mapping pdw minggu 11 mei 2015

3
9 DPJP : dr.Eva M, Sp.PD PPDS : dr. Ahdiah DM: DPJP : dr. Eva M, Sp.PD PPDS : dr. Ahdiah DM: 1./Mariani Yusuf, 58 tahun, 0906175 Ass/ 1. Penurunan Kesadaran ec. Dd/ 1). HE grade I 2). Sepsis e.c CAP 3). Stroke 2. syok sepsis ec CAP 3. Sirosis Hepatis Stad. Decompensata 4. Bradikardi 5. Hiperkalemia Sdang 6. CAP 7 AKI stage 3 pre Renal dd Hepatorenal Sindrom 8. Konstipasi 2./Nilawati TH, 60 tahun, 1003548 Ass/ 1. Ulkus diabetikum a.r cruris sin 2. DM tipe 2 obese grade I 3. Ulcus decubitus grade 1 4. CHF FC NYHA II e.c HHD 5.Hipertensi 6. OMI anteroseptal 7. Dispepsia tipe like ulcer DPJP : dr. Chacha M, Sp.PD PPDS : dr. andrie DM: DPJP :dr. Chacha M, Sp.PD PPDS : dr. Reza DM: 8 7 DPJP : dr. M. Fuad, Sp.PD PPDS : dr. Ahdiah DM: DPJP:dr. M. Fuad,Sp.PD DR:dr. Ahdiah 1)Mardiana, 68 tahun, 1050937 Ass/ 1.sepsis e c dd/1) ulkus diabetikum 2) pneumonia (HAP) 2.Ulcus diabetikum a.r pedis dextra 3.dd/1) Pneumonia 2) Tb paru dengan Infeksi Sekunder 3)mikosis paru 4. Anemia sedang e.c dd/ 1) perdarahan 2) penyakit kronik 3) defisiensi Fe 2./Syahtini,v65 tahun, 1031485 Ass/ 1.CKD stage 5 ec dd/1.PNC HD reguler 2.DM Tipe 2 Obese grade II 3.Abses a/r parietal 4. Abses a.r elbow joint 5.Ulkus diabetikus grade II 6.Iskemik anteroseptal 7.Cardio renal syndrom 8.anemia ringan e.c pey kronis 9. Hipoalbuminemia 10. Hipokalesemia 11. CAP 12. ISK 13.neuropati diabetikum 14.Spondilosis lumbalis 15.Retinopati diabetic ODS 16 Anxietas 1./Nurhayati Ismail,46 thn, 1015234 Ass/ 1. Selulitis a.r pedis (d) 2. DM type II normowheight 3.HT st II 4. Hipoalbuminemia 5. dyspepsia type like ulcer 6. stomatitis 7. anxietas 8. moderate MPDR 2. Asmawati, 54 thn, 0975637 Ass/ 1. Sepsis ec gangrene diabetikum a/r pedis sin 2. PAD 3. DM Tipe 2 obesitas grade I 4. dd/ 1). Gastropati diabetic 2). Dispepsia tipe like ulcer 3). Dispepsia tipe dismotility 5. Hipoalbuminemia 6. Dislipidemia 7. HT on Terapi 8. Moderate on PDR ODS 9. Post Amputasi Digiti II, III, IV pedis (S) hari ke 10 10. High risk thrombosis DPJP : dr. Eva M, Sp.PD PPDS : dr. Nadi DPJP :dr Desi S, Sp.PD PPDS : dr. Nadi DM: DPJP:dr.Eva M, Sp.PD PPDS: dr. Nadi DM: 6 5 DPJP :dr. Chacha , Sp.PD PPDS :dr. Reza DM: DPJP : dr. Chacha, Sp.PD PPDS : dr.Reza DM: DPJP: dr. Hendra Jufry, Sp.PD PPDS : dr.Reza 1/ Darmiana Yacob , 58 th , 1050220 Ass/ 1. Anemia ringan hipokrom mikrositer e.c dd/ 1)peny kronis 2) Infeksi parasit 2. CHF FC NYHA II ec dd/ 1) HHD 2) PJA 3. HT on terapi 4. OA lumbal 5. OA genu bilateral 6. nefrolithiasis dextra + hidronefrosis dextra 2/ Nurmalawati, 40 th, 1047824 Ass/ 1. Sepsis e.c dd / 1). Flebitis 2). Urosepsis 2. CKD stage V on HD regular e.c dd/ 1). HN 2). PNC 3). GMC 3. Anemia sedang e.c peny. Kronis 4. Hipertensi stage II 3/Nurmawati, 40 th , 105092 Ass/ 1. CKD st V ec dd/ 1) HN 2) DN + uremic syndrome 2. DM type II undewheight 3. hiperkalemia ringan 4. anemia ec peny kronis 5. Asidosis metabolic (perbaika) 6. DD/1). Pneumonia 2). TB paru dengan inf sekunder 1./ Fatimah syam, 64 thn 1049376 Ass/ 1. CKD stage 5 ec DN on + PNC on HD Reguler 2. CHF FC NYHA II – II e.c dd/ 1) PJK 2) HHD 3. HAP( perbaikan) 4.Iskemik anteroseptal 5. anemia e.c dd/1. Peny kronis 2. Perdarahan 6. DM type II normowheight 7. hipoalbuminemia 8. hipokalemia ringan 10. HT on therapy 11. retinopati diabetikum ODS 12. katarak sentralis ODS 13. geriatric 2./Salamah, 45 thn 1047803 Ass/ 1 KAD 2 CHF FC N 1-2 e.c dd/ -HHD -DCN 3.Hipoalbuminemia 4. Hipokalemia ringan . 5 Hiponatremia Hipoosmolar Hipovolemik 6. Anemia Ringan ec dd/ 1). Penyakit Kronis 2). Perdarahan 7. Diare kronike.c dd/ -IBS -Cholitis 8 ISK 9 Miliaria Kristalia 10 LBP 3./ Rannawati Ali Basyah, 45 thn, 0968987 Ass/ 1. Nodul tiroid D/S DenahPasienRuangRawatPenyakitDalam Wanita (Mamplam 2) Hari/tanggal :Selasa/ 12 Mei 2015 Tim jaga :dr.Hendra/dr.Yuni Dokter Muda :T.harmawansyah/Fingga/Aris/Riza/Khairunnisak/Yuli/Kiki

