IRINA A

BAWAH
No Kamar Identitas Keluhan Diagnosis Hasil Pemeriksaan Planning
utama
1. B8B4 Runtu Pieter Post 14/2/2018 R/ AFF DJ Stant
Bernard/L/57 Pemasangan DJ Leu 5.6 19/2/2018
thn/19-9-1960 Stent Eri 4.80
Hb 14.2
RM : 51.45.63 Ht 41.8
Trombo 203
MRS : 14-2- MCH 29.7
2018 MCHC 34.1
MCV 87.0
DPJP: dr. Ari SGOT 27
Astram, SpU SGPT 26
Ur 29
Cr 1.5
GDS 97
Cl 106.0
K 4.20
Na 137
IRINA A
ATAS
Keluhan
NO KAMAR IDENTITAS Diagnosis Hasil Pemeriksaan Planning
utama
1. A7 B4 Bill Dede Nyeri pinggang Post Nefrostomi 20/01/2018 04/02/2018 [+]Exp. Foto Ketorolak inj
Putih Tumigolung/L/22th/30-10- kiri dan kanan Bilateral Leu 9,0 Leu 5.2 Thorax dbn
1995/Bumi Nyiur Hidronefrosis Eri 3,83 Eri 4.80 Pasang infus
bilateral Hb 10,6 Hb13.2 [+]Exp EKG
RM : 16.12.37 Ht 32,4 Ht 39.4 terlampir ( Ceftriaxon inj
Trom 229 Trom 234 dalam batas
MRS : 17-01-2018 MCH 27,6 MCHC 33.5 normal )
MCHC 32,7 MCV 82.1
DPJP: dr. Ari Astram, Sp.U MCV 84,6 MCH 27.5 [+]Echo
SGOT 14 SGOT 28
SGPT 9 SGPT 19
Ur 33 Ur 41
Cr 1,9 Cr 1.6
GDS 108 GDS 80
Alb 3,81 Alb 4.41
Cl 108 Na 131
K 3,70 K 4.14
Na 137 Cl 97.9

07/02/2018
Ur 39
Cr 1.4
2. 3A1B1 Solla Alex/L/ 60 thn/ 6-4- Sulit BAK BPH 30/1/2018 05/02/2018 [+] EKG kesan Tx sesuai TS Interna
. Hijau 1957/Lapangan ling III Leu 22.6 TPSA 791 Sinus Rhytme +
Eri 2.66 Susp LAHB tgl
RM: 42.17.11 Hb 7.7 7-2-2018
Ht 20.1 12/2/2018
MRS 31/1/2018 Trom 343 Leu 9.6
MCH 28.9 Eri 3.60
DPJP: dr. Ari Astram, Sp.U MCHC 38.3 Hb 10.2
MCV 75.6 Ht 28.3
SGOT 15 Trom 329
 SGPT 16 MCH 28.3
Ur 117 MCHC 36.0
Cr 7.2 MCV 78.6
GDS 199 SGOT 12
Na 117 SGPT 11
K 4.00 Ur 135
Cl 89.0 Cr 7.6
PT 11.6 GDS 290
INR 0.96 Alb 3.49
APPT 25.9 Na 136
Urinalisis K 3.50
Eri >50 Cl 103.0
Leu >10-12
Epitel 2-3
Bakteri –
Jamur –
Amoeba -
3. A10B3 Laloan Gusye/L/ 59thn/ 2- Sulit BAK Tumor Ginjal 30/1/2018 09/02/2018 Terapi lanjut
Biru 10-1958/Kawangkoan disertai nyeri sinistra Leu 18 Leu 12.3
AKI dd CKD Eri 4.59 Eri 4.16
RM: 46.61.15 Hiponatremia Hb 10.3 Hb 9.7
Ht 33.2 Ht 32.2
MRS: 31-01-2018 Trom 451 Trom 506
MCH 22.4 MCH 23.3
DPJP: dr Ari Astram, Sp.U MCHC 31.0 MCHC 30.1
MCV 72.3 MCV 77.4
SGOT 17 SGOT 25
SGPT 25 SGPT 25
Ur 48 Ur 65
Cr 2.0 Cr 2.2
GDS 116 Albumin 3.41
Na 127 Chlo 96.6
K 4.74 Ka 5.26
Cl 88.5 Na 134
PT 13.4 PT 14.8 (14.0)
 INR 0.99 APPT 40.1
APTT 50.6 (37.6)

