Denah Ruang Rawat

Penyakit Dalam Wanita (AQSHA 3)

Hari/Tanggal : Sabtu / 7 Mei 2017

Tim Jaga : dr. Radit /dr. Tika
Dokter Muda : dm. Dian/ dm. Espi/dm.Vonna
K1B1 K1B2’ K1B3’ K1B4’
DPJP : dr. Eva M, Sp.PD DPJP : dr. Eva M, Sp.PD DPJP : dr. Eva DPJP : dr. Abdullah Sp.PD
COW : dr. Mirzal COW : dr. Wira COW : dr. Wira COW : dr. Cut Mena
DR : dr. Wira DR : dr. Mirzal DR : dr. Mirzal DR : dr. Mala
Divisi : Divisi : Divisi : Divisi :
Nama : Arfah Azwani Nama: Sasmita Nama : Anisah Nama : Handawiyah
Umur : 19 tahun Umur: 25 tahun Umur : 66 tahun Umur : 71 tahun
CM : 1128265 CM : 1122014 CM : 1051161 CM : 1128243
Hari Rawatan : 2 Hari rawatan : 3 Hari Rawatan : 2 Hari Rawatan : 2

Ass/ Ass/ Ass/ Ass/

1. DHF Grade 2 1. Bisitopenia ec dd 1. CKD Stage 5 ec dd 1. perubahan kesadaran ec dd
- Leukimia akut
 HN  SDA
- ITP
Th/
- Anemia aplastik  PNC  Demensia
Bedrest
- Mieofebritis  NSAID 2. Geriatri problem
Diet MII TKTP 2. Hiponatremi hipoosmolar :inanisi,imobilisasi,infeksi
IVFD RL 30 gtt/i Th/ 3. Hipokalemia sedang 3. ulkus dekubitus grade 2
PCT 3x500 gr Bedrest 4. Anemia NN ec dd/
Lansoprazole 1x30 mg Diet TKTP  PGK Th/
IVFD NaCl 0,9% 20 gtt/i  Perdarahan Bedrest
Lab/6/5/2017 IV Levofloxacin 500 mg/24 jam 5. HT stage 2 (perbaikan) Imolisasi pasif/2jam
Hb/Ht/E/L/T : 15,3/44/5,2/11,7/44 Betadin gargle 4x garg II IVFD NaCl 0,9% 20gtt/i
MCV/MCH/MCHC/RDW/MPV Transfusi TC 10 kolf Th/ Diet sonde 6x150cc
86/30/35/11,9/12,6/19 IV Metilprednisolon 250 mg/12j Bedrest Decobal salut
Diff: 2/0/0/21/69/8 Osteocal 3x1 tab Diet ginjal 1700 kkal/har IVFD Clinimix 1 fl/24j
Ur/cr : 18/0,56 IV Omeprazole 40 mg/12 jam IVFD NaCL 0,9% 20gtt/i IV ceftriaxone 1gr/24jam
Anti Dengue IgM : Positif IV metoclopramide 0,5 Climdamicyn 3x300gr
Anti Dengue IgG : Positif Lab 5/5/2017 Drip albumin 25% 100cc/hr
amp/8jam
Hb/Ht/E/L/T : 5,4/17/1,9/14,8/4 (selama 2hari)
MCV/MCH/MCHC: 91/28/31 IV lansoprazole 30gr/24j
Diff: 0/0/0/89/10/1 Valsartan 1x160mg
Lenal ace 3x1
As.folat 2x1 Lab/5/5/2017
KSR 2x60mg Hb/Ht/E/L/T
Balance cairan 8,8/23/2,9/6,1/312
MCV/MCH/MCHC
80/31/38
Lab/5/5/2017 Diftell : 1/0/0/63/24/12
Hb/Ht/E/L/T Ur/Cr : 197/4,7
8,8/23/2,9/6,1/312 Na/K/Cl : 118/2,8/88
MCV/MCH/MCHC
80/31/38
Diftell : 1/0/0/63/24/12
Ur/Cr : 197/4,7
Na/K/Cl : 118/2,8/88
 K2B1’ K2B2’ K2B3’ K2B4’ K2B5’
DPJP : dr. Azhari Gani DPJP : dr. Azhari DPJP : dr.Azhari DPJP : dr. Abdullah DPJP : dr. Chacha
COW : dr. Alfi Ghani Ghani COW : dr. Meina COW : dr. Wira
DR : dr. Rachmad COW : dr. Alfi COW : dr. Alfi DR : dr. Mala DR : dr. Mirzal
Divisi : DR : dr. Rahmad DR : dr. Rahmad Divisi : Divisi : GH, Geriatri
Divisi : Divisi :
Nama : Intan Sati Nama : Arwida Nama : Juwita Diana Nama : Raziah A Rani Nama : Marwati
Umur : 36 tahun Umur : 26 tahun Umur : 29 tahun Umur : 49 tahun Umur : 43 tahun
CM : 1-12-74-63 CM : 1-11-06-03 CM : 1-12-44-50 CM : 1127645 CM : 1128139
Hari Rawatan : 5 Hari Rawatan : 4 Hari Rawatan : 4 Hari Rawatan : 6 Hari Rawatan : 2

