MAPPING DR. RINALDY SP.

P(K)
10-12-2022

K4B2 RAUDAH 5 RAUDHAH 5 RAUDAH 5

ISO 2 K4B1 K6B2
DPJP : dr.Rinaldy,Sp.P DPJP: BPRE Dpjp : B. Digest Dpjp : B. Digest
Raber: dr. Rinaldy, Sp.P Raber : dr. Rinaldi Sp.P Raber : dr. Rinaldi Sp.P
Mawarni Pohan Tn, FAUZI SUARDI B ADNAMI IDRIS
MRS : 06/12/2022 (H4) Ttl: 25-10-1973 (49h) CM: 1-32-22-30 CM : 13-24-61-9
TTL : 08/06/1962 (60)
CM : 1325236 CM: 1-32-51-44 TTL :22-10-1970 ( 52 thn ) TTL : 15/06/1961 (61 thn )
Raber: 07-12-2022 MRS : 28/11/2022 ( H13 ) MRS : 30/11/2022
S/ S/ s/ S/
-Batuk darah Sesak Batuk sesekali Sesak napas
-Nyeri dada Batuk dahak sulit keluar
DX/ Dx/
Dx/ Dx/ - TB paru terkonfirmasi klinis kasus - pneumonia dd metastase proses
- Hemoptisis non masif ec dd 1. - Asma eksaserbasi akut derajat baru - PPOK stabil grup B
Malignansi, 2. Infeksi persisten ringan pada asma terkontrol - TB ekstra paru gastrointestinal -Adenocarcinoma gaster proksimal
- Susp Tumor mediastinum - combustion terkonfirmasi klinis post laparatomy eksplorasi
- Dyspepsia syndrome - Fistel enterokutan high output - Mikrotrombosis sistemik
Th/ - Hipoalbuminemia (2,6) - Hipoalbuminemia (2,9)
Th/ - iv ceftriaxon 1gr/12j (06/12)(H5 - Hipokalemia (2,9)
- Three way - iv novalgin 1amp/8j Th/
- Inj. Asam tranexamat 500 mg/12 - iv omeprazole 40mg/12j -Drip. B. Fluid 1 fls/24 jam Th/
jam - vitamin c 100mg 2x1 -Drip. Albumin 25 % 1 fls/24 jam - Drip B fluid 1 flash/24 jam
- Inj. Omeprazole 40mg/12 jam - asam folat 1x1 (05/12/2022 ) (STOP) - inj. Viccilin 1,5g / 6 jam ( 30/11) H11
- Codein 3x10mg - Fluimucyl 200mg 3x1 - Iv. Viccillin 1,5 gr/12 jam - inj. Dexketoprofen 1 amp/8 jam
- Vit C 2x500mg - zinc 1x1 (05/12/2022) H6 - Inj. Omeprazol 1 vial / 12 jam
- Lactulac syr 3xC1 - paracetamol 3x1000mg - Iv. Omeprazole 40 mg/12 jam
- Cetirizin 1x1 - Mupirocin 4x ue -Iv. dexketopren 1 amp/12 jam P/
- Curcuma 3x1 tab - Nebul ventolin 1resp/8j -curcuma 3x1 - Evaluasi KU, TTV dan saturasi
-Amlodipin 1x10 mg - Nebul pulmicort 1resp/12j -kaltrofen supp /24 jam - kultur sputum Mo gr K/R
- Lactulac syr 3 x CI Saran therapi: - Evalusi DR 3 hari post AB
P/ - Ab sesuai ts dpjp - Evaluasi Foto thorax 5 hari post AB
P/ - Evaluasi KU, TTV, dan Saturasi - N. Acetylsistein 3x200 mg - Gen expert sputum (TAD)
- Evaluasi KU dan saturasi - Foto thoraks evaluasi per 5hari - 4FDC 2 tab /24jam
- USG Thoraks (7/12) tidak tampak - kultur sputum mo gram (TAD) Laboratorium 5/12/2022
konsolidasi - cek lab Darah rutin per 3hari P/ Hb/Ht/Er/L/T: 15,3/46/6,4/249/9,26
- CT Scan thoraks K/NK (27/12) - APE harian - Evaluasi KU dan saturasi E/B/NB/NS/L/M. : 0/0/0/89/7/4
- Bronkoskopi (12/12) - Spirometri bila KU stabil - Kultur sputum mo gram K/R (TAD) Alb: 2,9
- Evaluasi batuk darah - Toleransi Operasi resiko sedang - TCM sputum (Gen Expert) D-dimer: 2380
- efaluasi efek samping OAT Na/K/Cl: 137/3.1/111
06/12/2022 Laboratorium (5/12/2022) - konsul gizi (evaluasi malnutrisi)
Hb/Ht/E/Leu/Trom : HB/HT/E/L/T 14,2/42/5,0/9,6/300 Lab 07/12/2022 :
13,2/40/4,8/8,42/257 E/B/NB/NS/L/M 7/1/0/56/21/15 Lab 04/12/2022 : Hb/Ht/E/T/L : 12,5/32/4.2/148/12,4
E/B/Nb/Ns/L/M : 3/0/0/59/31/7 Ur/Cr : 52/0,9 Hb/Ht/E/T/L : 11,3/32/4,3/442/9,48 E/B/NB/NS/Lim/Mo : 7/1/0/55/22/15
PT/APTT : 17/25,90 E/B/NB/NS/Lim/Mo : 1/0/0/83/10/6
07/12/2022 Na/K/Cl : 133/4,6/116 Alb : 2,60
Ur/cr : 18/0.56 GDS : 98
Na/K/CL : 144/3.10/109 Laboratorium 07/12/2022
Gds : 200 AGDA 07/12/2022 Hb/ Ht/E/T/L 10.2/ 30,1/ 4,7/ 159/
PT/Aptt : 13.70/27.00 pH : 7,516 10,2
AFP : 4.91 pCO2 : 23,80 E/B/NB/NS/L/M 0/0/0/85/9/6
Ca125 : 9.28 HCO3 : 19,4 KGDS 121
HbSAg : non reaktif Total CO2 : 20,2 Ur/Cr : 32/1.20
GDS : 83 BE : -1,4 Na/K/Cl 123/4.10/113
Albumin : 3,86 Saturasi O2 : 98,9
SGOT/SGPT : 37/33 Kesan : Alkalosis respiratorik
B HCG : < 2,00 terkompensasi sebagian

