This document contains 46 entries providing medical assessments and care plans for patients seen at Tulip and Mawar rooms. Each entry includes the patient's name, age, chief complaint, vital signs, medical history, assessment, and planned treatments which generally include IV fluids, medications to address symptoms and underlying conditions, and monitoring of lab results. The patients presented with issues such as weakness, headache, abdominal pain, fever, respiratory distress, and complications of diabetes, hypertension and kidney disease.

1. NO. TANGGAL RUANGAN IDENTITAS SUBYEKTIF OBYEKTIF ASSESMENT PLANNING
24. 20/07/2020 Tulip Ny. Y/70 th
48056
Penurunan Kesadaran GCS 2-1-4
KU : lemah
TD : 195/126
N: 78x/m
RR: 20x/m
S : 37.2
Kaku kuduk (-)
Lateralisasi (-)
Stroke
Haemorragic
-Kie keluarga
pasien
-inf. NaCl 16 tpm
-Inj. Citicolin
2x500mg
-Inj. Sanmol 2x1
-inj. Ranitidine 2x1
-inj. Ceftriaxone
2x1gr
-Nicardipin SP
7,5cc/jam
25. Tulip Ny. R/72 th
540539
Kelemahan anggota
gerak kanan
GCS 4-5-6
KU : lemah
TD : 130/90
N: 84x/m
RR: 20x/m
S : 36.0
Kaku kuduk (-)
Motorik 1 / 5
1 / 5
Stroke infark -inf. NaCl 16 tpm
-Inj. Citicolin
2x500mg
-Inj. Sanmol 2x1
-inj. Ranitidine 2x1
-inj. Ceftriaxone
2x1gr
-inj. Mecobalamin
2x1
26. Tulip Ny. W/70 th
540467
Kelemahan anggota
gerak kanan
GCS 4-5-6
KU : lemah
TD : 133/92
N: 80x/m
RR: 20x/m
S : 36.7
Kaku kuduk (-)
Motorik 1 / 5
1 / 5
SOP tumor
cerebri
-inf. NaCl 15 tpm
-Inj. Citicolin
2x500mg
-inj. Mecobalamin
2x1
-inj. Esomeprazole
2x40mg
-inj.
Dexamethasone
2x5mg

2. 27. Tulip Tn. S/63th
540591
Kelemahan anggota
gerak kanan
GCS 4-5-6
KU : lemah
TD : 180/100
N: 83x/m
RR: 22x/m
S : 36.2
Kaku kuduk (-)
Motorik 1 / 5
1 / 5
ICH -inf. NaCl 16 tpm
-Inj. Citicolin
2x500mg
-Inj. Antrain 2x1
-inj. Ranitidine 2x1
-inj. Manitol 4x125
-inj. Mecobalamin
2x1
28. Tulip Tn. A/68 th
357006
Kelemahan anggota
gerak kanan + tidak
bias bicara
GCS 4-X-6
KU : lemah
TD : 170/80
N: 68x/m
RR: 20x/m
S : 37.2
Kaku kuduk (-)
Motorik 1 / 5
1 / 5
CVA infark -inf. NaCl 16 tpm
-Inj. Citicolin
2x500mg
-Inj. Antrain 2x1
-inj. Ranitidine 2x1
-inj. Ceftriaxone
2x1 gr
-inj. Mecobalamin
2x1
29. Tulip Tn. K/75 th
540570
Penurunan kesadaran GCS 3-1-3
KU : lemah
TD : 160/80
N: 88x/m
RR: 20x/m
S : 36.5
Kaku kuduk (-)
Lateralisasi (-)
ICH -inf. NaCl 16 tpm
-Inj. Citicolin
2x500mg
-Inj. Antrain 2x1
-inj. Manitol 4x125
-inj. Mecobalamin
2x1
30. Tulip Ny. S/91 th
301363
Penurunan Kesadaran GCS 1-1-5
KU : lemah
TD : 189/97
N: 103x/m
RR: 20x/m
S : 36.8
Kaku kuduk (-)
Stroke Infark
+ AF Rapid
-inf. NaCl 16 tpm
-Inj. Citicolin
2x500mg
-Inj. Antrain 2x1
-inj. Ranitidine 2x1

