| A | B | C | D | E | F | G | H | I | J | |
|---|---|---|---|---|---|---|---|---|---|---|
1 | Mapping RIK 7 Lantai 3A | |||||||||
2 | Kamis, 23/11/2023 | |||||||||
3 | Bed | Identitas Pasien | MRS | Diagnosis | PPDS / Chief | DPJP | DPJPK | RABER | ASAL | Ket |
4 | 1 | Tn. Suli suwanto / 28 th / 10332765 | 22/11 | Thalasemia B Mayor + Anemia Hipokrom Mikrositer (Hb 7.3) + Trombositosis pro Evaluasi (Plt 1409000) | Lubis / Daviq | dr. Pradana Zaky Romadhon, Sp.PD K-HOM | POSA | |||
5 | 2 | Ny. Asri Ayu/ 27th/ 12861447 | 22/11 | Thalassemia Beta Mayor (ICD10 D56.1) + Anemia Hipokrom mikrositer (Hb 7,8) (ICD10 D64.9) | Fidi / Binsar | dr. Pradana Zaky Romadhon, Sp.PD K-HOM | POSA | |||
6 | 3 | Tn. Setiawan/ 40th/ 12544807 | 21/11 | Prolonged fever (Fever of unknown origin) pro evaluasi + Rheumatoid Arthritis + CAP PSI Score 40 Risk Class I + Hypoalbuminemia (Alb 2.75 ; 2.85) + Hiperuricemia (8.7) + DM type 2 | Alvin / Binsar | DR. dr. Lita Diah R,Sp. PD, K-R | IGD | |||
7 | 4 | |||||||||
8 | Nn. Shichah Sholichatun/ 23th/ 13047759 | 17/11 | Anemia Hipokromik Mikrositer pro evaluasi (Hb 9.1 ; 10.6 ; 11.1) + Hiperbilirubinemia (Bil. D 1.10 ; 0.9/ Bil. T 1.80 ; 1.5) + CAP Psi Score 33 class III + Hipoalbumin (Alb 2,26 ; 2.51 ; 2.8) + Hiponatremia Hipotonik hipovolemik (Na 132 ; 132 ; 133) + Hipokalemia terkoreksi (K 3,0 ; 4.2) | Nabila / Binsar | dr Pradana Zaky R Sp.PD K-HOM | IGD | KRS | |||
9 | 5 | Ny. Rani Murwanti/ 37th/ 13009782 | 21/11 | Vomiting Profus + Hiponatremi Hipotonik Hipovolemik (Na 122, mOsm 254) + Hipokalemia (3.2) + Anemia Hipokromik Mikrositer (Hb 8.0 > 8,2) + Susp ISK + DMT2 teregulasi | Rita / Daviq | Dr. dr. Sony Wibisono, Sp. PD, K-EMD | IGD | |||
10 | 6 | Ny. Windi Agustin/ 27th/ 12868481 | 15/11 | SLE (Sledai Score 6) + Lupus Nefritis + ACKD (SK 3.3; 2.5 ; 2.4 ; 2.1) + Anemia normorkomik normositik (7; 7,4 ; 6.5) + Hiperuricemia (18.6 ; 14.4 ; 14.1) + DCM + Hiperkalemia membaik (5.4; 4.0 ; 3.8 ; 4.2) + Asidosis metabolik uncompensated (AG 6,8) + Hipoalbuminemia (2.69) | Alvin / Binsar | Dr. dr. Lita Diah R., Sp.PD, K-R | Dr. Artaria Tjempakasari, dr, Sp.PD, KGH | Poli Remato | ||
11 | 7 | Tn. Mochammad Zaelani/ 35th/ 10367684 | 21/11 | Gastritis Erosiva pro Endoskopi (23/11) + Hipokalemia (2.9) + Anemia Hipokrom Mikrositer (7.8) | Fidi / Binsar | dr. Ulfa Kholili, Sp.PD, K-GEH | IGD | |||
12 | 8 | Ny. Nur Rachmi / 54 th / 13028223 | 21/11 | Anemia Aplastik (Hb 7.8 ; Leukosit 1.320 ; Plt 5000) (D61.9) + Hipokalemia (2.9) (E87.6) | Alfan / Binsar | dr. Pradana Zaky, Sp.PD, K-HOM | IGD | |||
13 | 9 | Ny. Devi Lutvita Sari/ 19 thn / 11090460 | 22/11 | Thalassemia Beta Mayor + Anemia hipokromik mikrositer (8.2) | Nabila / Binsar | dr. Pradana Zaky, Sp.PD, K-HOM | POSA | |||