Ass/ Ass/ Ass/ Ass/ Ass/

1. CKD Stage V ec dd/ 1.Anemia Berat ec dd/ 1. anemia aplastik 1. Ulkus diabetikum + 1.DHF grade II
1. PNC 1. AIHA 2. HAP ec dd selulitis a/r pedis sinistra 2. ISK
2. Anemia NN ec dd/ 2. defisiensi as. Folat 1. TB paru sekunder 2. DM tipe 2 overweight
1. PGK 2. Grave disease 2. Mikosis paru 3. Hipertensi stage II on Th/
3. Hiponatremia hipoosmolar 3. CHF Fc II-III ec 3. Emfisema paru theraphy Bed rest
euvolamik 1. PJT 4. dyspepsia tipe Diet MII
2. PDA Th/ -like ulcer IVFD RL 30 gtt/i
Th/ -Bedrest -mixed IV Omeprazole 40
Bedrest Th/ -Diet lunak 1700 kkal/hr -dismotil mg/12 jam
Diet ginjal 1700kkal dengan Bedrest -IVFD NaCl 0,9 % 20 5. ISK Paracetamol 3x500 mg
36g protein (sonde 6x200) Diet MII 1700 kkal gtt/i IV Ondansetron 4 mg/12
Threeway IVFD NaCl 0,9 %10 -Ceftriaxone 2 gr/24 jam Th/ jam
IV ceftriaxon 2g/24jam gtt/i -azitromisin 1 x 500 mg Bedrest Fluconazole 1x150 gr
IV Ondansentron 4mg/8jam IV anbacim 1 gr/ 12 - metilprednisolon 3 x 16 Diet DM 1800 kkal/hari
Lenal ace 2x1 mg jam mg IV ranitidin 1amp/12jam Lab 5/5/2017
As.Folat 2x1 mg IV Metilprednisolon - sandimun 2 x 100 mg Drip PCT 1 gr/8 jam Hb/Ht/E/L/T
Amlodipine 1x10mg 125 mg/12 jam -omeparzole 2 x 20 mg Herbesser 2x100 mg 14,8/42/5,3/7,8/18
HD As folat 2 x 1 Cetirizin 2x10 mg MCV/MCH/MCHC/RDW
Transfusi PRC 1kolf sd >7 IV paracetamol 1 gr/ Codein 3x10 mg 80/28/35/12,4
12 jam Lab 3/5/17 Drip vankomicin 750 Diftell : 0/1/0/42/50/7
Lab/5/5/2017 Transfusi WRC s/d hb Hb/Ht/E/L/T mg/12 jam
Hb/Ht/E/L/T 9 gr/dl 7,8/23/2,8/23,9/16 SC Novorapid 10-10-10 Urinalisa 5/5/2017
5,2/14/1,7/11,1/208 Thyrozol 2 x 10 mg MCV/MCH/MCHC SC Levemir 0-0-0-16 Bj/pH : 1,015/8,0
MCV/MCH/MCHC Omeprazole 2x20 mg 81/28/35 Rawat luka/hari Protein : +1
82/30/37 Diftell : 0/0/0/87/5/8
Diftell : 6/1/0/71/14/8 PT : 10,3 Lab/30/04/2017
Ur/Cr : 119/9,60 Lab 3/5/17 Kontrol : 11,5 Hb/Ht/E/L/T
Hb/Ht/E/L/T INR : 0,96 10,7/32/4,5/16/509
3,2/10/0,9/12/400 APTT : 28,3 MCV/MCH/MCHC
MCV/MCH/MCHC/R Kontrol 33,7 70/24/34
DW Diftell : 1/1/0/80/13/5
115/38/33/18,9 HbsAg : negatif
Diftell : 1/0/0/60/30/9 Ur/Cr : 22/0,8
Bilirubin Na/K/Cl : 132/5,0/97
Total/indirect/direct
3,6/3/0,6
GDS : 125
Ur/Cr : 22/0,30
Na/K/Cl : 139/3,5/104
 K3B1’ K3B2 K3B3’ K3B4’ K3B5’
DPJP : DPJP : dr. Azhari DPJP : dr. Abdullah DPJP : dr. Abdullah DPJP :
COW : Ghani COW : dr. Mena COW : dr. Mena COW :
DR : COW : dr. Alfi DR : dr. Mala DR : dr. Mala DR :
Divisi : DR : dr. Rahmad Divisi : Divisi : Divisi :
Divisi :
Nama : Nurhayati Nama : Darmiati Nama : Sri Handayani Nama : Nurhasanah Nama : Raimatussadiah
Umur : 55 tahun Umur : 27 tahun Umur : 39 tahun Umur : 55 tahun Umur :48 tahun
CM : 1123464 CM : 1-12-80-09 CM : 0-67-88-28 CM : 1-12-63-72 CM : 1026038
Hari rawatan : 1 Hari rawatan : 4 Hari Rawatan : 2 Hari Rawatan : 16 Hari rawatan : 1

