Mapping
Mapping
A/ A/ A/ A/ A/
1. CKD stage V dengan 1. Ulkus ar cruris dextra et 1. Ulkus dekubitus ar 1. CKD Stage V On HD 1. Diare kronik ec dd/
uremic syndrome sinistra pedis sinistra reguler -Ca. Recti
( perbaikan) dd PNC, HN 2. AKI stage 3 dd acute on 2. DM tipe 2 NW 2. Hernia umbilical 2. Anemia berat hipokrom
2. Anemia berat HM ec dd CKD 3. Anemia berat NN ec irreponible mikrositer ec perdarahan
Penyakit kronis 3. Dyspepsia type dd (perbaikan)
3. Hipertensi grade II (on dimotility dd type mixed - Perdarahan Th/ 2. Status koagulasi dengan
therapy) 4. Gout Arthritis kronik (perbaikan) - Bed rest manifestasi perdarahan
dengan multiple tofus - Penyakit kronis - O2 2-4 lpm (perbaikan)
Th/ 5. Anemia ringan NN ec 4. AKI stage I pre renal - Three way 3. Candidiasis oral
- Bedrest dd/ ec dd - Diet ginjal 1700 kkal/ ( perbaikan)
- Diet ginjal 1700 – penyakit kronis - Dehidrasi hari + 24 gram
kkal/hari + 50 gram – perdarahan - infeksi protein Th/
protein 6. Diare kronik ec dd: - Lenal ace 2x169 1. Bed rest
- threeway -clostridium difficle - Asam folat 2x400mg 2. Diet MB 1700
- IV lansoprazole -chrons desease Th/ - Alprazolam 0,25mg kkal/hari
30mg/12jam -IBD - Bed rest extra 3. IVFD futrolit 1 fls/ hari
- IV ondansetron - Diet DM 1700 kkal/hari - Kalitake 4. IV omeprazole 40
4mg/12jam - transfusi PRC 1 kolf - HD ( selasa dan mg/12 jam
- Lenal ace 2x169mg Th/ - IVFD Futrolit 1 fls/hari jumat) 5. IV transamin 500mg/8
- Asam folat 2x400mg - Bedrest - IV ceftriaxone 2gr/24jam jam
- Amlodipine 1x10mg - Diet ginjal 1700 kkal - IV lansoprazole 30mg/24j Lab 19-09-2019 6. Hemorrhoid sup 3x2
- Paracetamol 1 gr (extra) - IVFD Nacl 0,9% 20 tpm - Metronidazole 500mg/ 8j Hb/HT/E/L/T: 7. Atalpulgit 1 tab/x
- HD selasa jumat - O2 2-4 lpm nk - Lantus 0-0-0-10 10,9/31/3,3/7,6/185 mencret maks 12
- IV Omeprazole - Asetilsistein 3x200 mg MCV/MCH/MCHC : tab/hari
Lab 21/09/2019 40mg/12jam - Domperidone 3x10 mg 93/33/35 8. Drip metronidazole
Hb/Ht/E/T/L : 7,9/22/2,8/115/12,1 - Synbio 3x1 - Xarelto 15mg/24jam Diftel: 2/0/0/74/14/10 500mg/8jam
MCV/MCH/MCHC : 77/28/37 - Metoclopramide ½ - Futrolit 1 fls 24 jam Albumin : 3,5 9. Drip Fluconazole
Diftel : 1/1/0/80/8/10
Ca : 6,3
amp/8jam - Xarelto 15 mg / 24 jam Ur/cr : 181/10,8 200mg/hari
Ur/cr : 175/17,00 - IV Ceftriaxone Na/K/Cl : 139/5,9/104 10. Nystatin 2cc/6j