4. A 11 Bed 1 Modi Ramoon/L/53 BAK berdarah Hematuria e.c. 11/02/2018 [+] Ekspertisi Terapi lanjut
Merah tahun/23-9-1964/Tateli Jaga 4 disertai nyeri Susp. Ca Prostat Leu 21.3 X-foto thoraks
Eri 3.91 terlampir
RM : 49.17.95 Hb 12.1 [+] Ekspertisi
Ht 33.5 EKG terlampir
MRS : 11-2-2018 Trom 190
MCH 30.9
DPJP : dr. Ari Astram, Sp.U MCHC 36.1
MCV 85.7
SGOT 21
SGPT 14
Ur 28
Cr 1.1
GDS 122
Cl 99.0
Ka 2.80
Na 134
5. A 8 Bed 3 Markus Haruna/L/57 Benjolan di lipat HIL dextra + 8/2/2018 14/2/2018 R/ TUR Prostat
Abu Abu thn/01-03-1960/Desa Sea paha kanan BPH dengan Leu 10.4 Leu 8.0
hingga kantung Luts berat Eri 2.88 Eri 2.94
RM : 52.48.93 buah zakar Hb 7.9 Hb 8.3
Ht 23.4 Ht 24.7
MRS : 9-2-2018 Trom 371 Trombo 347
MCH 27.4 MCH 28.2
DPJP : Ari Astram, Sp.U MCHC 33.8 MCHC 33.6
MCV 81.3 MCV 84.0
SGOT 9 SGOT 14
SGPT 8 SGPT 11
Ur 141 Ur 129
Cr 6.5 Cr 5.6
GDS 93 GDS 127
 Cl 106.0 Alb 2,98
Ka 3.60 Cl 109.7
Na 136 K 3.45
Na 138
PT
@Detik
19.7(14.6)
@INR
1.81(14.6)
APPT
35.1(34.8)

6. A11 Bed 2 Herung BAK berdarah Hidronefrosis 15/2/2018

Thimotius/L/63th/11-05- disertai nyeri Bilateral Leu 3.4
1954 perut bawah Eri 3.12
Hb 8.9
RM: 52.54.63 Ht 27.2
Trombo 101
MRS: 15 Februari 2018 MCH 28.6
MCHC 32.7
DPJP: dr, Ari Astram, SpU MCV 87.3
SGOT 22
SGPT 13
Ur 132
Cr 6.1
GDS 93
Cl 108.0
K 4.10
Na 135
IRINA A
TERATAI

No Kamar Identitas Keluhan Diagnosis Hasil Pemeriksaan Planning

Utama
1. Kelas I Bed I Surentu Nyeri di perut ILO + urosepsis 05/02/2018 12/02/2018 [+] EKG Rawat luka
Christian/ L/ 56 bawah Post sistostomi Leu 13.1 Leu 9.9 ekspertisi 2x/hari
thn/ 24-12-1961 ec post Eri 3.26 Eri 3.91 21/01/2018
Vesikolithiasis Hb 9.3 Hb 11.5 Global ST Antibiotik
RM: 46.66.33 Ht28.7 Ht 34.3 depresi ec
MRS: Trom 431 anemia dd Analgetik
Trom 487
21/01/2018 Post MCH 28.5 elektrolit
uretrocystostopi MCHC 32.4 MCH 29.4 imbalance Terapi lain
DPJP: dr. Ari ec post MCV 88.0 MCHC 33.5 sesuai TS
Astram, Sp. U cystostomi SGOT 39 MCV 87.7 [+] X Thorax Interna
SGPT 30 ekspertisi kesan
Ur 18 18/02/2018 dbn
Cr 1.0 Leu 11.1
GDS 75 Eri 3.95
Na 134 Hb 10.9
K 4.90 Ht 34.9
Cl 103 Trom 484
Alb 2.40
MCH 27.5
09/02/2018 MCHC 31.1
Leu 7.3 MCV 88.3
Eri 3.01 SGOT 24
Hb 8.7 SGPT 26
Ht 26.3 Ur 20
Trom 460 Cr 0.9
MCH 28.9 GDS 84
MCHC 33.1 Cl 106
 MCV 87.4 K 4.6
SGOT 45 Na 137
SGPT 36
Ur 19
Cr 1.2
GDS 79
Albumin 2.82
Chlo 100.2
Ka 3.72
Na 134

