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 Satri Miranda Firdaus Bin Daud Ismail Rohani Binti M. Nur
CM : 1-23-27-70 CM :1-30-63-42 CM : 1-30-61-50 CM : 1-16-79-04
Umur : 52 tahun TL : 16/04/1990 (32th) TL : 11/03/1964 (58th) TL : 01/07/1965 (56th)
MRS : 11/05/2022 (H5) MRS : 08/05/2022 (H8) MRS : 15/05/2022 (H2)
MRS : 07/05/22
Raber : Gizi Klinik
S/ S/ S/ S/
- Sesak nafas -Sesak nafas - Batuk sesekali - Penurunan Kesadaran
- Batuk berdarah - batuk - Lemas
- nyeri dada Dx:
Dx/ Pneumonia dd TB paru Dx: - CAP ec dd 1. Vital, 2 Bacterial
-Hemoptisis derajat sedang Dx: - TB paru kasus baru terkonfirmasi - TB paru on terapi
-Susp Massa paru kanan - TB paru terkonfirmasi bakteriologis bakteriologis - Diafragma letak tinggi
-Syok Sepsis fase intensif H (40) - Pneumonia CAP - Drug Induced hepatitis ec OAT
-CHF Fc NYHA III - Bullae Hemithoraks Sinistra - Geriatri Problem
-AKI stage III dd akut on CKD - Malnutrisi berat - Malnutrisi berat Th:
-Hipoalbuminemia ringan (2,7) - Comafurin hepar 1fls/24jam
Th: Th : - Cefoperazone sulbactam 1g/8jam
- IVFD Nacl 0,9% - IVFD Asering s/s B- Fluid 1 fls/24 jam (16/05)
Terapi DPJP - O2 SM 5Lpm - Inj Ceftriaxone 1g/12jam (08/05) (H9) - Lansoprazole 30mg + 50 cc Nacl 9%
-Inj Cefoperazone 1gr/12jam - Inj Omperazole 40mg/24jam - Inj Omeprazole 40mg/24jam Drip
(13/05/22) - Codein 3x10mg - Curcuma 3x1 - Curcuma tab/8jam
-Drip Lansoprazole 0,5cc/jam - Curcuma 3x1 - Fluimucyl syr 3x1 STOP - Flumucyl 200mg/8jam
-Drip Norepinefrin/jam - Vastral 1x1 - Vastral 1x1 - Albumin 25% fls/24jam
-Vit K 1amp/8jam - OAT 4FDC 1x2tab (40) - Vit D 2x1 - KSR 600/12jam
- AS Traneksamat 1amp/8jam - Nystatyn 4x1gtt - Vit K 1amp/8jam
- UDCA 250/12jam P:
-Sukralfat syr 3x1 - Cek evaluasi KU dan saturasi P/ Saran th:
- Curcuma 3x1 - Evaluasi efek samping OAT - Evaluasi KU dan saturasi - Drip Levofloxacin 750mg/24jam
- CT Scan K/NK (24/05) - Kultur sputum mo gram K/R (susul - Inj Streptomycin 750mg/24jam
- Foto thorax PA (11/05/22) susul hasil hasil) -Etambutol 750mg/24jam Po
- Titrasi pemakaian O2 - Gen Expert Medium detected
Planing - Cek DR ulang post 3 hari Ab
- Evaluasi KU P:
Lab darah 11/05/2022 - Cek foto thorax ulang 5 hari post ab - Cek evaluasi Ku dan Saturasi
-Evaluasi Batuk darah (13/05) susul hasil
- Foto Thorax evalusi 5 hari post AB Hb/Ht/erit/trom/leuko: - Periksa Swab RT PCR
12,1/36/4,4/434/13,13 - Konsul Gizi klinik (+) Malnutrisi berat : - Periksa Sputum (Gene Xpert)
-Cek DR evaluasi 3hari post AB Aminofluid /24jam
-Kultur Sputum Mo gram E/B/NB/NS/L/M : 3/0/0/76/13/8 - Periksa Kultur sputum Mo Gram K/R
-Gen Expert jika ada dahak sgot/sgpt : 22/32 - Kultur Darah
-Mantox test Albumin : 2,9 Lab darah 08/05/2022 - USG Thorax
-USG Thorax Na/K/Cl : 137/3,40/99 Hb/Ht/erit/trom/leuko: - USG Abdomen
-Broncoscopy Ur/cr : 27/0,50 9,7/28/3,5/656/13,96
E/B/NB/NS/L/M : 1/0/0/79/13/7 Lab darah 15/05/2022
Bil dir/Ind/tot: 0,32/0,28/0,60 Hb/Ht/erit/trom/leuko:
Lab (9/5/2022) sgot/sgpt : 27/33
Hb/Ht/E/Leu/Trom 9,0/23/3,5/531/35,51
Na/K/Cl : 134/3,60/104 E/B/NB/NS/L/M : 0/0/0/85/9/6
14,1/41/5,3/12,43/71 Ur/cr : 21/0,70\
E/B/NB/NS/Lim/Mon PT/APTT : 41,80/57,40
0/0/0/93/3/4 Fibrinogen : 138
Na/K/Cl : 135/4,30/108 Lab 11/05 Anti HCV negative
SGOT/SGPT : 227/175 Hb A1c ; 4,70 HBsAg Non Reaktif
Albumin : 2,70 GDP : 131 Albumin : 1,9
Bil.Total : 7,35 Na/K/Cl : 123/3,10/96
Bil.Direct : 4,90 Bil Total : 21,27
Bil.Indirect : 2,45 Bil Dir/Ind : 10,56/10,71
Lab darah 12/05/2022 SGOT/PT : 113/186
PT/APTT : 23,5/47,30 Hb/Ht/erit/trom/leuko: Ur/cr : 42/0,70
9,3/27/3,4/560/13,01
Lab (13/5/2022) E/B/NB/NS/L/M : 4/0/1/72/14/9
Hb/Ht/E/Leu/Trom
12,5/36/4,7/14,56/130
E/B/NB/NS/Lim/Mon
0/0/1/86/5/8
PT/APTT : 19,20/46,60