Lab 08/12/2022
Hb/Ht/L/T : 12.0/34/12.05/235
E/B/NB/NS/L/M : 1/0/1/70/14/4
 MAPPING DR. RINALDY SP.P(K)
10-12-2022

RAUDAH 3 Raudah 1 ICU 1 MINA 1

K1B1 K6B4 B4 K6B3
DPJP: Neurologi DPJP : Kardio DPJP : ANes DPJP: Neurologi
Raber: dr.Rinaldi, Sp. P Raber : dr. Rinaldi Sp.P Raber : dr. Rinaldi Sp.P Raber: dr.Rinaldi, Sp. P
Ny. SAKDIAH M. ALI ABDY HAWILAH ALI Tn. SYARLIMI
Usia. : 58 thn Umur : 01/07/1943 (79 tahun) usia. : 11/12/1950 (71 thn) TTL: 12/07/1960(53 thn)
CM: 1-30-24-49 CM: 1-03-97-58 Alamat : Samalanga CM: 1-20-99-80
Raber: 07-12-22 MRS : 07/12/2022 (H-4) CM: 1-32-51-76 Raber: 07-12-22
S/ S/ s/ S/
Batuk kering Nyeri dada penurunan kesadaran Sesak
Nyeri dada Batuk
Dx/ dx/
Dx/ -Bekas TB dd TB kambuh - Susp Massa paru kanan dd atelektasis Dx/
- Tumor paru kanan jenis ? -UAP paru kanan - PPOK eksaserbasi akut derajat
T4N2M1b(vertebrae) stage IVA ecog 3 -AKI stage I -Bekas TB dd TB kambuh sedang
- Tetraparesis tipe UMN susp -Dyspepsia syndrome - Penurunan kesadaran + hemiparesis -Pneumonia CAP PSI 73
metastase med spinalis sinistra ec stroke hemoragik -Susp TB paru
- Cancer pain NRS 3-4 Th/ -HT stg 2 -DM tipe 2
-IV. Pantoprazole 40 mg/24 jam -HT stg 2
Th/ -ISDN 1x5 mg Th/ -Reccuren stroke iskemik
-iv. Dexketropen 1 amp/8 jam -CPG 1x75 mg -Drip Perdipin titrasi
- iv. Omeprazole 40 mg/12 jam -Aspilet 1x80 mg - Inj Ceftriaxone 2gr/24jam (08/12) H3 Th/
-Loperamide 2 x100 mg -Atorvastatin 1x40 mg - IV Citicolin 500mg/12jam -IV Cefoperazon sulbactam 1gr/12jam
- Aspilet 1x 75 mg -Alprazolam 1x0,25 mg - IV Omeprazol 40mg/12jam (07/12) H4
- pentoxifylline 2x 400 mg -Ramipril 1x 5 mg -Drip Perdipin titrasi
-N. Acetylsisetin 3x200 mg p/ -IV Citicolin 500mg/12jam
P/ -Sc arixtra 2,5 mg/24 jam - USG thorax -IV N Acetyl sistein 3x200
- CT scan toraks ulang K/NK ( Belum di -Laxadin sirup 3xC1 - CT Scan Thorax K/NK -PO CLopidogrel 1x75mg
daftar dari Bedah ) -TTNA USG/CT Guided -Fartison 2x 100 mg
- TTNA USG/CT guide (Tidak dilakukan P/ - Gene xpert -Nebul Combivent 1flc/6jam
lagi ) - Evaluasi KU dan saturasi -Nebul Pulmicort 1flc/8jam
- Kultur sputum mo gram K/R (TAD) Lab 6/12/2022 -Codein 3x10mg
Laboratorium tgl 7/12/2022 - Cek TCM sputum (Gen expert) Hb/ht/erit/Trom/Leu :
Hb/ht/E/T/L 10,0/29/3,5/374/12,34 14,2/41/4,8/249/7,82 P/
E/B/NB/NS/L/M :0/0/0/83/11/6 Lab 07/12/2022 : E/B/NB/NS/L/M :1/0/0/76/12/11 -Kultur sputum mo gram K/R (TAD)
GDS 78 Hb/Ht/E/T/L : 14,7/41/4,6/224/8,61 Ur/Cr : 16/0,6 -Kultur darah (-)
Ur/Cr 19/0,4 E/B/NB/NS/Lim/Mo : 19/1/0/47/25/8 Na/K/Cl : 146/2,9/107 -Cek lab DR Evaluasi 3 hari post AB
Na/K/Cl 139/4,3/ć Gds : 105 -Foto thorax evaluasi 5 hari post AB
Ur/Cr : 45/1,80 -TCM TB sputum (TAD)
Na/K/Cl : 142/4,60/112 -Spirometri jika KU stabil
Tropinin T : < 0,04
Laboratorium tgl 7/12/2022
Hb/Ht/E/T/L 13,3/37/4,3/253/15,75
E/B/NB/NS/L/M :5/0/0/81/7/7
 MAPPING DR. RINALDY SP.P(K)
10-12-2022