2. Kelas I Bed 2 Jhonny Nyeri pinggang Nefrolitiasis 01/02/2018 13/02/2018 [+] foto thorax: Antibiotik
Johanis kanan dan kiri sinistra Leu 10.2 Leu 7.6 normal adekuat
Saraisang/L/6 Eri 3.60 Eri 3.78 [+] EKG: Sinus
3th/04-05-1954 Hb 9.8 Hb 10.1 rytme + susp Analgetik
Ht 29.2 Ht 31.3 OMT Lateral
RM: 52.42.30 Trom 395 Trom 248 tgl 10-2-2018 Pro nefrostomy
MCH 27.2 MCH 26.7 [+] CT-Scan :
MRS: MCHC 33.6 MCHC 32.3 batu ginjal Cek lab
01/02/2018 MCV81.1 MCV 82.8 dextra lengkap
SGOT 20 SGOT 16
DPJP: dr. Ari SGPT 13 SGPT 14
Astram, SpU Ur 27 Ur 19
Cr 0.6 Cr 0.5
GDS 116 Cl 105
Na 133 K 4.40
K 3,44 Na 142
Cl 95.6
PT
Pasien 10.5
APPT
 Pasien 30.8

3. Kelas I Bed 4A Jetty Ivonne Nyeri pinggang Hidronefrosis ec 12/02/2018 18/02/2018 Pro Nefrostomi
Pojoh/P/66thn/1 dan nyeri saat Nephrolitiasis Leu 14.2 Leu 8.3
7-02-1951 BAK sinistra Eri 3.91 Eri 3.59 Analgetik
Hb 11.5 Hb 10.5
RM: 52.48.66 Ht 33.1 Ht 31.1 Antibiotik
Trom 422 Trom 105
MRS: 8-2-2018 MCH 29.4 MCH 29.2 Terapi lain
MCHC 34.7 MCHC 33.7 sesuai TS
DPJP: dr. Ari MCV 84.7 MCV 86.6 Interna
Astram, SpU Ur 50 SGOT 104
Cr 1.9 SGPT 37
GDS 100 Ur 53
Chlo 99.5 Cr 1.6
Ka 2.92 GDS 65
Na 129 Cl 108
K 3.3
URINALISIS Na 132
08/02/2018
MAKROSKOPIS
Warna: Yellow
Kekeruhan:
Jernih
MIKROSKOPIS
Eri 15-20/LPB
Leu 10-15/LPB
Epitel 2-3/lpk
Bakteri +++/LPB
Jamur +/LPB
Amoeba -
KIMIA
Berat jenis 1015
pH 6
 Leu 3+
Nitrit –
Protein 3+
Glukosa -
Keton -
Urobilinogen -
Bilirubin –
Darah/eri 5+
Silinder –
Kristal -
4. Kelas II Bed 9 Dantje Hendrik Nyeri pinggang Nefrolitiasis 07/02/2018 Antibiotik
Tamba/L/74thn/0 dan pinggul dextra Leu 8.8
5-12-1943 Eri 2.76 Analgetik
Anemia Renal Hb 8.7
RM: 52.47.31 Ht 25.3 Terapi lain
AKI Trom 81 sesuai TS
MRS: 7-2-2018 Superimposed MCH 31.5 Interna
CKD MCHC 34.4
DPJP: dr. Ari MCV 91.7
Astram, SpU Ur 104
Cr 5.5
GDS 128
Chlo 93.0
Ka 3.60
Na 129

