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Mapping Zamzam SAbtu 26 Februari 2022
Mapping Zamzam SAbtu 26 Februari 2022
Nama : Ahmad firman Nama : sayed badrul Nama : Sumainuddin bin Nama : Cut Hanim
CM : 1300470 munirsyah Laode Maidi CM : 1174488
TL : 14/3/1978 TL : 28/06/1968 ( tahun) CM : 1-29-29-02 TL : 02/02/1973
TM : 20/2/2022 CM : 1287342 TL : 06/08/1965
TM : 18/02/2022
Ass/ Ass/ Dx Ass/
1. Obstruksi joundice ec 1. Cephalgia 1. PSMBA ec dd penurunan kesadaran
dd 2. Cholelithiasis - ulcus Gaster (perbaikan) ec dd: 1.
1. Choledocholitiasis 3. Ht stage I - ulcus Duodenum uremic encephalopaty 2.
2. Chilesistitis dengan 4. Post vaksin covid- - Gastritis erossiva sepsis
cholelitiasis 19 2. ISK ec dd Ulcus diabetic grade 4 dg
3. Cholangitis Cystitis osteomielitis dan charcot
2. Dm tipe 2 NW Uretritis foot
3. Post tb paru 2019 Th/ 1. Anemia Sedang ec dd ISK dg piuria
Diet MB 1700 kkal/hari Def Fe CKD stg V on HD reguler
Threeway peny Kronis anemia berat NN
Th/ Lansoprazole 30 mh/12 4. Paraplegia ec dd HT stg II
Bedrest jam -HNP GAD
Diet Hati 1 1700 PCT 500 mg/8 jam -SGB Diabetic neuropathy
kkal/hari Propranolol 1,5 5. Iskemik Anterolateral
IV Cefoperazone Urdafak 250 mg 6. BPH Th/
Sulbactam 1 gram/12 Spasminal 2x1 7. Hipokalemia Sedang Bedrest
jam Ramipril 1x5 mg -GI Loss IV. Lansoprazole
IV Lansoprazole 30 Renal Loss 30mg/12jam
mg/12 jam Lab 10/02/22 IV. Ondancetron
SC Lantus 0-0-0-10 Hb/L/Tr : 13,9/11,0/273 Th/ 4mg/8jam
UDCA 2x250 mg Diftel : 3/1/0/1/68/7 IV Moxifloxacin IV. Ceftriaxone 2gr/24jam
Domperidon 3x10 mg GDS: 118 400mg/24jam IV Levofloxacin 500 g/24
Kolesteramin 2x1 Na/K/Cl : 140/4,1/112 IV Omeprazole jam
40mg/12jam Asam folat 2x0,4 mg
Lab 20/2/22 IV Ondancentron lenal ace 2x169 mg
Hb/L/Tr : 14,7/11,3/491 4mg/8jam gabapentin 1x100 mg
Diftel : 3/0/0/71/17/9 KSR 2x600 mecobalamin 2x500 m
AntiHCV/:negative Atorvastatin 1x20mg transfusi PRC 2 kantong
HBsAg :non reaktif Sukralfat 3xCI
PT/APTT: 0,89/0,1 Lab (14/2/22)
Gds : 327 Lab 19-12-2022 Hb/L/Tr : 6,7/ 8,23/294
SGOT/SGPT : 32/42 Hb/L/Tr : 7,8/26.15/83 MCV/MCH: 81/29
Na/K/Cl : 141/4,3/105 Diftel : 0/0/0/92/2,9/111 Difftel : 1/0/0/73/19/7
Biltot/bildir/indir : AntiHCV/:negative GDS 168
6,8/3,78/3,02 HBsAg :non reaktif PT/APTT: 0,98/0,9
Protot/Alb/Glb : Gds : 117 UR/cR: 91/8,5
6,5/3,3/3,2 Ur/Cr : 15/0,6 Na/K: 132/4,0
Na/K/Cl : 113/2,9/111 Albu/Ca: 3/8
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MAPPING ZAMZAM, Sabtu 26 Februari 2022
dr. Vera Abdullah, dr. T. Mamfaluti, Sp.PD Dpjp : Dr. dr. Fauzi DPJP: dr. Hendra Zufry,
Sp.PD K-Psi Yusuf, SpPD-KGEH Sp.PD., KEMD
Nama : Muthiah Fadhilah Nama : Yusnidar Nama: Nasril Adly Nama: Rizawati
CM : 1196607 TL : 44 tahun JK: Pria JK: wanita
TL : 6/6/2002 TM : 21/2/22 Umur: 41 tahun Umur: 42 th
TM : 21/2/22
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MAPPING ZAMZAM, Sabtu 26 Februari 2022
DPJP : dr. T. Mamfaluti, SpPD DPJP : Dr. dr. Azhari Gani, Dpjp : dr. Hendra Zufry Dpjp : Dr. dr. Fauzi
COW : dr. Suprinardi SpPD-KKV Sp.PD KEMD Yusuf, SpPD-KGEH
Ruangan : dr. Kiani Laras COW : dr. Suprinardi COW: dr. Riza COW: dr.
