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    Shafa 17 Mei

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    nina purnamasari
    1. The document provides medical records and summaries for 4 patients seen at K1B1, K2B2, K4B4, and K6B2. 2. The patients presented with symptoms including shortness of breath, chest pain, diarrhea, and cough. 3. Diagnoses included pleural effusions, suspected malignancy, exacerbated pneumonia, and low albumin. Treatment plans involved IV medications, labs, imaging, and consultations.

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    Shafa 17 Mei

    Uploaded by

    nina purnamasari
    13 views1 page
    1. The document provides medical records and summaries for 4 patients seen at K1B1, K2B2, K4B4, and K6B2. 2. The patients presented with symptoms including shortness of breath, chest pain, diarrhea, and cough. 3. Diagnoses included pleural effusions, suspected malignancy, exacerbated pneumonia, and low albumin. Treatment plans involved IV medications, labs, imaging, and consultations.

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    SHAFA 17 MEI

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    1. The document provides medical records and summaries for 4 patients seen at K1B1, K2B2, K4B4, and K6B2. 2. The patients presented with symptoms including shortness of breath, chest pain, diarrhea, and cough. 3. Diagnoses included pleural effusions, suspected malignancy, exacerbated pneumonia, and low albumin. Treatment plans involved IV medications, labs, imaging, and consultations.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    13 views1 page

    Shafa 17 Mei

    Uploaded by

    nina purnamasari
    1. The document provides medical records and summaries for 4 patients seen at K1B1, K2B2, K4B4, and K6B2. 2. The patients presented with symptoms including shortness of breath, chest pain, diarrhea, and cough. 3. Diagnoses included pleural effusions, suspected malignancy, exacerbated pneumonia, and low albumin. Treatment plans involved IV medications, labs, imaging, and consultations.

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    MAPPING SHAFA 17 MEI

    K1B1 K2B2 K4B4 k6b2


    DPJP : dr. Ferry Dwi K, Sp.P (K) DPJP dr. Budi Yanti DPJP:dr. Herry Priyanto, Sp.P(K() DPJP : dr T Zulfikar Sp. P (K)
    PPDS: dr afif PPDS: dr Afif PPDS: dr. Afif
    SYUHADA M ASYEK IRWANDI BIN TARMUDI ADNEN ZULFAHMI
    CM: 1-29-71-11 CM: 1-30-55-83 CM: 1306601 CM : 1305542
    TTL: 15-6-1974 TTL: 25-10-1989 TTL:31/12/1957 TTL :17101965
    MRS: 09-05-2022 MRS 16-05-2022 MRS:13-05-22 MRS: 13/05/2022
    S/ sesak napas S/ Sesak napas Dx : S/
    Nyeri dada - Nyeri dada -efusi pleura dextra dd/ malignancy Nyeri dada kanan (+)
    diare - Demam -ppok eksaserbasi akut Batuk sesekali
    -susp massa paru kanan Sesak napas
    Dx/ Dx/ Hipoalbumin
    - Efusi pleura bilateral on Pigtail - Tumor Mediastinum Dx/
    hemithorax Kanan ec DD 1. Malignancy 2. - Efusi pleura dextra ec Malignancy TH/ - Efusi pleura dextra on wsd ec
    Pleuropneumonia
    - SVKS -Iv omeprazole 40 mg/24 j Malignancy
    - Susp Proses metastasis paru
    - Cancer pain NRS 7-8 -Iv methylprednisolone 125 mg/12j (STOP) -low intake
    - Ca ovarium Stadium II C
    - Cancer pain NRS 4-5
    -pulmicort nebule / 12 j
    - Anemia (7,8) Th/ -ventolin nebule 1 resp/8 j Th/
    - Hipoalbuminemia Berat (1.86) - IV Omeprazole 40mg/24jam -fluimucyl syr 3 x c2 -inj. Ceftriaxone 1 gr/12 jam
    - Hipokalemi (2.60) - IV Furosemide 20mg/24jam -curcuma 3 x1 (14/05/2022(H3)
    - Diare Akut - IV Dexamethasone 5mg/24j (16/5) H2 -iv levofloxacine 750 mg/24 j (mulai -inj. Omeprazole 40 mg/24 jam
    - MST 2x10 mg PO 13/5/22) Curcuma 3x1
    - Codei 3x10mg PO -drip plasbumin 1 fls/24 j (13/5) Vitamin d 3x1
    Th/
    - O2 2lpm - Tracetate 160mg/12jam PO
    - Diet extra putih telur P/ p/
    - Three way -foto thorax (13/5/22) : susul hasil
    P/ cek lab 13/05/2022
    - IV omeprazole 40mg/24jam -usg thorax (+) efusi pleura dekstra
    - Evaluasi KU dan Saturasi foto thorax(13/05/2022
    - IV Ketorolac 1 amp/8jam -toracosintesis (14/5/22) (+) jumlah cairan
    - Vastral 1x1 PO - USG thorax usg thorax
    - Thoracosintesis 990 cc rencana kemoterapi
    - Curcuma 3x1 PO -Sitologi CP,Kultur CP,Analisa CP (14/5/22)
    - Plasbumin 25% 1flash/24 jam - Susul Hasil : Sitologi BAL, FNAB konsul neuologi
    (+) Susul hasil konsul Cradio untuk bc (+)
    - Paracetamol 1gr/12jam DRIP
    -CT scan Thorax K/NK, Daftar (+)
    - Attapulgit 2 tab/BAB, max 8tab/24jam Lab 16-05-2022
    - Synbio 3x1 PO Hb/Ht/L/T 11.7/34/14.34/507 LAB 13/05/2022
    - KSR 3x600mg PO
    E/B/NB/NS/L/M 0/0/0/83/7/10 Lab 13-06-2022 HB/HT/L/T
    - Domperidone 10mg 3x1 PO Hb/Ht/l/T : 13,3/41/23,45/278
    PT/APTT 13.90/34.60 12,9/38/12,68/245
    - loperamide 1tab/8jam PO E/B/NB/NS/L/M 0/0/0/89/3/8
    Alb 3.30 Sgot/sgpt : 19/23
    Ur/Cr 32/0.70 PT/APTT 11,10/24,20 Na/k/cl : 139/3,20/104
    P/ Na/K/Cl 136/4.90/100 SGOT/SGPT 33/ Ur/cr : 13/0.56
    - Evaluasi KU dan saturasi KGDS 106 Alb : 2,30
    - USG thorax (+) 09/05/2022 Ur/Cr 24/0,5
    - Cek Lab lengkap Na/K/Cl 140/4/103
    - Pleurodesis ditunda hingga KU baik ALB : 2,6
    - Koreksi albumin, cek ulang albumin
    (12/5)
    - TransFusi PRC s/d Hb 10
    - Konsul IPD GEH (+) Diare akut

    Lab 09-05-2022
    Hb/Ht/E/L/T 7.8/23/7.31/399
    Alb 1.86
    Globulin 3.16
    Protein total 5.02
    SGOT/SGPT 17/5
    Na/K/Cl 131/2.60/91

    Lab 14-05-2022
    Na/K/Cl : 126/3,90/100
    Albumin : 1,80
    Sgot Sgpt : 49/14\

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