IRINA B
Kamar Identitas Keluhan Diagnosis Hasil Pemeriksaan Planning
Utama
K4 Tommy Lemah badan Hidronefrosis 10/02/2018 14/2/2018
Towoliu/L/ bilateral Leu 11.9 Leu 27.5
 53thn/30-10- Anemia bilateral Eri 3.57 Eri 2.54
1964/Malendeng Susp. ISK Hb 10.1 Hb 7.1
Lk.1 Susp. Pneumonia Ht 28.4 Ht 20.1
CKD 5 HD Trom 267 Trom 300
RM:19.01.04 nefropati obstruksi MCH 28.3 MCH 28.0
dd DKD MCHC 35.6 MCHC 35.3
MRS: 3-2-2018 MCV 79.6 MCV 79.1
SGOT 9 SGPT 13
DPJP: SGPT 13 Cl 91.1
Ur 340 K 3.59
Cr 17.7 Na 126
Chlo 81.2
Ka 3.23
Na 121

Anggrek 2
Kamar Identitas Keluhan Diagnosis Hasil Pemeriksaan Planning
Utama
Kamar 114 Lumoring BAK Berdarah Hematuria ec susp 09/02/2018 12/02/2018 Jawaban konsul Antibiotik adekuat
Alexander/L/ Ca Prostat Leu 7.8 Leu 7.0 Interna tgl 11-02-
72thn/11-07- Eri 2.84 Eri 3.08 2018 sudah Terapi lain sesuai TS
1945/Singkil Hb 9.0 Hb 9.7 dijawab. Pasien Interna dan Neuro
Ht 21.1 Ht 28.9 RABER SF 1x1 tab
RM:43.02.54 Trom 413 Trom 311 INTERNA!
MCH 31.7 MCH 31.5
MRS: 9-2-2018 MCHC 34.5 MCHC 33.6
 MCV 91.9 MCV 93.8
DPJP: dr. Ari Ur 24 SGOT 12
Astram, SpU Cr 0.5 SGPT 9
GDS 123 Ur 16
Chlo 93.0 Cr 0.4
Ka 4.10 Asam urat 3.4
Na 122 GDS 172
PT 15.7 (14.0) Cl 94.7
INR 1.34 (1.05) K 3.63
APTT 36.4 (37.6) Na 129

Anggrek 1
Kamar Identitas Keluhan Diagnosis Hasil Pemeriksaan Planning
Utama
B 11 Herman N Kelemahan badan Susp osteoartrithis 09/02/2018 13/02/2018 17/02/2018 [+] X-Foto Cegah infeksi
Kukus/L/69thn/19- genu bilateral Leu 10.1 Leu 11.2 Leu 14.5 thorax
03- Eri 2.33 Eri 2.50 Eri 3.04 Antibiotik adekuat
terlampir
1948/Malalayang 1 Ca prostat on Hb 6.1 Hb 6.8 Hb 8.1
kemoterapi Terapi lain sesuai
Ht 18.4 Ht 20.7 Ht 26.2 TS Interna
RM: 41.50.92 General weakness Trom 535 Trom 353 Trom 274
MCH 26.2 MCH 27.2 MCH 26.7 Konsul ICU
MRS: 10-02-2018 MCHC 33.2 MCHC 32.9 MCHC 30.9
DPJP: dr. Ari MCV 79.0 MCV 82.8 Eosinofil 0
Astram, SpU SGOT 67 Ur 42 Basofil 0
SGPT 16 Cr 0.9 Netrofil btg
Ur 17 Prot 4.72 39
Cr 0.6 Fosfor 3.4 Netrofil
GDS 114 Mg 1.83 segmen 52
Chlo 78.0 Alb 2.43 Limfosit 6
Ka 4.50 Globulin Monosit 3
Na 109 2.29 MCV 86.4
PT 15.5 (14.0) Cl 80.2 Ur 82
INR 1.32 (1.05) K 4.37 Cr 1.7
APTT 38.0 (37.6) Na 111 Prot 4.39
Ca 6.9 GDS 133
Fosfor 2.9
Mg 2.16
Alb 2.20
Globulin
2.19
Cl 94.7
K 4.43
Na 127
Ca 7.65

PT 15.4
(14.6)
INR 1.17
(1.10)
APTT 39.3
(37.1)