Upload: rizky-fachri

Post on 15-Jan-2016

222 views

Category:

Documents


0 download

DESCRIPTION

Mapping Pdw Minggu 11 Mei 2015

TRANSCRIPT

Page 1: Mapping Pdw Minggu 11 Mei 2015

DenahPasienRuangRawatPenyakitDalam Wanita (Mamplam 2) Hari/tanggal :Kamis malam /01Mei 2015Tim jaga :dr.Andri/dr.IrfanDokter Muda :Atika /Suci /Dinda /Yudi/Aris

9DPJP : dr.Eva M, Sp.PDPPDS : dr. AhdiahDM:

DPJP : dr. Eva M, Sp.PDPPDS : dr. AhdiahDM:

1./Mariani Yusuf, 58 tahun, 0906175Ass/1. Penurunan Kesadaran ec. Dd/

1). HE grade I2). Sepsis e.c CAP3). Stroke

2. syok sepsis ec CAP3. Sirosis Hepatis Stad. Decompensata4. Bradikardi5. Hiperkalemia Sdang6. CAP7 AKI stage 3 pre Renal dd Hepatorenal Sindrom8. Konstipasi

2./Nilawati TH, 60 tahun, 1003548Ass/1. Ulkus diabetikum a.r cruris sin2. DM tipe 2 obese grade I3. Ulcus decubitus grade 14. CHF FC NYHA II e.c HHD5.Hipertensi6. OMI anteroseptal7. Dispepsia tipe like ulcer

DPJP : dr. Chacha M, Sp.PDPPDS : dr. andrieDM:

DPJP :dr. Chacha M, Sp.PDPPDS : dr. RezaDM:

8 7DPJP : dr. M. Fuad, Sp.PDPPDS : dr. AhdiahDM:

