MAPPING RSL

17 MEI 2022
K1 3D K4B K8
DPJP : IPD DPJP : dr Dewi B Sp.P (k) DPJP : dr Ferry D K Sp.P(K) DPJP : IPD dr Mahriani Sp PD
Raber: dr. Dewi, Sp.P(K) PPDS : dr Mikhwan PPDS : dr. Mikhwan Raber : Dr dr Budi Yanti Sp.P (K)
PPDS : dr. Mikhwan
Anwar Bin M Amin
K11 Satri Miranda Firdaus Bin Daud Ismail Rohani Binti M. Nur
DPJP : dr Ferry D K Sp.P(K) CM :1-30-63-42 CM : 1-30-61-50 CM : 1-16-79-04
CM : 1-23-27-70
PPDS : dr. Mikhwan
Umur : 52bin tahun TL : 16/04/1990 (32th) TL : 11/03/1964 (58th) TL : 01/07/1965 (56th)
Fakhrurrazy Mahdy MRS : 11/05/2022 (H5) MRS : 08/05/2022 (H8) MRS : 15/05/2022 (H2)
MRS : 07/05/22
CM : 0-95-46-88 Raber : Gizi Klinik
TLS/: 08/04/1987 (35th) S/ S/ S/
MRS : 09/05/2022
- Sesak nafas (H5) -Sesak nafas - Batuk sesekali - Penurunan Kesadaran
Raber : BTKV,
- Batuk Gizi Klinik, IPD PTI
berdarah - batuk - Lemas
S/ Lab 11/05/2022
- nyeri dada
- Sesak nafas (-), Batuk (-) Nyeri dada(-) Anti HCV negative Dx:
Dx/ Pneumonia
- Nyeri dd TB paru
punggung (bisul) HbSAg Reaktif Dx: - CAP ec dd 1. Vital, 2 Bacterial
-Hemoptisis
- nyeri derajatsusah
tenggorokan sedangmakan Dx: - TB paru kasus baru terkonfirmasi - TB paru on terapi
-Susp Massa paru kanan - TB paru terkonfirmasi bakteriologis bakteriologis - Diafragma letak tinggi
-Syok Sepsis Tes
faseHIV 3 metode
intensif H (40)REAKTIF 3X - Pneumonia CAP - Drug Induced hepatitis ec OAT
Dx:-CHF Fc NYHA III - Bullae Hemithoraks Sinistra - Geriatri Problem
- TB Paru
-AKI kasus
stage baru
III dd akutterkonfirmasi
on CKD klinis - Malnutrisi
CD4 8 berat - Malnutrisi berat
on-Hipoalbuminemia
OAT kategori 1 + 2ringanbulan(2,7) Th:
- Sepsis ec PCP - Comafurin hepar 1fls/24jam
- Obs jaundice ec dd 1. OAT 2. Hepatitis Th: 14/05/2022
Lab Th : - Cefoperazone sulbactam 1g/8jam
- SIDA - IVFD
Bil Nacl 0,9%
Tot/Dir/Ind : 9,71/6,76/2,95 - IVFD Asering s/s B- Fluid 1 fls/24 jam (16/05)
- PCP
Terapi DPJP - O2 SM 5Lpm
SGOT/SGPT : 69/24 - Inj Ceftriaxone 1g/12jam (08/05) (H9) - Lansoprazole 30mg + 50 cc Nacl 9%
- Anemia berat (Hb 6,5)
-Inj Cefoperazone 1gr/12jam - Inj Omperazole 40mg/24jam - Inj Omeprazole 40mg/24jam Drip
- Syndrom
(13/05/22) Dyspepsia - Codein 3x10mg - Curcuma 3x1 - Curcuma tab/8jam
Lab 16/05/2022
- Malnutrisi berat 0,5cc/jam
-Drip Lansoprazole - Curcuma 3x1 - Fluimucyl syr 3x1 STOP - Flumucyl 200mg/8jam
Hb/Ht/erit/trom/leuko:
-Drip Norepinefrin/jam - Vastral 1x1 - Vastral 1x1 - Albumin 25% fls/24jam
8,9/24/3,4/124/5,43
- OAT 4FDC 1x2tab (40) - Vit D 2x1 - KSR 600/12jam
Th-Vit
: K 1amp/8jam E/B/NB/NS/L/M : 1/0/0/90/5/4
- Nystatyn 4x1gtt - Vit K 1amp/8jam
- AS Traneksamat
- IVFD 1amp/8jam
IVELIP S/S B Fluid /24jam
- UDCA
- Inj 250/12jam
Ceftazidim 1g/8jam (11/05) STOP P:
-Sukralfat syr500mg/8jam