Ruangan : dr. Irfandy Ruangan : dr. Ulva Suprinardi
Ruangan : dr.
Suhemi
Nama : Muhammad Fadli Nama : Mariany Binti Ahmad Nama : Sarinah Nasril Adly, Pria
CM : 1301052 CM : 1118542 TTL : 15/4/53 TTL : 6/6/80 41
TL : 12/12/1998 TL : 08/10/1962 CM : 0938213 tahun
CM : 1300923
Ass/ Ass/
1. RUQ pain ec dd 1. Ckd stage 5 dgn Uremic Diagnosa Diagnosa
- Cholelitiasis sindrome ec dd 1. Pneumonia HAP dd TB 1. Hematoskezia
dengan - HN paru ec.dd
cholesistitis - GN 2. TB mata os on therapy 1. Hemoroid
- Choledocolitiasis - PNC OAT interna
- Cholangitis 2. Atipikal chest pain 3. HF stage C 2. Polip Recti
- Ca caput 3. Pneumonia DD Covid 19 4. Dislipidemia 3. Ca colorectal
pancreas 4. Hiperkalemia ringan 5. Hiperurecemia 2. Epigastric pain
2. Hemoroid interna syndrome dengan
Th/ Th alarm symptom
Th/ Bedrest IVFD RL 20 tpm 3. Anemia Berat
Bedrest O2 2-4L/i IV. Ceftriaxon 2g/24j NN ec.dd
Diet MII 1700 kkal/hari Diet ginjal 1700 kkal/hari PCT 3x500mg 1. Perdarahan
IV. Cefoperazone Treeway IV lansoprazole 40mg/24j 2. Peny. Kronis
sulbactam 1gr/8jam IV. Ceftriaxone 1gr/12jam Fluimucyl 3x200mg 4. Hipertensi Stage
IV. Omeprazole IV. Omeprazole 40mg/12jam Curcuma 3x1 2
40mg/12jam IV. Ondancetron 4mg/8jam
IV. Ondancetron Asam folat 2x400mg 25/2/22 Th
4mg/8jam CPG 1x75mg Hb/L/Tr : 13/4,0/240 IVFD RL 20 tpm
UDCA 2x250mg N-acetyl cysteine 3x200mg PT/APTT : 0,8/0,9 IV lansoprazole
Curcuma 3x1 Herbesser 1x200mg Albumin :3,6 40mg/12j
Lactulac syr 3xCI Kalitake 3x1 Ca : 7,8 Amlodipin 1x5mg
Ur/Cr : 12/0,5 Anti hemoroid
P/ USG abdomen P/ Na/K/Cl : 144/3,9/105 supp k/p
Urinalisa GDS : 100
Lab 25/2/2020 USG urologi OT/PT :102/103 23/2/22
Hb/L/Tr : 11,1/12,36/217 Screening HD Bil tot/dir/indir : Hb/L/Tr :
MCV/MCH/MCHC : 0,5/0,2/0,3 4,4/8,8/278
82/28/34 Lab 24/2/2022 PT/APTT : 1,0/0,9
Diftel : 0/0/0/85/11/4 Hb/L/Tr : 7,9/6,91/166 Anti HCV neg
Bil. T/D/I : 3,57/0,43/3,14 MCV/MCH/MCHC : 71/24/34 HbsAg neg
GDS : 149 Diftel : 0/0/0/89/8/3 Albumin :3,9
Na/K/Cl : 147/4,00/110 hbsAg/Anti HCV : negative Ca : 8,2
GDS : 199 Ur/Cr : 16/0,8
Ur/cr : 96/5,90 Na/K/Cl :
Na/K/Cl : 130/5,70/109 144/4,2/110
Ca : 7,2
Albumin : 2,90
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MAPPING ZAMZAM, Sabtu 26 Februari 2022