DPJP:dr. M. Fuad,Sp.PDDR:dr. Ahdiah

1)Mardiana, 68 tahun,1050937Ass/1.sepsis e c dd/1) ulkus diabetikum 2) pneumonia (HAP)2.Ulcus diabetikum a.r pedis dextra3.dd/1) Pneumonia 2) Tb paru dengan Infeksi Sekunder 3)mikosis paru4. Anemia sedang e.c dd/ 1) perdarahan 2) penyakit kronik 3) defisiensi Fe

2./Syahtini,v65 tahun, 1031485Ass/1.CKD stage 5 ec dd/1.PNC HD reguler2.DM Tipe 2 Obese grade II3.Abses a/r parietal4. Abses a.r elbow joint5.Ulkus diabetikus grade II6.Iskemik anteroseptal7.Cardio renal syndrom8.anemia ringan e.c pey kronis9. Hipoalbuminemia10. Hipokalesemia11. CAP12. ISK13.neuropati diabetikum14.Spondilosis lumbalis15.Retinopati diabetic ODS16 Anxietas

1./Nurhayati Ismail,46 thn, 1015234Ass/1. Selulitis a.r pedis (d)2. DM type II normowheight3.HT st II4. Hipoalbuminemia5. dyspepsia type like ulcer6. stomatitis7. anxietas8. moderate MPDR

2. Asmawati, 54 thn, 0975637Ass/1. Sepsis ec gangrene diabetikum a/r pedis sin2. PAD3. DM Tipe 2 obesitas grade I4. dd/

1). Gastropati diabetic2). Dispepsia tipe like ulcer3). Dispepsia tipe dismotility

5. Hipoalbuminemia6. Dislipidemia7. HT on Terapi8. Moderate on PDR ODS9. Post Amputasi Digiti II, III, IV pedis (S) hari ke 1010. High risk thrombosis

DPJP : dr. Eva M, Sp.PDPPDS : dr. Nadi

DPJP :dr Desi S, Sp.PDPPDS : dr. NadiDM:

DPJP:dr.Eva M, Sp.PDPPDS: dr. NadiDM:

6 5 DPJP :dr. Chacha , Sp.PDPPDS :dr. RezaDM:

DPJP : dr. Chacha, Sp.PDPPDS : dr.RezaDM:

DPJP: dr. Hendra Jufry, Sp.PDPPDS : dr.Reza

1/ Darmiana Yacob , 58 th , 1050220 Ass/1. Anemia ringan hipokrom mikrositer e.c dd/ 1)peny kronis 2) Infeksi parasit2. CHF FC NYHA II ec dd/ 1) HHD 2) PJA3. HT on terapi4. OA lumbal5. OA genu bilateral6. nefrolithiasis dextra + hidronefrosis dextra

2/ Nurmalawati, 40 th, 1047824 Ass/1. Sepsis e.c dd /

1). Flebitis2). Urosepsis

2. CKD stage V on HD regular e.c dd/1). HN2). PNC3). GMC3. Anemia sedang e.c peny. Kronis4. Hipertensi stage II

3/Nurmawati, 40 th , 105092 Ass/1. CKD st V ec dd/ 1) HN 2) DN+ uremic syndrome2. DM type II undewheight3. hiperkalemia ringan4. anemia ec peny kronis5. Asidosis metabolic (perbaika)6. DD/1). Pneumonia 2). TB paru dengan inf sekunder

1./ Fatimah syam, 64 thn 1049376Ass/1. CKD stage 5 ec DN on + PNC on HD Reguler2. CHF FC NYHA II – II e.c dd/ 1) PJK 2) HHD3. HAP( perbaikan)4.Iskemik anteroseptal5. anemia e.c dd/1. Peny kronis 2. Perdarahan6. DM type II normowheight7. hipoalbuminemia8. hipokalemia ringan10. HT on therapy11. retinopati diabetikum ODS12. katarak sentralis ODS13. geriatric problem:-impairment of vision-instabilitas-inanisi14. disequilibrium syndrome (perbaikan)15 vertigo perifer

2./Salamah, 45 thn1047803Ass/1 KAD2 CHF FC N 1-2 e.c dd/-HHD-DCN3.Hipoalbuminemia4. Hipokalemia ringan .5 Hiponatremia Hipoosmolar Hipovolemik6. Anemia Ringan ec dd/