Lab (15/05/2022)
Alb 2,2
Ca/Mg :7/1,2
Na/K/CL : 132/4,5/1122
 MAPPING RSL
17 MEI 2022

K11
DPJP : dr Ferry D K Sp.P(K)
PPDS : dr. Mikhwan
Fakhrurrazy bin Mahdy
CM : 0-95-46-88
TL : 08/04/1987 (35th)
MRS : 09/05/2022 (H5)
Raber : BTKV, Gizi Klinik, IPD PTI
S/ Lab 11/05/2022
- Sesak nafas (-), Batuk (-) Nyeri dada(-) Anti HCV negative
- Nyeri punggung (bisul) HbSAg Reaktif
- nyeri tenggorokan susah makan
Tes HIV 3 metode REAKTIF 3X
Dx:
- TB Paru kasus baru terkonfirmasi klinis CD4 8
on OAT kategori 1 + 2 bulan
- Sepsis ec PCP
- Obs jaundice ec dd 1. OAT 2. Hepatitis Lab 14/05/2022
- SIDA Bil Tot/Dir/Ind : 9,71/6,76/2,95
- PCP SGOT/SGPT : 69/24
- Anemia berat (Hb 6,5)
- Syndrom Dyspepsia Lab 16/05/2022
- Malnutrisi berat Hb/Ht/erit/trom/leuko:
8,9/24/3,4/124/5,43
Th : E/B/NB/NS/L/M : 1/0/0/90/5/4
- IVFD IVELIP S/S B Fluid /24jam
- Inj Ceftazidim 1g/8jam (11/05) STOP
- Meropenem 500mg/8jam (13/05)
- Gentamicin 160mg/8jam (13/05)
- Inj Omeprazole 40mg/ 12jam
- USG Thorax tidak ada
- Curcuma 3x1
- Mikostatin drop 4x1 (11/05)
- Kotrimoksazole 2x2 tab (11/05)
- Fluconazole 2x150mg (11/05)
- KSR 1x600mcg
- Paracetamol 3x500mg
- Tramadol amp /8jam

P:
- Evaluasi Ku dan Saturasi
- Evaluasi efek samping OAT (OAT STOP
Sementara)
- Evaluasi fungsi hati/3hari (12/05)
- Konsul IPD- PTI (10/5/22) (+) cek hiv 3
metode REAKTIF
- Konsul Gizi klinik (10/5/22) :
Malnutrisi berat : IVFD IVELIP S/S B
Fluid /24jam
- Gene Expert : TAD
- Kultur sputum mo gram K/R (TAD)
- Periksa HIV tiga metode (11/5/22)
Reaktif
- Konsul BTKV Abses thorakalis
posteriror rencana insisi drainage
- USG soft tissue (17/05) : proses
inflamasi a/infeksi
- Konsul IPD GEH (+)

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