Denah Pasien Ruang Rawat Intermediet 2

Hari/tanggal :Selasa/1 Oktober 2015Tim WH :dr. Ricky/dr. ArieDM :Ade/Yoga/Ivanda

DPJP : dr. Vera, Sp.PDDR : dr. RickyDM :

DPJP : dr. Vera, Sp.PDDR : dr. RickyDM :

2 4 DPJP : dr. Vera, Sp.PDDR : dr. RickyDM :

DPJP : dr. Vera, Sp.PDDR : dr. RickyDM :

A.Nama: RamliUmur: 67 thnCM: 1067098Hari Rawatan: 6

Ass/1. penurunan kesadaran

e.c. DD/1. sepsis berat2. imbalance

elektrolit2. sepsis berat e.c DD/

1. Urosepsis2. Pneumonia

3. PSMBA e.c DD/1. Gastritis erosif2. Ulkus Gaster3. Varises bleeding4. Gastropasti

Hipertensi portal4.Anemia Berat e.c DD/

1. perdarahan2. def. Fe

5. DD/ 1. Acute On CKD 2. CKD stage 5 e.c. PGOI6. hipoalbuminemia

B.Nama: SyafruddinUmur :58 thnCM: 0965408HariRawatan:

Ass/1. Candidiasis oral2. Anemia aplastik3. Pneumonia dd/ TB paru

dengan infeksi sekunder4. Dispepsia tipe mixed

dd/ 1. Tipe dismotility 2. Tipe like ulcer

5. DM Tipe 2 normoweight

A. Nama: SugiantoUmur :52thnCM: 1071881HariRawatan:

Ass/1. CKD Stage V e.c PNC on HD

reguler2. Hipokaliemi Sedang3. Susp. Lesi Intrakranial (Stroke

Iskemik)

B.Nama:SafriUmur :50thnCM: 0989919HariRawatan:

Ass/1. Penurunan Kesadaran e.c

Uremic enselopati2. dd/ 1. AKI Stage 3

2. Akut on CKD3. TB Paru on terapi4. Hiper uraemia5. Post Nefrektomi Dex dengan

Vistula mukokutan6. Hiperkalemia Ringan

DPJP : dr. Vera, Sp.PDDR : dr. RickyDM :

DPJP : dr. Vera, Sp.PDDR : dr. RickyDM :

DPJP : dr. Vera, Sp.PDDR : dr. RickyDM :Atikah

4 5 DPJP : dr. Vera, Sp.PDDR : dr. ArieDM :

DPJP : dr. Vera, Sp.PDDR : dr. ArieDM :

DPJP : dr. Vera, Sp.PDDR : dr. ArieDM :

DPJP : dr. Vera, Sp.PDDR : dr. RickyDM :

DPJP : dr. Vera, Sp.PDDR :dr. RickyDM :

1

A.Nama: Nur AiniUmur : 52 thnCM: 0679138Hari Rawatan:4

Ass/1. post hipoglikemia e.c.

glibenklamide2. 2. Hipertensi terkontrol3. Anemia sedang hipokrom

mikrositer.4. DM tipe 2 normoweight

B.Nama: Zakaria HamkaUmur : 68 thnCM: 0982729Hari Rawatan:2

Ass/1. Hiccup ec:

dd: 1. GERD 2 Tumor Paru Dextra 3 Tumor Media Stenum

Superior

C.Nama:Ari harnidaUmur:28thnCM:1072237Hari rawatan:

Ass/1.Efusi Pleura Sin ec DD/ 1.pleura Pneumonia 2.pleuritis TB 3.Hipoalbuminemia2.Bisitopenia ec DD/ 1.CML 2.Myelofibrosis 3.Auto imun Deases

D.Nama: HasanUmur: 64 thnCM : 1072576Hari rawatan: 5

Ass/1.Massa at regio colli dextra e.c.DD/1. Carsinoma nasofaring2. Limpom Maligna3.Ca Parotis4.Ca.Laring5.Metastase Proses2. HT Stage 13.AKI Stage II

E.Nama:NasruddinUmur:35thnCM:0976607Hari rawatan: 4

Ass/1. PSMBA ec dd/ 1.gastritis Erosif 2.Uremic Bleeding 3.Ulkus Gaster 4.ulkus duodenum2. CKD ST.5 on HD Reg.3. HT stg.14.Anemia Berat ec.PGK5.Asites Permagna ec dd/ 1.Sirosis Hepatik std.DC 2.TB peritonial 3.Hipoalbuminemia