1). Penyakit Kronis2). Perdarahan

7. Diare kronike.c dd/-IBS-Cholitis

8 ISK9 Miliaria Kristalia10 LBP

3./ Rannawati Ali Basyah, 45 thn, 0968987Ass/

1. Nodul tiroid D/S

DenahPasienRuangRawatPenyakitDalam Wanita (Mamplam 2) Hari/tanggal :Selasa/ 12 Mei 2015Tim jaga :dr.Hendra/dr.YuniDokter Muda :T.harmawansyah/Fingga/Aris/Riza/Khairunnisak/Yuli/Kiki

Page 2: Mapping Pdw Minggu 11 Mei 2015

DPJP :dr. Eva, Sp. PDDR :dr. Nadi

DPJP:dr.Eva M, Sp.PDDR:dr.Nadi

DPJP :dr. Chacha M, Sp.PDDR :dr. Reza

DPJP :dr. Chacha M, Sp.PDDR :dr. Reza

4./Juliar, 43 thn01-04-98-57

Ass1. DD/ 1. DVT

2.Selulitis2. Abses cruris (S)

5./ulfa, 37 tahun, 01-04-42

Ass/1. SLE2. Hipoalbuminemia3. CAndidiasis oral

4./ Ti Hajar, 50 Tahun,1051231

Ass/1.penurunan kesadaraan e.c DD/ 1) Uremic Ensepalopati 2) sepsis berat2. Sepsis berat e.c DD/ 1. Urosepsis 2) pneumonia3. Ckd Stage 5 e.c dd/ 1) PGOI 2) PNCDengan nefrostomi bilateral4.Pneumonia (HAP) DD/ 1) TB paru dengan Infeksi sekunder5. Hipoalbuminemia6. Hipokalemia berat7. PSMBA e.c dd/ 1) Stress ulcer 2) Uremic Bleeding8. Nefrolithiasis sinistra9.Cardio renal syndrome

5./ Nurjannah, 75 tahun,1049238Ass/1. Hepatoma sekunder (metastase hepar)2. cholelitiasis multiple3. Anemia Sedang ec.

1. Perdarahan2. Penyakit Kronis

4. Post PSMBA ec ulkus gaster5. HAP

6. Ganguan Bowel habit e.c DD/1) IBS 2) Colitis 3) Ca colon.

DPJP : dr. M. Fuad, Sp.PDDR : dr. RidhaDM:

DPJP : dr. M. Fuad, Sp.PDDR : dr. RidhaDM:

DPJP : dr. M. Fuad, Sp.PDDR : dr. RidhaDM:

4 3 DPJP:dr.Islamuddin,Sp.PDDR :dr. AndrieDM:

DPJP :dr.Islamuddin,Sp.PDDR :dr. AndrieDM:

DPJP :dr.Islamuddin,Sp.PDDR :dr. Andrie

1/Tihalimah Idris, 61 th, 1051542Ass/1. Penurunan kesadaran ec

dd/ 1. Sepsis berat 2.imbalance elektrolit 3. Uremic Encephalopati

4.Stroke2. Sepsis berate c dd/1.CAP 2.Urosepsis3. AKI stage I4. Anemia ec dd/ 1. Def besi 2.perdaran 3.Penyakit kronis

2/Ti Rahmat, 45 tahun, 1050942

Ass/1. Hiponatremi2. Hipokalemia3. Dispepsia like

ulcer dd/ 1)tipe like ulcer 2) Tipe mixed

3./Yusda Lindawati, 47 thn, 1050537Ass/

1. Sepsis ec dd/1). Ulkus diabeticum ar pedis sinistra2). ISK

2. Ulkus Diabetikum ar pedis sinistra

3. ISK4. DM tipe 2 Normoweight5. Hiponatremi

Normoosmolar Euvolemik

6. DD/ 1. Gastroparese diabetikum

2.Dispepsia tipe Dismotility7. Hipoalbuminemia8. Non proliperatif diabetic

retinopati

1./ Nurul Maulizar, 21 thn, 1050376Ass/1. Cerebral Lupus2. SLE3.DD/1) Sindrom Vaskulin 2) HSP4. Hipoalbuminemia5. Sepsis (Perbaikan) ec dd/