Ass/ Ass/ Ass/ Ass/ Ass/

1.efusi pleura sinistra ec dd/ 1.Bisitopenia ec dd/ 1.Diare kronik ec dd/ 1. CKD stage V on HD 1. ISK komplikasi
1. plera pneumonia 1. ITP 1. Colitis infeksi reguler ec DN 2. Diabetik nefropati
2. Tb paru 2. ALL 2. Colitis TB 2. Hipertensi Stage 2 3. Diabetik neuropati
3. meish sindrme 2. Hipokalemi sedang 2. CKD stage 5 on 3. DM tipe 2 4. Hipertensi Stage 1
CAPD normoweight 5. DM tipe 2 obes grade
2. Ascites ec sirosis hepatis Th/ 3. Hipokalemia berat 4. HAP dd/ TB paru 2
Bed rest 4. Anemia berat ec PGK infeksi sekunder 6. Anemia sedang ec
Th/ Diet M2 1700 kkal 5. Efusi pleura dextra PGK
Bed rest IVFD NaCl 0,9% 20 Th/ 6. Skizofrenia
O2 2-4 gtt/i -Bed Rest 7. ulkus diabetikum Th/
Diet sonde cair 6x200 cc Omeprazole 2 x 40 mg -Diet ginjal 1700 kkal + pedis dex Bed rest
Threeway KSR 2 x 600 mg 50 gr prot/hari 8 syok sepsis Diet ginjal 1700kkal
IV aminofusin hepar 1fl/hr Transfusi TC 10 kolf - IVFD NaCl 0,9% 15 Kateter,threeway
IV cefriaxon 2gr/24j gtt/i Th/ IV meropenem
KSR 1x600mg Lab/6/5/2017 - IV Cefotaxim 1 gr/24 - Diet ginjal 1700 kkal + 500mg/12 j
Lactulace syr 3xC1 Hb/Ht/E/L/T jam 40 gr protein /hr IV omeprazole 40
Sistenol 3x500 mg 8,6/26/3,4/6,3/2 IV Ondansetron 4 mg/8 - iv ceftazidime mg/24 j
MCV/MCH/MCHC: jam 500mg/12jam SC novorapid 16-16-16
Lab/7/5/2017 77/26/34 -Drip KCl 1 flacon falam -Drip metronidazole 500 IU
Hb/Ht/E/L/T Diftell 500 cc NaCl 0,9% 15 mg/8 j Sc levemir 0-0-0-10 IU
10/31/3,9/21,3/146 4/0/0/52/38/6 gtt/i - Asam folat 2x1 PCT 3x500mg
