole 40mg/12jam
Pt/aptt : 1,06/0,93 Iv dexametason 5mg/24jam
DPJP : SGOT/SGPT : 105/49 Drip resfar 8-8-9
Dr IM Gds : 332 Sc heparin 500mg/12jam
Ur/cr : 45/1,3 Curcuma 3x1 tab
Na/k/cl : Amlodipin 1x 10mg
Raber : 141/4,8/110 Phenitoin drip 300mg habis dalam
IPD 24jam, 2,1 /jam
Pulmo 31/10/21
Ca : 8,3 1/10
Mg : 2,3 Phenitoin 3x100mg
PPDS : Ur/cr : 58/1,0
Dr kahfi/dr.reza Na/k/cl :
142/4,8/113

7
 SUBJEKTIF
NO. KAMAR IDENTITAS DIAGNOSIS LABORATORIUM TERAPI PLANING
Keluhan GCS TD
4 K7B2

Tgl periksa :

DPJP :

RABER:

PPDS :

8
 SUBJEKTIF
NO. KAMAR IDENTITAS DIAGNOSIS LABORATORIUM TERAPI PLANING
Keluhan GCS TD
4 K7B3

Tgl masuk :

DPJP :

RABER:

PPDS :