1). CAP2). ISK

6. Candidiasos oral

2./Kande, 74 th, 1051308Ass/

1. Sepsis ec dd/1. TB paru dengan inf sekunder 2.CAP

2. CHF FC NYHA III ec dd/ 1.PDA 2.HHD

3. OMI anteroseptal4. Anemiahipokrom

mikrositer ec dd/ 1.def besi 2. Peny. Kronis

5. Dispepsia tipe 1.like ulcer 2. Tipemixed

6. Candidiasis oral

3./Rahmah, 42 th, 0798528

Ass/1. CKD stage V ec HN

dd udem paru2. Hipertensi stage II

dd hipertensi rgency3. Asidosis metabolic

murni dengan hiperoksemia

4. Hiperkalemia

DPJP : dr. M. Fuad, Sp.PDDR : dr. RidhaDM:

DPJP : dr. M. Fuad, Sp.PDDR : dr. RidhaDM:

DPJP :dr.Islamuddin,Sp.PDDR :dr. AndrieDM:

DPJP:dr.Islamuddin,Sp.PDDR :dr. AndrieDM:

4/Hayatun Nufus, 41 th, 1051319Ass/1. PSMBA e.c dd/ 1.Gastritis

erosive 2. Ulkus gaster 3.Ulkus duodenum

2. Anemia berate c dd/perdarahan

3. Retardasi mental

5/Sukesmi, 71 tahun, 0602234Ass/1.Sepsis ec ulcus diabetikum ar pedis dextra2. DM tipe 23. Hipertensi stage II4. Osteoartritis genu bilateral5. Ileus paralitik

4./Mariani, 49 thn, 1050327Ass/1. CKD stage 5 ec dd/

1). HN2). PNC

2. Hipertensi on Terapi3. Dispepsia Tipe dd/ 1). Like Ulcer, 2). Mixed4. Konstipasi

5./Nurhayati, 68 thn, 1049103Ass/1.HE grade 12.Sirosis hepatis std DC 3.Varises esofsgus grade II4. fistula Vesicovaginalis5.Caruncula uretra

DPJP : dr.Islamuddin, Sp.PDPPDS : dr.NazarDM:

DPJP :dr. M. Fuad. Sp. PDDR : dr. NazaruddinDM:

2 1DPJP : dr. Islamuddin, Sp. PDDR : dr. NazarDM:

DPJP : dr. Islamuddin, Sp.PDPPDS : dr. NazarDM:

1./Khairani, 44 tahun, 105 1100

Ass/1. CKD Stage V e.c dd/1) PNC 2)

PGOI2. Hiperkalemia Ringan3. Anemia sedang e.c DD/ 1)

Penyakit kronik 2) perdarahan4. HAP e.c TB paru inf. Sekunder5. Hipertensi stage I on terapi

2. /Darsiah, 57 thn, 1040198

Ass/1. CKD stage 5 ec dd 1). DN, 2). GNC2. DM tipe 2 underweight3. HT stage I4. Hipokalemia sedang5. Iskemik anteroseptal6. CHF FC NYHA I e.c CAD7. ISK8. Fraktur Ramus Inferior Simfisis Pubis Sinistra9. RBBB10. Anemia ringane.c dd/1. Penyakit kronis 2. Def11. Konstipasi

1/. Nurmala, 63 tahun, 1050604Ass/1. Gastropati diabetikum2. DM Tipe 2 underweight3. Hipertensi Terkontrol4. Spondilosis lumbalis5. Hipokalemia ringan6. Trombositosis Reaktif dd/ trombositosis primer7. ISK8. Pneumonia dd TB paru dengan infeksi sekunder

2./Juniati Muhammad, 40 thn, 1049880Ass/1. CKD stage 5 ec dd/ 1. PGOI 2. PNC2. Anemia sedang ec dd/ 1. penyakit kronik 2. perdarahan3. Hidronefrosis Bilateral4. Hipoalbuminemia5. Hipertensi Stage 16. Konstipasi7. Abdominal Discomfort dd/

1). ISK2). PID

Page 3: Mapping Pdw Minggu 11 Mei 2015