A. Nama : Agus MaulanaUmur: 20 thnCM: 1071561Hari rawatan: 23

Ass/1. dd/ 1. CML

2. CLL1. Cancer pain

(VAS 5-6)

B.Nama : Samsul BahriUmur: 42thnCM: 1070099Hari rawatan:

Ass/1. Hepatoma dd/ 1. Kista Hepar 2. Metastase Proses2. Gastritis antral sedang3. Anemia sedang hipokrom normositik ec dd/ 1. Defisiensi Fe 2. Penyakit kronik4. Stomatitis (perbaikan)5. Cancer pain(VAS 5-6)

C. Nama:Ilyas IbrahimUmur :70thnCM:1072062Hari Rawatan :

Ass/1.Nyeri Suprapubik DD/ 1.ISK 2.BSK2.Dispepsia DD/ 1.Tipe like User 2.Dismotility 3.Mixed3.OA Lumbal4.Pneumonia5.BPH

DPJP : dr. Vera, Sp.PDDR : dr. ArieDM :

DPJP : dr. Vera, Sp.PDDR : dr. ArieDM :

5 7 DPJP : dr. Vera, Sp.PDDR : dr. ArieDM :

DPJP : dr. Vera, Sp.PDDR : dr. ArieDM :

D.Nama:M. NasirUmur :64thnCM: 1065602HariRawatan:

Ass/1. PSMBA e.c DD/

1. Gastritis erosi2. Ulkus Peptikum3. Varises bleeding4. Gastropasti

Hipertensi portal2. Pnemonia dd TB

paru3. Infeksi Skunder4. Hiponatremi

E.Nama : Abdullah BasyahUmur :60 tahunCM : 0824883Hari Rawatan :

Ass/1. Pansitopenia ec

dd/1. Anemia aplastik2. MDS3. Mielofibrosis

2. dd/ 1. Pneumonia 2. TB paru

dengan infeksi sekunder

3. PPOK stabil4. AF NVR5. Geriatri problem

(inanisi, impairment of hearing)

6. Hipoalbuminemia (3,54)

A.Nama: HasballahUmur: 62 thnCM: 1096225Hari Rawatan:

Ass/1.Paraparese

extremitas inferior ec dd/1. Infiltrasi tlg belakang2. HNP

2.Post kemoterapi siklus ke III dg regimen CHOP

3.dd/ 1. Pneumonia 2. TB Paru dg infeksi sekunder

4.Anemia ringan normokrom normositer ec dd/1. Penyakit kronis2. Defisiensi fe

5.DM Tipe II normoweight

6.OA lumbal

B.Nama: Syahbuddin SulaimanUmur: 59 thnCM: 1072457Hari Rawatan:

Ass/1. Sirosis hepatis

stadium DC dgn hepatoma

2. DM Tipe 2 normoweight

DPJP : dr. Vera, Sp.PDDR : dr. ArieDM :

DPJP Bedah 8 10 DPJP : dr. Vera, Sp.PDDR : dr. ArieDM :

DPJP : dr. Vera, Sp.PDDR : dr. RickyDM :

A.Nama : DarmawaniUmur : 62 thnCM : 1072251Hari Rawatan : 7

Ass/1. Sepsis ec ulkus diabetikum dg celulitis a/r pedis sinistra2. Ulkus diabetikum a/r pedis sinistra3. DM Tipe 2 overweight4. Anemia normokrom normositer ec dd/ 1. Penyakit kronis 2. Perdarahan5. Neuropati diabetikum

B.Nama : ZurainiUmur :40 thnCM : 0862829Hari Rawatan :

Ass/1. Ca mama ain

Stage IV metafase Tulang

2. Dispepsia

ISO 1.Nama: NurliansyahUmur: 64 thnCM: 0936511Harirawatan:

Ass/1.Sepsis ec dd/

1. Pneumonia2. urosepsis

2.Pneumonia dd/ TB paru dengan infeksi sekunder

3.Dispepsia tipe dismotility dd/1. Tipe mixed

3. Tipe like ulcer

4.Hipertensi terkontrol

5.CHF FC NYHA II ec dd/1. HHD2. IHD

6.Hipokalemia sedang (2,5)

7.Geriatri problem (infeksi, inanisi, incontinensia, risiko jatuh)

2.Nama: BadriahUmur: 54 thnCM: 1072591Hari rawatan:

Ass/1. Dispepsia dd/

1. Tipe like ulcer2. Tipe dismotility3. Tipe mixed

2. dd/ 1. CML 2. CLL

3. Hipokalemia sedang

4. Hiponatremia hipoosmolar euvolemik