14 | 10 | Ny. Ismatulloh / 25 th / 10137718 | 22/11 | Thalassemia Beta Mayor + Anemia hipokromik mikrositer (6.2) | Vidya / Daviq | dr. Pradana Zaky SpPD KHOM | POSA | |||
15 | 11 | |||||||||
16 | Ny Hartini Zulfa/ 59th/ 12528901 | 17/11 | AIHA ( Hb 5.3 > 5.2 > 7.8) + SLE SLEDAI-2K Score 4 point + Acute on CKD terkait Lupus Nefritis membaik ( SK 1.5 > 0.9 / BUN 16.0 ) + Hipokalemia terkoreksi ( K 3.1 > 4.2 ) + Hipertensi Stage 1 INASH 2021 + Riwayat APS + Hiperurisemia ( As. urat 7.5 ) | Lubis / Daviq | Dr. Lita Diah, dr., Sp.PD, K-R | Poli Remato | KRS | |||
17 | 12 | |||||||||
18 | Tn Abdul Hadi/ 48th/ 13048156 | 19/11 | CAP PSI Score 108 Class IV + CKD HD reguler rabu-sabtu (terakhir HD sabtu 18/11/23) + Anemia Normositik Normokromik (6,5) + Hiponatermia hiperosmolar euvolemik (Na 131 mOsm 0) + Hipoalbumin (2,63) + Susp ISK + HT Stage 1 | Rita / Daviq | dr. Satriyo Dwi Suryantoro, Sp.PD, K-GH | IGD | Pindah HCU | |||
19 | 13 | Tn. Slamet / 64 th / 12893063 | 22/11 | Thalassemia beta mayor + Anemia Normokromik Normositik (Hb 6.2) + Trombositopenia (52.000) | Alvin / Binsar | dr. Pradana Zaky, Sp.PD K-HOM | POSA | |||
20 | 14 | |||||||||
21 | Ny. Nurul Janah/ 29th/ 13045921 | 9/11 | SLE LN + Edema Anasarka + Ascites grade II + CKD stage V (BUN 56.5>63.9>88.1>88.9>93, SK 4.5>4.9>4.8>5.0>5.7) + Efusi Perikard moderate + Efusi Pleura S + Anemia hipokromik mikrositik (Hb 6.7>6.9>7.0>6.4) + Hipoalbumin on koreksi (1.03>1.65>1.81>2.14>2.21) + Asidosis Metabolik (pH 7,27 pCO2 30 HCO3 13.8) + + Hiperurisemia (AU 10,6) + Hipertensi stage II INASH 2021 | Fidi / Binsar | Dr. Artaria Tjempakasari, dr, Sp.PD, KGH | Dr. Lita Diah, dr, Sp.PD, K-R | IGD | PP | ||
22 | 15 | KULIT | ||||||||
23 | 16 | Ny. Atminadjeng/ 67th/ 13048098 | 19/11 | Penurunan kesadaran ec Acute confusional state dd encephalophaty sepsis + CAP PSI Score 157 Class V + AKI dd ACKD (BUN 45.7 ; SK 1.3) + Hipokalemia (K 3,6 ; 3.1; 3.3) + Hiponatremi Hipotonik Hipovolemik terkoreksi (Na 123, Na 140 OSm 308) + Anemia Normositik Normokromik (Hb 9,3) + Asidosis Metabolik terkompensasi sebagian (PH 7,33, HCO3 14,2) + Geriatric Syndome (imobilisasi, infeksi, frailty) + Susp OA Genu dextra sinistra + DM tipe 2 + Manultrisi | Vidya / Daviq | dr. Jusri Ichwani, Sp.PD, K-Ger | IGD | |||
24 | 17 | |||||||||
25 | Ny. Syifak Al Hadad/ 62th/ 12611762 | 17/11 | Obs. Dyspneu ec susp. CHF + Cancer pain + Adenocarcinoma gaster dd Cholangiocarcinoma dd pancreatobillier + Vomitting dehidrasi sedang + Hipoalbumin (2.70) + Meta liver | Rita / Daviq | dr. Titong Sugihartono, Sp.PD,K-GEH | IGD | KRS | |||
26 | 18 | |||||||||
