Mapping_PDW_26_Juni_2015.docx
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Denah Pasien Ruang Rawat Penyakit Dalam Wanita (Mamplam 2) Hari/tanggal : Jumat/ 26 Juni 2015 Tim jaga : dr. Meta/dr. Nadi Dokter Muda : Chairatu/Cut Nova/Marezzy/Riza M./Lia/Febi/Fitara/Musyawarah/Putri W./Lili/Fera DPJP : dr. Eva,Sp.PD PPDS : dr. Nadi DM: DPJP : dr. Eva M, Sp.PD PPDS : dr. Nadi DM: 1.Nuraini A Rahman,53 th, 1056427 Hari rawatan : 4 Ass/ 1.CAP dd/ TB paru dgn inf sekunder 2.Dispepsia tipe dismortilty dd/ 1. mixed 2.tipe like ulcer 2.Hasuna Amin,84 tn,1056426 Hari rawatan: 5 Ass/ 1.SDA dgn pencetus 1.infeksi 2.imbalance elektrolit 3.mulnutrisi 2.Ulkus decubitus ar gluteus dextra + sakrum grd 3 3.Hipokalemia 4.Hipolbuminemia 5.Demensia 6.Geriatri Problem (Incontinensia urine et alvi, inanisi, imobilisasi, infeksi, impairment of hearing and vision) 7.ISK 8. Hipertensi Stage I 9. Trombositosis reaktif DPJP : dr. Price Maya, Sp.PD PPDS : dr. Reza DM: DPJP : dr. Price Maya, Sp.PD PPDS : dr. Reza DM: 8 7 DPJP : dr. Chacha M, Sp.PD PPDS : dr. Yuni DM: DPJP: dr Chacha M, Sp.PD DR: dr.Yuni DM : 1/ 2/.Suwita, 42 th, CM: 1031485 Hari rawatan: 8 Ass/ 1. dd/ 1. Syok sepsis 2. Syok kardiogenik 3. Syok hipovolemik 2.Ca Mammae Stad. IV post kemoterapi siklus IV metastase ke otak dan tulang belakang 3.Febrile neutropenia (perbaikan) 4.HCAP 5.ISK 6. Anemia ringan ec dd/ 1. Penyakit kronis 2. Perdarahan 7. Hipoalbuminemia 8. Hipokalemia ringan 1/ Yusnawati, 51 tahun, 1055404 Hari rawatan : 15 Ass/ 1. CKD Stage 5 ec PNC on HD regular 2. Cystitis 3. Anemia sedang ec dd/ 1. Penyakit kronik 2. Perdarahan 4. Hipoalbuminemia 5. HT on therapy 6. dd/ 1. Pneumonia 2. TB Paru 3. Bronkhitis 7. DD/ PJA 8. Konstipasi 9. Highrisk trombosis 2. Cut Indayani, 47 tahun, 0773805 Hari rawatan: 14 Ass/ 1. CML 2. AKI stage I 3. CHF FC NYHA I-II ec PJA 4. Hiperferitinemia 5. hipokalemia 6. Hippoalbuminemia 7. Stomatitis DPJP : dr. Eva M, Sp.PD PPDS : dr. Nadi DM: DPJP : dr. Eva,Sp.PD PPDS : dr. Nadi DM: DPJP: dr. Eva M, Sp.PD PPDS: dr. Nadi DM: 6 5 DPJP : dr. Price Maya , Sp.PD PPDS : dr. Reza DM: DPJP : dr. Price Maya, Sp.PD PPDS : dr.Reza DM: DPJP: dr. Price Maya, Sp.PD PPDS : dr.Reza DM : 1/ Dasriani, 21th, 1056595 Hari rawatan : 2 Ass/ 1. Hipotensi dd/ syok hipovolemik 2. Dyspepsia tipe dd/ 1. Dismotility 2. Mixed 3. Like ulcer 3. Luka terinfeksi post op closure wasting a/i Hirschprung disease 4. Konstipasi 2. Nyak puteh, 78 th, 1056686 Hari rawatan: 2 Ass/ 1. Massa a/r abdomen ec dd/ 1. Ca ovarium 2. Ca colon 3. Limfoma Maligna 2. Efusi pleura dd/ massa paru 3. Stroke iskemik 4. Anemia ringan : normokrom normositer ec dd/ 1. Penyakit kronis 2. Perdarahan 5. Hipokalemia ringan 3. Fauziah, 54 th 1055980 Hari rawatan : 8 Ass/ 1. Hematoscezia ec dd/ 1. Tumor recto sigmoid 2. Metastase proses 2. Metastase proses di ovarium dd/ Ca Ovarium 3. Post histerektomi ai Ca Serviks 4. Anemia 1. Nani Mariani, 60 th, 1056646 Hari rawatan : 2 Ass/ 1. Ulkus diabetik ar Pedis Sin P1E15x10D1I4S2 2. DM Tipe 2 overweight 3. Hipertens i on terapi 4. Neuropati diabetik 5. Hiponatrm ia hiperosmolar euvolemik 2. 3.