3. Lateralisasi ke kanan -inj. Furosemide
2x1
-inj. Mecobalamin
2x1
-Ramipril 1x10 mg
-amlodipin 1x10mg
-concor 1x2,5mg
Notisil 1x2mg
31. 24/07/2020 Melati Sdr. G/25 th
540990
Demam, badan lemas GCS 3-1-3
KU : sedang
TD : 108/56
N: 81x/m
RR: 18x/m
S : 37.3
Ptechiae (-)
Sumber perdarahan
(-)
Malaria dd/
DF
-Inf. Asering 30
tpm
-inj. Esomeprazole
1x1
-sanmol3x1
-imunos 2x1
-lagesyl syr 3xc1
-chloroquin 2x1 tab
-DL/hari
32. Melati Tn. S/71 th
540949
Hiperglikemia, luka
pada kaki
GCS 4-5-6
KU : sedang
TD : 111/64
N: 92x/m
RR: 20x/m
S : 37.4
GDS : 325
WBC : 25.210
Dm +
ganggren
pedis D +
sepsis
-inf. Asering 16
tpm
-inj. Metronidazole
3x1
-inj. Pantoprazole
1x1
-sansulin log G
1x20 u
-humalog 3x8 u
-rawat luka
33. Melati Tn.F / 50 th
530667
Perut membesar GCS 4-5-6
KU : sedang
TD : 117/76
N: 96x/m
RR: 20x/m
Hepatitis B +
Ascites +
hipokalemia
-inf. PZ 16 tpm
-inj.
Pantoprazole1x1
-inj. Santagesik 3x1
-KSR 3x1

4. S : 37.0
Sclera icteric +/+
Abdomen : BU (+),
NT (-), ascites (+)
Asam folat 2x1
Biocurliv 3x1
Vip albumin 3x1
34. Melati Tn. S/ 78 th
359995
Badan lemas, BAB
merah segar
GCS 4-5-6
KU : sedang
TD : 100/70
N: 72x/m
RR: 20x/m
S : 36.3
CA +/+
GDS 305
Hb : 7.2
HbA1C 10,5
Anemia et
causa
hematochezia
+ DM
-Inf. Pz 16 tpm
-inj. Asam
tranexamat
3x500mg
-inj. Pantoprazole
1x1
-Novorapid 3x 6
unit
-transfusi PRC
-cek gda/hari
35. Tulip Tn. S/70 th
540974
Bicara pelo, tidak
bisa makan, kaki
kanan kiri terasa
kesemutan
GCS 4-5-6
KU : lemah
TD : 180/100
N: 83x/m
RR: 22x/m
S : 36.2
Kaku kuduk (-)
Motorik 5/ 5
4 / 4
WBC : 14.053
General
weakness dd/
cva infark
Inf. RL 8 tpm
-inj. Citicolin 2x
500mg
-inj.mecobalamin
2x1
-inj. Ranitidine 2x1
-inj. Antrain 2x1
-inj. Ceftriaxone
2x1gr
36. 28/07/2020 Mawar Ny. S / 59 th
234610
Bengkak pada kaki GCS 4-5-6
KU : sedang
TD : 142/88
N: 82x/m
RR: 20x/m
S : 36.4
GDS 567
HbA1C 11,0
Gangren pedis
D + DM
Inf. Nacl 14 tpm
-inj santagesik 2x1
Inj. Esomeprazole
2x1
-inj. Infimox 2x1
-novorapid 3x12
unit

5. RCI 3x6 unit, cek
gda post rci
37. Mawar Ny. E/ 25 th
233410
Pusing, badan lemas GCS 4-5-6
KU : sedang
TD : 100/70
N: 62x/m
RR: 19x/m
S : 36.7
CA +/+
Hb 7.5
Anemia
-Inf. Pz 16 tpm
-inj. Pantoprazole
1x1
-inj. Santagesik 2x1
-vip albumin 3x1
-curcuma 2x1
Transfusi prc 2 kolf
38. Mawar Ny. R /50 th
541013
Badan lemas, mual GCS 4-5-6
KU : sedang
TD : 120/80
N: 73x/m
RR: 21x/m
S : 36.6
CA +/+
Hb 6.95
CKD st V +
anemia
-Inf. Pz 16 tpm
-inj. Pantoprazole
1x1
-inj. Santagesik 2x1
-inj. Farsix 2x1
Transfusi prc 1
kolf/hari
-aminoral 3x1
-calos 3x1
-asam folat 3x1
39. Mawar Ny. K/62 th
299996
Nyeri perut, mual GCS 4-5-6
KU : sedang
VAS : 8
TD : 173/92
N: 88x/m
RR: 20x/m
S : 36.0
Thorax : s1s2
tunggal
Kolik
abdomen +
HHD
-Inf. Pz 20 tpm
-inj. Pantoprazole
1x1
-inj. Santagesik 2x1
-amlodipin 1x10mg
-furosemide tab
1x1
-asam folat 3x1