27 | Nn. Mafaza/ 21th/ 13023434 | 18/11 | GERD + Esofagitis Grade B + Pan-gastritis + GEA Dehidrasi Ringan Sedang (A09.9) + Hipokalemia Terkoreksi (2,7 > 3,5) (E87.6) + Hipoalbuminemia (2,84) (R77.0) + Riw. Intoksikasi Basa Kuat Juli 2023 (R63.8) | Alfan / Binsar | dr. Brian Eka Rachman, Sp.PD | dr. Husin Thamrin, Sp.PD, K-GEH | IGD | KRS | ||
29 | 19 | Nn. Nanda Wardatul / 20 th / 10876644 | 22/11 | Thalassemia Beta Mayor + Anemia Hipokromik Mikrositik (Hb 6.7) | Alfan / Binsar | dr. Pradana Zaky Romadhon, Sp.PD, KHOM | POSA | |||
30 | 20 | Nn. Anggraeni / 18 th / 12778539 | 21/11 | Thalassemia Beta Mayor + Anemia (Hb 7.4) | Nabila / Binsar | dr. Pradana Zaky Romadhon, Sp.PD, KHOM | POSA | |||
31 | 21 | Nn. Amanah Rizkiyatul / 19 th/ 12878453 | 21/11 | Lupus Nefritis + Systemic Lupus Erithematosus Post Cyclo Siklus ke 3 (21/10) + Transverse Myelitis + Hipoalbuminemia (2.72) + HT stage I INASH 2021 | Alvin / Binsar | Dr. dr. Lita Diah, Sp.PD, K-R | Poli Remato | |||
32 | 22 | |||||||||
33 | Tn. Ahmad Syauqi / 20 th / 12711706 | 22/11 | Thalassemia Beta Mayor + Anemia Hipokromik Mikrositik (Hb 6.4) | Rita / Daviq | dr. Pradana Zaky, Sp.PD, K-HOM | POSA | KRS | |||
34 | 23 | Ny. Ismaria Tutik/ 48th/ 13036801 | 20/11 | Cholangitis + Choledocolithiasis Post ERCP (K80.5) + Trombositosis (622.000) Pro Evaluasi (D75.2) + DMT2 Teregulasi (E10.9) + Hipoalbuminemia (3,26) (R77.0) | Alfan / Binsar | dr. Annisa Zahra, Sp.PD | Poli GEH | |||
35 | 24 | |||||||||
36 | Ny. Lies Ratna Budiwati/ 64th/ 13021173 | 18/11 | Myelofibrosis (JAK2 terdeteksi) + Anemia normokromik normositer (Hb 5.7; 7.9 ; 9.9, MCV 87.7; 85.3 ; 81.5 MCHC 30.6 ; 31 ; 32.7) + s. ISK + Inkontinensia urin + Post Hematemesis et Post Hematuria + Dextroscoliosis thoracalis + Suspek anemic heart disease + Post Stroke ICH (Okt 2023) + Post Stroke Epilepsi | Alvin / Binsar | Prof. Dr. dr. S. Ugroseno Y.B. Sp.PD K-HOM | Neuro | IGD | KRS | ||
37 | 25 | |||||||||
38 | 26 | Nn. Sella Putri Lestari/ 24th/ 12663366 | 18/11 | Colitis TB on OAT + Enteropati artritis + Anemia hipokromik mikrositer (Hb 9.8; MCV 60.7; MCH 18.9) + Spondiloarthrophaty + Tendocitis Achiles dextra + Leukositosis pro evaluasi (WBC 19.690; Neut% 93) + Pemanjangan FH jalur intrinsik (APTT 40.6) + Hipokalemia (K 3.0) + RBBB inkomplit + Right axis deviation ec suspek RVH | Vidya / Daviq | Dr. dr. Awalia Sp.PD K-R | IGD | |||
39 | 27 | Tn. Sujono/ 33th/ 13048101 | 18/11 | CML fase kronis (myeloblast 7%) + Anemia normokrom normositer (Hb 7.8; 9.7) + Trombositosis (PLT 1.092.000 ; 861.000) + Hipokalemia terkoreksi (K 3.4 ; 4) | Vidya / Daviq | dr. Pradana Zaky Romadhon, Sp.PD, KHOM | IGD | |||
40 | BOR TOTAL = 26/25 (104%) ( 25 IPD, 1 KULIT) | |||||||||