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Transcript of Mapping_PDW_26_Juni_2015.docx
Denah Pasien Ruang Rawat Penyakit Dalam Wanita (Mamplam 2)
Denah Pasien Ruang Rawat Penyakit Dalam Wanita (Mamplam 2)
Hari/tanggal: Jumat/ 26 Juni 2015Tim jaga: dr. Meta/dr. NadiDokter Muda: Chairatu/Cut Nova/Marezzy/Riza M./Lia/Febi/Fitara/Musyawarah/Putri W./Lili/Fera
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DPJP : dr. Eva,Sp.PDPPDS : dr. NadiDM:DPJP : dr. Eva M, Sp.PDPPDS : dr. NadiDM:
1.Nuraini A Rahman,53 th, 1056427Hari rawatan : 4Ass/1.CAP dd/ TB paru dgn inf sekunder2.Dispepsia tipe dismortilty dd/ 1. mixed 2.tipe like ulcer2.Hasuna Amin,84 tn,1056426Hari rawatan: 5Ass/1.SDA dgn pencetus 1.infeksi 2.imbalance elektrolit 3.mulnutrisi2.Ulkus decubitus ar gluteus dextra + sakrum grd 33.Hipokalemia4.Hipolbuminemia5.Demensia6.Geriatri Problem (Incontinensia urine et alvi, inanisi, imobilisasi, infeksi, impairment of hearing and vision)7.ISK8. Hipertensi Stage I9. Trombositosis reaktif
DPJP : dr. Price Maya, Sp.PDPPDS : dr. RezaDM:DPJP : dr. Price Maya, Sp.PDPPDS : dr. RezaDM:8 7DPJP : dr. Chacha M, Sp.PDPPDS : dr. YuniDM:DPJP: dr Chacha M, Sp.PDDR: dr.YuniDM :
1/
2/.Suwita, 42 th, CM: 1031485Hari rawatan: 8
Ass/ 1. dd/ 1. Syok sepsis 2. Syok kardiogenik 3. Syok hipovolemik2. Ca Mammae Stad. IV post kemoterapi siklus IV metastase ke otak dan tulang belakang3. Febrile neutropenia (perbaikan)4. HCAP5. ISK6. Anemia ringan ec dd/ 1. Penyakit kronis 2. Perdarahan7. Hipoalbuminemia8. Hipokalemia ringan1/ Yusnawati, 51 tahun, 1055404Hari rawatan : 15
Ass/ 1. CKD Stage 5 ec PNC on HD regular2. Cystitis3. Anemia sedang ec dd/ 1. Penyakit kronik 2. Perdarahan4. Hipoalbuminemia5. HT on therapy6. dd/ 1. Pneumonia 2. TB Paru 3. Bronkhitis7. DD/ PJA8. Konstipasi9. Highrisk trombosis2. Cut Indayani, 47 tahun, 0773805Hari rawatan: 14
Ass/1. CML2. AKI stage I 3. CHF FC NYHA I-II ec PJA4. Hiperferitinemia5. hipokalemia6. Hippoalbuminemia7. Stomatitis
DPJP : dr. Eva M, Sp.PDPPDS : dr. NadiDM:DPJP : dr. Eva,Sp.PDPPDS : dr. NadiDM:DPJP: dr. Eva M, Sp.PDPPDS: dr. NadiDM:6 5DPJP : dr. Price Maya , Sp.PDPPDS : dr. RezaDM:DPJP : dr. Price Maya, Sp.PDPPDS : dr.RezaDM:DPJP: dr. Price Maya, Sp.PDPPDS : dr.RezaDM :
1/ Dasriani, 21th, 1056595Hari rawatan : 2
Ass/1. Hipotensi dd/ syok hipovolemik2. Dyspepsia tipe dd/ 1. Dismotility 2. Mixed 3. Like ulcer3. Luka terinfeksi post op closure wasting a/i Hirschprung disease4. Konstipasi2. Nyak puteh, 78 th, 1056686Hari rawatan: 2