MCV/MCH/MCHC: Attapulgite - Valsartan 1x80mg IV ondansentron4gr/24j
80/26/32 Lacbon 3x1 - Amlodipin 1x10mg Grapalac syr 3xC1
Diftell : 0/1/0/82/10/7 KSR 2x600gr - iv Furosemide 1 gr/8 Amlodipin 5mg 1x1
jam Tanapres 5mgx1
Lab/ 4/5/2017 -Diazepam 2x2 mg Balance cairan
Hb/Ht/E/L/Tr -Risperidon 2 mg 2x1/2 Gabapentin 1x30 mg
6,1/19/2,5/6,8/363 tab
MCV/MCH/MCHC -Sc Novorapid 6-6-6 UI
76/24/32 - Gabapentin 1x300mg Lab/7/5/2017
Diff: 2/1/0/77/15/5 - iv tramadol amp/8 jam Hb/Ht/E/L/T
HbsAg: - -HD 3x/minggu 8,4/24/3/8,3/133
Bil. Tot/dir/indir/ MCV/MCH/MCHC:
0,42/0,35/0,07 Lab : 4/5/2017 80/28/35
SGOT/SGPT : 10/7 Hb/Ht/E/L/Tr Diftell : 2/0/0/68/17/13
GDS: 183 8,7/27/3,4/23,9/341 Ur/Cr : 174/7,23
Ur/Cr: 56/8,95 MCV/MCH:81/26 Na/K/Cl : 137,4,3/104
Diff: 0/0/0/88/4/5
Lab 5/5/2017 Na/K/Cl : 136/3,3/100
Na/K/Cl : 138/2,5/109 Albumin : 2,79
 K4B1’ K4B2’ K4B3 K4B4’ K4B5’
DPJP : dr. Eva DPJP : dr. Chacha DPJP : dr. Abdullah DPJP : dr. Azhari DPJP : dr. Azhari
COW : dr. Wira COW : dr. Wira COW : dr. Cut Mena Gani COW : dr. Alfi
DR : dr. MIrzal DR : dr. Mirzal DR : dr. Mala COW : dr. Alfi DR : dr. Rahmat
Divisi : Divisi : EMD Divisi : EMD,GEH DR : dr. Rahmad Divisi :
Divisi :
Nama : Dika Nofrida Nama : Maisarah Nama : Nurhayati Nama : Yusmaniar S Nama : Roslaini
Umur : 21 tahun Umur : 56 tahun Umur : 51 tahun Umur : 63 tahun Umur : 39 thn
CM : 1-05-28-58 CM : 1-12-74-84 CM : 0-95-64-50 CM : 1128018 CM : 1128237
Hari Rawatan : 8 Hari Rawatan : 8 Hari Rawatan : 9 Hari Rawatan : 3 Hari Rawatan : 2