6. Ves+/+, Rh -/-, wh
-/-
Abdomen : BU +,
NT +, timpani
40. 1/08/2020 Mawar Ny. B / 53 th
540220
Kepala pusing, mual,
nyeri perut
GCS 4-5-6
KU : sedang
TD : 90/60
N: 71x/m
RR: 18x/m
S : 36.2
Kalium : 6.6
SK :5.71
CA +/+
Abdomen : BU +,
NT +, timpani
CKD st V +
anemia + DM
+
hiperkalemia
-Inf. Pz 10 tpm
-inj. Pantoprazole
1x1
-aminoral 3x1
-asam folat 3x1
-kalitake 3x1
-sucralfat syr
41. Mawar Ny. M / 38 th
541276
Demam, nyeri perut GCS 4-5-6
KU : sedang
TD : 118/83
N: 73x/m
RR: 18x/m
S : 37.6
Ptechiae (-)
Sumber perdarahan
(-)
Abdomen : BU +,
NT +, timpani
DHF -Inf. Asering 30
tpm
-inj. Lansoprazole
1x1
-sanmol 3x1
-imunos 2x1
-sucralfat syr 3xc1
-curcuma syr 3xc1
-DL/hari
42. Mawar Ny. P / 69 th
507326
Sesak sedikit
berkurang, terkadang
berdebar-debar
GCS 4-5-6
KU : sedang
TD : 179/91
N: 96x/m
RR: 22x/m
S : 36.0
ADHF +
HHD
Inf.PZ 7 tpm
-inj. Furosemide
2x1
-ramipril 1x5mg
-concor 1x2,5mg

7. Thorax : s1s2
tunggal
Ves+/+, Rh +/+, wh
-/-
-spironolactone
1x25mg
-minum dibatasi
43. Mawar Ny. K/70 th
541212
Nyeri pinggang GCS 4-5-6
KU : sedang
TD : 124/66
N: 93x/m
RR: 20x/m
S : 36.5
GDS :265
SK: 5.7
DM + CKD st
III +
Gastroparese
Inf.PZ +
ondansentron 1
amp. 10 tpm
-inj. Furosemide
2x1
-inj. Lanzoprazole
1x1
-inj. Antrain 3x1
-inj. Granicetron
2x3gr
-Sansulin log G
1x12 u
-Novorapid 3x 6 u
-Sucralfat syr 3xc1
-aminoral 3x1
As. Folat 2x1
-gda/hari
44. Mawar Ny. N / 59 th
541240
Badan masih lemas,
mual
GCS 4-5-6
KU : sedang
TD : 157/92
N: 111x/m
RR: 20x/m
S : 36.3
CA +/+
Gangrene pedis s
DM +
gangrene
pedis sinistra
digiti 1 +
anemia
Inf.PZ 14 tpm
-inj. Lanzoprazole
1x1
-inj. Antrain 3x1
-inj. Ceftriaxone
2x1gr
-Sansulin log G 1x8
u
-Novorapid 3x 6 u

8. Gda : 427
Hb : 7.2
-tranfusi prc 1kolf
/hari
-gda/hari
45. 13/08/2020 Mawar Ny.S / 59 th
536260
Masih sesak, mual
terkadang masih
muntah
GCS 4-5-6
KU : sedang
TD : 113/70
N: 90x/m
RR: 22x/m
S : 36.2
Edema tungkai +/+
CKD st V +
CHF +
nephrolithiasis
D/S
Inf.PZ 8 tpm
-inj. Furosemide
2x1
-drip vascon 1 amp
dlm pz 100cc 20
tpm mikro
-inj. dexketoprofen
3x1
-inj. Granicetron
2x3gr
-omeprazole
2x40mg
46. Mawar Ny. D/36 th
251033
Badan lemas GCS 4-5-6
KU : sedang
TD : 85/50
N: 90x/m
RR: 22x/m
S : 36.2
CA +/+
Hb : 4.2
Anemia +
thalasemia
Inf. PZ 14 tpm
-curcuma 3x1
Inj. Oxtercid
2x750mg
-asam folat 2x1
Transfusi prc2 kolf/
hari
MST 1x10mg
47. 21/08/2020 Mawar Ny. E/ 44th
251502
Sesak GCS 4-5-6
KU : sedang
TD : 142/79
N: 91x/m
RR: 23x/m
S : 36.1
ADHF +
HHD
-inf. Futrolit 7 tpm
-inj uresix 1x1
-v block 6,25mg
-spironolactone
1x25 mg

9. Thorax : s1s2
tunggal
Ves+/+, Rh +/+, wh
-/-
48. Mawar Ny. K / 73 th
542234
Nyeri perut GCS 4-5-6
KU : sedang
TD : 102/53
N: 74x/m
RR: 21x/m
S : 37.1
CA +/+
Hb :5.2
Abdomen : BU +,
NT +, timpani
DM + Anemia -.inf Nacl 16 tpm
-inj. Novorapid 3x6
u
-inj sansulin log G
1x 12u
-transfusi prc 2
kolf/hari
-sucralfat syr 3xc1