Ass/1. Massa a/r abdomen ec dd/1. Ca ovarium2. Ca colon3. Limfoma Maligna2. Efusi pleura dd/ massa paru3. Stroke iskemik4. Anemia ringan : normokrom normositer ec dd/ 1. Penyakit kronis2. Perdarahan 5. Hipokalemia ringan6. Geriatric problem (impairment of vision, malnutrisi)3. Fauziah, 54 th1055980Hari rawatan : 8
Ass/1. Hematoscezia ec dd/ 1. Tumor recto sigmoid 2. Metastase proses2. Metastase proses di ovarium dd/ Ca Ovarium3. Post histerektomi ai Ca Serviks4. Anemia sedang ec dd/ 1. Perdarahan 2. Malignancy5. Hipoalbuminemia6. Hipokalemia 1. Nani Mariani, 60 th, 1056646Hari rawatan : 2
Ass/1. Ulkus diabetik ar Pedis Sin P1E15x10D1I4S22. DM Tipe 2 overweight3. Hipertensi on terapi4. Neuropati diabetik5. Hiponatrmia hiperosmolar euvolemik
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DPJP : dr. Eva,Sp.PDDR : dr. NadiDM :DPJP: dr. Eva M, Sp.PDDR: dr. Nadi
DPJP : dr. Price Maya, Sp.PDDR : dr. Reza
DPJP : dr. Price Maya, Sp.PDDR : dr. Reza
4. 5. Cek Maryam, 68 th, 1055325Hari rawatan: 2
Ass/1.Massa di bronkus ec dd Ca Bronkogenik2. TB paru3. Hepatitis B kronis
4. Rohani Ali, 49 thCM: 1055595Hari rawatan: 10
Ass/1. Sepsis ec dd/ 1. Urosepsis 2. Pneumonia2. CKD stage V ec PGOI on HD3 ISK4.DD 1. HAP 2. TB paru dengan sekunder infeksi5. Anemia sedang ec dd/ 1. Penyakit kronik 2. Perdarahan6. Nefrolitiasis bilateral7. Hidronefrosis grade IV Dextra8. Hipoalbuminemia9. Post nefroctomy dextra a/I hidronefrosis grade IV Dextra5.Saudah Maun, 69 th, 984040Hari rawatan: 1
Ass/1. Anemia aplastik2. PSMBA ec dd/ 1. Drug induced2. Gastritis erosive3. Ulkus gaster3. AF RVR
DPJP : dr. Chacha M, Sp.PDDR : dr. YuniDM :DPJP : dr. Chacha M, Sp.PDDR : dr. YuniDMDPJP : dr. Chacha M, Sp.PDDR : dr. Yuni
4 3DPJP: dr. Islamuddin, Sp.PDDR : dr. Andrie
DPJP : dr. Islamuddin, Sp.PDDR : dr. Andrie
DPJP : dr. Islamuddin, Sp.PDDR : dr. Reza
1/ Nafsah Majid, 49 th, 1055895Hari rawatan : 10
Ass/1. Ca caput pankreas metastase hepar dan usus Stadium IV2. Cholestasis ekstra hepatik3. Hipoalbuminemia4. Hipokalemia ringan5. Trombositosis reaktif6. High risk thrombosis7. Pneumonia (HAP)8. Konstipasi9. Dislipidemia
2. Citra Aruna, 31 th, 1054546Hari rawatan : 21
Ass/1. CKD stage 5 ec PNC2. Atelektasis paru Sinistra ec dd/ Massa paru3. Ostegenesis imperfecta4.. Efusi pleura sinistra ec dd/ - parapneumonia - plueritis TB5. Pneumonia 6. Trombositosis ec dd/ trombositosis reaktif7.Hipoalbuminemia8.ISK9.Hiperurisemia10.Hipertensi on terapi11.Hipokalemia3/ 1. Laila, 41 th, cm: 1055415Hari rawatan : 14