Ass/ Ass/ Ass/ Ass/ Ass/

1.Hipokalsemia ringan ec 1.DVT ar. Pedis (S) 1. Tumor intraabdomen ec 1.Cholestasis pasca 1. PSMBB ec dd/
Lowparathyroid hormon 2. CHFfc NYHA II ec dd/ 1. Ca Colon hepatik ec dd/ 1. Haemoroid
2. PJT DCM 2. abses psoas 1. cholelitiasis 2. Polip Recti
3. Abses renal
3 AF RVR 3. Hipokalemia ringan 4. Ca ovarium
3. Ca Caput Pankreas 3. Diverticilosis
4. Candidiasis oral 4. diabetik nefropati 5. Ca Renal 4. Ca Ampula Vateri 2. Bisitopenia ec dd/
5. Hipokalemia berat stage 4 2. Sepsis ec dd/ 2. Anemia NN ec dd/ 1. Leukimia Akut
6. Hiponatremi hipoosmolar 5. hipoalbuminemia 1. CAP - perdarahan 2. Anemia aplastik
hipovolemik 6. DM tipe 2 obese 2. TB paru dengan infeksi - penyakit kronik 3. myelodisplasia
7. Hipotiroid grade 2 sekunder syndrome
7. Neuropati diabetik 3. Anemia Th/
Th/ 8. Hiperurisemia 4. DM tipe II overweight Bedrest Th/
Bed rest 9. Dislipidemia 5. Hipoalbumin Diet hati M II 1700 kkal Bedrest
6. Cancer pain
IVFD NaCl 0,9% 20 gtt/i +kcl 10. dd ( perbaikan) IVFD Aminofusin hepar kateter
1 fls 1. HAP Th/ 1 fls/hr Diet MII 1700 kkal
Ostriol 2 x0,25 mg 2. TB Paru Bedrest IVFD NaCl 09% 20 gtt/i IVFD NaCl 0,9% 20gtt/i
Tanapres 1x5 mg 3. Mikosis Paru. kateter Cetrizine 1 x 10 mg Iv Meropenem 1 gr/8
Lenal ace 3x1 11. gastroperesis Diet DM 1700 kkal Transfusi PRC s/d Hb 10 jam
Bisoprolol 1 x 2,5mg diabetik IV meropenem 1 gr/8 jam gr/dl IV As. Tranexamat
Nystatin drop 4 gtt II IV omeprazole 40 mg/12 j KSR 2x600 Anti haemoroid supp
Euthyrox 1 x 50 mg Th/ Drip albumin 100 cc Drip KCL 25mg/hari Transfusi Tc 10 kolf
Salisilk Talk Bed rest Duragesic Patch
Nistatin drop 4x2 cc
KSR 1x600 gr Diet DM 1800 kkal + MST 3x100 mg
Lab 5/5/2017
ekstra putih telur KSR 2x600 mg Lab/3/5/2017 Hb/Ht/E/L/T
Lab 5/5/2017 Threeway Sc Novorapid 8-8-8 IU Hb/Ht/E/T/L 8,6/25/2,8/30,6/15
Alb: 3,67 IV furosemide 40 mg/8 Sc Levemir 0-0-0-10 IU 6,6/20/2/7,4/573 GDS : 158
Ca/Na/K: 9,0/135/2,9 j MCV/MCH/MCHC/RDW Ur/Cr : 17/0,69
Spironolakton 2x25 mg 98/33/33/19,3 Na/K/Cl: 141/3,3/106
Lab 5/5/2017 Diftell; 5/0/1/66/23/5
Lab 02/05/2017 PCT 3x500 mg CT/BT: 8/3 Bilirubin total : 11,33
Hb/Ht/E/L/T Flumucyl 3xCI Alb: 2,50 SGOT/SGPT : 115/55
13,9/37/5/11,4/288 Sc Lavenox 0,6 cc/12 Ur/Cr: 10/0,70 Albumin : 2,59
MCV/MCH/MCHC/RDW jam Na/K/Cl: 131/3,8/99 GDS : 214
74/28/38/13,7 Valsartan 1 x 80 mg Ur/Cr : 13/0,65
Diftell : ISDN 3x5 mg Lab 02-05-2017 Na/K/Cl : 137/2,2/108
2/0/0/68/20/10 KSR 1 x 600 mg Hb/Ht/E/L/T
FT4 :3,01 Pradaxa 1 x 75 mg 11,8/35/4,9/20,1/282
TSH : < 0,005 N Asetil sistein 3x100 MCV/MCH/MCHC/RD
Protein total : 5,90 mg W
Alb/ globulin : 3,55/2,35 Rosuvastatin 1x20 mg 72/24/33/21,2
Ur/Cr : 11/0,34 Gabapentin 1x300 mg Diftell :
Na/K/Cl : 129/2,0/94 Allupurinol 3x100 mg 2/0/0/83/10/5
Domperidon 3x10 Protein total : 6,30
Albumin : 2,37
Lab 02-05-2017 Na/K/Cl : 133/2,8/108
HbA1C : 7,10