- Meropenem 3x1 (13/05) - Cek evaluasi KU dan saturasi P/ Saran th:
- Curcuma 3x1
- Gentamicin 160mg/8jam (13/05) - Evaluasi efek samping OAT - Evaluasi KU dan saturasi - Drip Levofloxacin 750mg/24jam
- Inj Omeprazole 40mg/ 12jam - CT Scan K/NK (24/05) - Kultur sputum mo gram K/R (susul - Inj Streptomycin 750mg/24jam
- USG Thorax tidak ada - Foto thorax PA (11/05/22) susul hasil hasil) -Etambutol 750mg/24jam Po
- Curcuma - Titrasi pemakaian O2 - Gen Expert Medium detected
Planing 3x1 - Cek DR ulang post 3 hari Ab
- Mikostatin drop 4x1 (11/05)
- Evaluasi KU P:
- Kotrimoksazole - Cek foto thorax ulang 5 hari post ab
-Evaluasi Batuk 2x2 tab (11/05) Lab darah 11/05/2022 - Cek evaluasi Ku dan Saturasi
darah (13/05) susul hasil
- Fluconazole
- Foto Thorax evalusi 5(11/05)
2x150mg hari post AB Hb/Ht/erit/trom/leuko: - Periksa Swab RT PCR
- KSR - Konsul Gizi klinik (+) Malnutrisi berat :
-Cek1x600mcg
DR evaluasi 3hari post AB 12,1/36/4,4/434/13,13
Aminofluid /24jam
- Periksa Sputum (Gene Xpert)
- Paracetamol
-Kultur Sputum3x500mg
Mo gram E/B/NB/NS/L/M : 3/0/0/76/13/8 - Periksa Kultur sputum Mo Gram K/R
- Tramadol amp
-Gen Expert jika/8jam
ada dahak sgot/sgpt : 22/32 - Kultur Darah
-Mantox test Albumin : 2,9 Lab darah 09/05/2022 - USG Thorax
P:-USG Thorax Na/K/Cl : 137/3,40/99 Hb/Ht/erit/trom/leuko: - USG Abdomen
- Evaluasi Ku dan Saturasi
-Broncoscopy Ur/cr : 27/0,50 9,7/28/3,5/656/13,96
- Evaluasi efek samping OAT (OAT STOP E/B/NB/NS/L/M : 1/0/0/79/13/7 Lab darah 15/05/2022
Sementara) Bil dir/Ind/tot: 0,32/0,28/0,60 Hb/Ht/erit/trom/leuko:
Lab (9/5/2022) sgot/sgpt : 27/33
- Evaluasi fungsi hati/3hari (12/05) 9,0/23/3,5/531/35,51
Hb/Ht/E/Leu/Trom Na/K/Cl : 134/3,60/104
- Konsul IPD- PTI (10/5/22) (+) cek hiv 3
14,1/41/5,3/12,43/71 E/B/NB/NS/L/M : 0/0/0/85/9/6
metode REAKTIF Ur/cr : 21/0,70 PT/APTT : 41,80/57,40
E/B/NB/NS/Lim/Mon
- Konsul Gizi klinik (10/5/22) :
0/0/0/93/3/4 Fibrinogen : 138
Malnutrisi
Na/K/Cl :berat : IVFD IVELIP S/S B Anti HCV negative
135/4,30/108
Fluid /24jam
SGOT/SGPT : 227/175 HBsAg Non Reaktif
- Gene Expert : TAD Albumin : 1,9
Albumin : 2,70
- Kultur
Bil.Total : 7,35 mo gram K/R (TAD)
sputum Na/K/Cl : 123/3,10/96
- Periksa HIV: 4,90
tiga metode (11/5/22) Bil Total : 21,27
Bil.Direct
Reaktif
Bil.Indirect : 2,45 Bil Dir/Ind : 10,56/10,71
- Konsul BTKV Abses thorakalis SGOT/PT : 113/186
PT/APTT : 23,5/47,30
posteriror rencana insisi drainage Ur/cr : 42/0,70
tanggal menunggu hasil usg thorax soft
Lab (15/05/2022)
tissue, Rencana CITO
Alb 2,2IPD GEH (+)
- Konsul
Ca/Mg :7/1,2
Na/K/CL : 132/4,5/1122
Lab darah 09/05/2022
Hb/Ht/erit/trom/leuko:
6,5/17/2,5/104/2,35
E/B/NB/NS/L/M : 4/0/0/62/20/14
Bil dir/Ind/tot: 9,29/6,19/15,48
sgot/sgpt : 64/37
GDS 106
Na/K/Cl : 128/3,20/104
Ca : 7,9
Ur/cr : 17/0,80