Ass/1.Hidronefrosis Bilateral 2. Cancer pain3. Anemia Sedang ec dd/ 1. Penyakit kronis 2. Def. Fe4. AKI stage 3 DD akut on CKD5.ISK6. Ca Serviks post kemoterapi7. Obstruksi ureter kanan
2. Salamah, 45 thn, 1047803Hari rawatan: 22
Ass/ 1. AKD on HD reguler2. Hipokalemia3. Hipoalbuminemia 4. Anemia ringan ec peny.kronik 5. Hemangioma di colon transversum6. Multiple polip di colon descendens7. Divertikel dicolon sigmoid8. Dispepsia tipe like ulcer3. Salbiah, 63 th, 1003864Hari rawatan : 2
Ass/1. Anemia Aplastik2. Limfadenopati ec dd/ 1. Limfadenopati TB2. Viral infection3. Limfoma maligna
DPJP : dr. Chacha M, Sp.PDDR : dr. YuniDM :DPJP : dr. Chacha M, Sp.PDDR : dr. YuniDPJP : dr. M. Fuad, SP.PDDR : dr. AndrieDM: DPJP: dr. Islamuddin, Sp.PDDR : dr. Andrie
4. Huriah, 56 th1056020Hari rawatan : 9
Ass/1. Massa intraabdomen ec dd/ 1.Ca ovarium 2.Ca colon 3.Limfoma malignansi 4. Ca cervix2. Efusi pleura dextradd/ 1. Malignancy 2. Para pneumonia 3. Tb paru 4. Hipoalbumin3. DM tipe II normoweight4. Ulkus diabetikum a/r pedis Dex5. Iskemik septal6. hipokalemia7. hipoalbuminemia8. high risk thrombosis9. dd/ 1. Ca mammae 2. FAM10. HAP11. ISK5. Nurniati, 47 th, 1055333Hari rawatan: 2
Ass/ 1. Reumathoid arthritis 4. Murni, 45 th, 1056594Hari rawatan : 1
Ass/1. Sirosis hepatis Stad. DC related Hepatitis B2. AKI Stage I dd/ Hepato-renal Syndrome3. Hiponatremia normoosmolar hipervolemik4. dd/ 1. HAP 2. TB Paru dengan Infeksi Sekunder5. Konstipasi
5.Sulasmi,20 th, 1056432Hari rawatan : 4Ass/1. CKD Stage 5 ec dd/ 1.GNC 2.Nefritis Lupus2. dd/ 1. Pneumonia (HAP) ; 2. TB Paru ; 3.Mikosis Paru3. Hipertensi stage I on terapy4. Anemia berat ec dd/ 1. peny kronik 2. perdarahan5. Hiperkalemia6. Hipoalbuminemia
DPJP : dr. Islamuddin,Sp.PDPPDS : dr. AndrieDM:
DPJP : dr. Eva M ,Sp.PDDR : dr. RezaDM:2 1DPJP : dr.Islamuddin,Sp.PDDR : dr. AndrieDMDPJP : dr. Chacha M, Sp.PDPPDS : dr. AndrieDM:
1/Nurbayani, 46 th, 495773Hari rawatan : 2
Ass/1. CKD stage III dd akut on CKD2. DM tipe 2 obese grade I3. Anemia4. Hipertensi stage I 2. Hissa Arfira,18 th,1054498Hari rawatan : 4
Ass/1.Grave Disease2.Grave Optalmopathy1/Rahmati, 21 th, 1056756Hari rawatan: 2
Ass/1. SLE
2.Cut Rukiah, 73 th 1048919Hari rawatan: 12
Ass/1. DD/ 1 Pneumonia (HCAP) 2. TB paru dengan infeksi 3. Mikosis paru2. Ulkus multiple ar gaster3. candidiasis orofaring 4. HHD5. spondilosis lumbalis6. Fraktur tibia sinistra7. Geriatri Problem: inanisi, imobilisasi, depresi, infeksi, instabilitasdanjatuh8.Hepatitis B kronis9. Brain atrophy10. Hipoalbumin 11. Hipokalemia 12. White matter disease