Na/K/Cl : 137/3,3/104 2gr/24jam Lab 21-09-2019 11. Paracetamol
- Lenal ace 169mg/12jam HB/HT/E/L/T: 500mg/8jam
Lab 19/09/2019 - Asam folat 8,3/26/3,3/6,6/361
Urinalisa 400mg/12jam MCV/MCH/MCHC : Lab 20-09-2019
Warna : kuning - Bicnat 500mg/8jam 80/26/32 HB/HT/E/L/T:
Kejernihan : jernih - Fluimucyl 200mg/8jam Diftel: 2/1/0/88/72/0 10,3/32/4,5/15,8/694
Berat jenis : 1,012 - Allupurinol Ca : 7,6 MCV/MCH/MCHC :72/23/32
Ph: 6,0 300mg/24jam Ur/cr : 16/1,00 Diftel:2/0/0/79/12/7
Leukosit : + - Clindamisin Na/K/Cl : 139/4,3110 Na/K/Cl:142/3,6/107
Protein : +3 300mg/8jam
Glukosa : +1 - Attapulgit 1 tab/BAB Lab 20-09-2019 Lab 19-09-2019
Keton : - - Ondansetron 8 mg/8 HB/HT/E/L/T: HB/HT/E/L/T:
Nitrit : - jam 6,9/23/2,9/6,7/386 8,1/27/3,8/11,1/635
Urobilinogen : - MCV/MCH/MCHC : MCV/MCH/MCHC : 70/21/31
Bilirubin :- Lab(20-09-19) 80/24/30
Darah : + HB/HT/E/L/T: 9,8/30/3,3/314/14,2
Diftel: 103/0/0/64/17/9 Lab 15-09-2019
MCV/MCH/MCHC : 90/30/33
Diftel:6/1/0/58/27/8 MDT : Normokrom HB/HT/E/L/T:
Lab 16/09/2019 pt: pasien/control/inr: Anisositosis dengan 8,4/27/3,8/20,8/569
Hb/Ht/E/L/T: 14,00/13,9/0,99 eusiofilia MCV/MCH/MCHC : 70/22/31
MCV/MCH/MCHC: APTT: pasien/control Kolesterol
35,80/34,3
Diftel: Total/HDL/LDL/TG : Lab 13-09-2019
Anti HCV: neg
PT pasien/control/INR: HbSAg: non reaktif 82/49/488/50 Anti HCV : negative
15,70/13,3/1,11 Ur/Cr: 51/2,50 HBsAG : non reaktif
APTT pasien/control: Na/K/Cl: 142/4,6/111 Lab 17-09-2019
32,50/33,9 HB/HT/E/L/T: Lab 13-09-2019
Lab(18-09-19)
Ur/Cr : 51/6,5 5/16/1,9/14,8/418 HB/HT/E/L/T:
Ur/Cr: MCV/MCH/MCHC : 9,5/30/4,3/21,1/610
Na/K/Cl: Urinalisa(16-09-19) 83/26/31 MCV/MCH/MCHC : 69/22/32
Warna : kuning jernih Diftel: 3/0/0/78/9/10 Diftel: 3/1/0/81/8/7
Leukosit : (+) 6-8
GDS: 113 Ur/Cr : 12/0,6
Lab 16-09-2019 Ur/cr: 48/1,3 PT/APTT : 0,93/5,37
Asam urat : 13,8 Na/K/Cl :139/4/111 GDS : 96
Lab 15-09-2019 NA/K/Cl : 140/3,7/107
HB/HT/E/L/T: 9,1/29/3,3/13,4/462
MCV/MCH/MCHC : 89/29/33
Diftel: 6/1/1/56/27/9
Albumin : 2,70
Ur/Cr : 44/2,30
Na/K/Cl : 134/5,1/100
Lab 18/09/2019
Hb/Ht/E/L/T:
12,3/40/6,7/10,4/140
MCV/MCH/MCHC: 61/19/31
Diftel: 3/0/0/82/10/5
Anti HCV : negatif
HbsAg : non reaktif
AGDA
pH: 7,468
pCO2: 39,80
pO2: 48
HCO3: 29,1
Total CO2: 30,3
Kelebihan basa (BE): 5,6
Saturasi O2: 85,5
Ur/cr : 172/1,90
Albumin: 3,10
Na/K/Cl : 168/3,9/131