MINA 2
K5B2
DPJP: NEURO
Raber: dr. Rinaldy, Sp.P
Ny. SURAHANINGSIH BINTI SUARI
Umur. : 63 thn
CM : 1-32-46-30
Tgl MRS : 30/11/2022
S/
Sesak

Dx/
- CAP PSI 128 dd 1.bakterial 2. Viral
-Penurunan kesadaran + hemiparasis
sinistra ec stroke iskemik tipe emboli
( infark ar cerebelum )
- PPOK eksaserbasi derajat sedang
-Atrial fibrilasi
-HT stage I
-CHF NYHA II-III
-Anemia berat (7,7)

Th/
-Drip. Levofloxacin 750 mg/24 jam
(05/12) H6
- Drip Resfar 8-8-9/24 jam (7/12) H4
-Iv. Citicoline 500 mg/12 jam
-Iv. Omeprazole 40 mg/12 jam
-Iv. Novalgon 1 Amp/12 jam
-Atorvastatin 1x40 mg
-xarelto 1x10 mg
-Valsartan 1x80 mg
-N. Ventolin 1 resp/8 jam
-Flumucyl sirup 3xC1
-Betadin gurgle 2x C1
-Flumucyl sirup : Stop
-Trf PRC HB> 10 gr/dl
Saran :
Dobel dengan iv. meropenem 1 gr/12
jam
N. pulmicort 1 resp/12 jam
-Suction berkala
-Konsul rehab

P/
- Evaluasi KU, TTV dan saturasi
- Evaluasi DR 3 hari post AB
- Foto thorax evaluasi
- Kultur sputum Mo gram K/R (TAD)
- Kultur darah (-)
- Kultur Urin (-)

Laboratorium tanggal 05/12/2022

Hb/Ht/E/L/T 7,7/24/2,8/11,50/221
E/B/Nb/Ns/L/M : 1/0/0/78/12/9
Ur/cr : 30/0,33
Na/K/CL : 145/3,60/116
Gds : 114
Alb : 2,05
Procalcitonin : 0,28

Lab 8-12-2022
Hb/Ht/L/T 8.9/28/16.63/335
E/B/NB/NS/L/M 0/0/0/88/6
AGDA
pH 7.447
pCO2 47.60
pO2 108
HCO3 33.1
Total CO2 34.6
BE +8.4
spO2 98.4
Kesan : Alkalosis Metabolik
terkompensasi Sebagian