Lab 5/5/2017
Hb/Ht/E/L/T
9,6/31/3,6/12,1/330
MCV/MCH/MCHC
88/27/31
LED: 49
Diff: 9/1/0/52/29/9
 K5B1 K5B2’ K5B3’ K5B4’ K5B5’
DPJP : dr. Eva DPJP : dr. Abdullah DPJP : dr. Eva DPJP : dr. Abdullah DPJP : dr. Abdullah
COW : dr. Wira COW : dr. Cut mena COW : dr. Wira COW : dr. Cut Mena COW : dr.Cut Mena
DR : dr. Mirzal DR : dr. mala DR : dr. Mirzal DR : dr. Mala DR : dr. Mala
Divisi : Divisi : Divisi : Divisi : Divisi :
Nama : Maulidar wati Nama : Asnidar Nama : Murniati Nama : Ernidar Nama : Husna Said
Umur : 28 tahun Umur : 71 tahun Umur : 51 Umur : 45 tahun Umur : 65 tahun
CM : 1-12-77-21 CM : 1128312 CM : 1-12-78-93 CM : 1128303 CM : 1-12-79-06
Hari rawatan : 6 Hari Rawatan : 1 Hari Rawatan : 4 Hari Rawatan : 1 Hari Rawatan : 3

Ass/ Ass/ Ass/ Ass/ Ass/

1. Bistopenia ec dd/ 1.TB paru relaps dd 1.ikterik ec dd/ 1. 1.Prolonged fever ecdd/
-leukemia akut  Pneumonia -Cholesistitis akut 2 DM tipe 2 - TB Paru
-SLE  Bronkietasis -Choledocolithiasis normoweight -.autoimune disease
-ITP 2. Susp kolitis TB dengan cholesistitis 3 Neufropati diabetkum - malignancy
-Mielofibrosis 3. Hipertensi stage 2 -Ca ampula vateri 4 AKI stage 1 2. anemia sedang
-MDS 4. Anemia hipokrom -Ca Caput Pankreas 5 konstipasi hipokrom/mikrositer
2. Herpes simplek mikroster ec def zat 2. CHF FC NYHA II ec - perdarahan
besi dd/ - penyakit kronik
Th/ - HHD Th/ 3. Hiponatremi
Bedrest Th/ - Penyakit jantung Bedrest hipoosmolar hipovolemi
IVFD Nacl 0,9% 20 gtt/i Bedrest Katup IVFD NaCL 0,9%
Transfusi PRC sd HB <10 Diet MB -CAP Diet DM 1700 kkal Th/
Asiklovir 5x500 mg IVFD NaCl 20 gtt/i 3. AF NVR IV prosogan 200 gr/12j Diet MB TKTP
Primolut 2x1 4.post sstroke iskemik IV ondansentron IVFD NaCl 0,9 % 20 gtt/i
IV ceftriaxone 1gr/24
5. high risk trombosis 4gr/8jam Iv Ceforoxime 750 mg/12
jam jam
Amlodipin 1x10 gr 6. OMI Septal Gabapentin 1x100gr PCT 3 x 500 mg
Lab/ 6/5/2017 IVprosogan 7.Hipoalbuminemia Sukralfat syr 3xC1 Lansoprazole 2 x 30 mg
Hb/ht/e/L/T 1amp/12jam 8. Hipokalemia sedang Amlodipine 1x10gr Sucralfat Syr 3 x C1
10,3/30/3,8/7,5/15 9. ISK Transfusi PRC sd Hb >10
Diftell: 0/1/0/55/22/22 Lab 6/5/17 10. Dislipidemia Lab/
MCV/MCH/MCHC/RDW/M Hb/Ht/E/L/T Lab/4/5/2017
PV 9,1/30/4,7/5,7/141 Th/ Hb/Ht/E/L/T
79/27/35/16,4/8,7/11,7 MCV/MCH/MCHC Bedrest 8,4/26/47/7,2/181
64/20/31 Diet Hati 1800 kkal + MCV/MCH/MCHC
Diftell: 6/1/0/66/18/9 ekstra putih telur 56/18/32
IVFD NaCl 0,9 % 10 Diftel: 0/0/0/51/40/9
gtt/i
IV Cefoperazon Anti Dangue IgM/IgG ;
sulbactam 1 gr/8 jam Negatif/negatif
Flukonazol 1x150 mg GDS : 119
Urdafalk 3 x 250 mg Ur/Cr : 15/0,80
Curcuma 3 x 1 tab Na/K/Cl : 125/3,6/100
Tanapres 1x 5 mg
ISDN 1 x 5 mg
Furosemid x 40 mg
Sprinolakton 1 x 25 mg
KSR 1 x 600 mg
Aspilet 1 x 80 mg
Resovastatin 1 x 20 mg

