Nama

No. RM
Kamar
Diagnosa
DPJP

: Atlanta R. Siahaan
: 661875
: RA1- III.3 Bed 4
: Liver abscess
: dr. Franciscus, Sp. PD

Ruan

Identitas

g/

Pasien

Bed
III.3/

Atlanta R.

- Abses liver dd/

Siahaan/

hepatoma dd/

Perempuan/
19 tahun

Diagnosis

kista hepar
- Anemia defisiensi
besi ad penyakit

Masuk: 16
Desember
2015

kronik
- hipoalbuminemia

Hasil Pemeriksaan

Terapi

16-12-15:
Darah Rutin
Hb/Ht/RBC/WBC/PLT:

Tirah baring
Diet MB
IVFD RL 20 gtt/i

9,7/28,6/3,76/11,26/471
Faal hemostasis
INR/APTT/TT:

(makro)
Inj. Ketorolac

1,02/0,78/0,89
Kimia Klinik
Alb./KGDadrandom/
Ur./Cr./Na/K/Cl:

DPJP: dr.

3/92,8/10/0,58/137/4,0/1

Franciscus,

07

Sp. PD

17-12-15:
Darah Rutin
Hb/Ht/RBC/WBC/PLT:
9,7/29,8/3,9/9,32/487
Faal hemostasis
Ferritin/besi/TIBC:
349,4/18/127
LFT
Bilirubin total/bilirubin
direk/ALP/AST/ALT/GT/
albumin/globulin/protein
total:
0,34/0,25/155/109/26/15
7/
2,9/3,1/6,0
Imunoserologi
HbsAg/anti HCV: -/AFP/PCT: 1,77/3,47
18-12-15:
Hasil USG
Hati:
Permukaan ireguler
Pinggir tumpul

30mg/8jam/IV
Inj. Ranitidin
50mg/12jam/IV
Metronidazole
3x750mg
PCT 3X500mg
(KP)
USG Abdomen
Rencana:
Konsul Gizi klinik

Ukuran membesar
Parenkim multiple nodul
di lobus kanan hepar
Limpa/kandung empedu/
Pankreas/ginjal:
Normal
Kesimpulan:
DD/ -HCC
-Liver abscess
-Fokal lesi hiperplasia