Lab/5/5/2017
Bilirubin total: 17
Bilirubin direk: 13,97
Bilirubin indirect: 3,03
SGOT/SGPT: 46/34
Albumin : 2,58
 K6B1’ K6B2` K6B3 K6B4’ K6B5’
DPJP : dr. Eva DPJP : dr. Abdullah DPJP : dr. Azhari gani DPJP : dr. Eva DPJP : dr. Abdullah
COW : dr. wira COW : dr. Cut Mena COW : dr. Alfi COW : dr. Wira COW : dr. Mena
DR : dr. mirzal DR : dr. Mala DR : dr. Rahmat DR : dr. Mirzal DR : dr. Mala
Divisi : Divisi : Divisi : Divisi : Divisi :
Nama : Ajimah Nama : Ismiati Nama : Rosdiana Abd Nama: Khatijah Nama: Suryati
Umur : tahun Umur : 39 tahun Umur : 33 tahun Umur : 64 tahun Umur : 46
CM : 1-12-74-29 CM : 1128310 CM : 1128048 CM : 1128044 CM : 1128156
Hari Rawatan :9 Hari Rawatan : 1 Hari Rawatan : 3 Rawatan: 3 Rawatan: 2

Ass/ Ass/ Ass/ Ass/ Ass/

1.Sirosis hepatis stad DC 1. CKD stage 5 1. Bisitopenia ec dd/ 1. dd/ 1. CML fase krisis 1. CKD stage 5 on HD
related Hepatitis B Child 2. DM tipe 2 1. Anemia aplastik blast reguler dengan Ureum
Mugh normoweight 2. Leukimia akut 2. CML fase akselerasi syndrom
2.hipoalbumin 3. MDS 3. CML fase kritis 2. PSMBA
3. DM tipe 2 normoweight Th/ 2. Hemiparese sinistra ec 4. CLL 3. Hiperkalemia sedang
4. Pneumonia geriatri Bedrest dd/ 1. Intracranial 2. omi inferior 4. Anemia berat ec dd/
5. Hipokalemia (perbaikan) O2 2-4 l 2. Stroke haemorage 3. dd/ 1. CAP 1. PGK
Diet ginjal 1700 kkal 2. TB paru dengan 2. perdarahan
Th/ IV cefriaxon 1 gr/24 Th/ infeksi sekunder 5. Hipoalbumin
Bedrest jam Bedrest 3. Mikosis paru 6. Hepatitis B
Diet DM 1800 kkal Balance cairan IVFD NaCl 0,9% 20 gtt/i 4. kandidiasis oral 7. HHD
IVFD Aminofusin hepar 500 Pasang NGT IV Omeprazole 40 mg/ 5.VES trigemini
cc/24 jam Drip herbeser~stock 24 jam (perbaikan) Th/
Curcuma 3x1 obat d rs habis jadi stop Drip Ciprofloxacin 200 Bedrest
IV Sufoperazin sulbactam 1 Herbeser CD mg/12 jam Th/ Diet gnjal 6x200 cc
gr/12 jam 3x300mmg tab Sukralfat syr 3xC1 Bedrest NGT
KSR 1x600 Drip perdipin mulai Transfusi TC 10 kolf Diet TKTP Kateter
Lenal Ace 3x1 0,05,trget tek darah Citicolin 500 mg/12 jam IVFD NaCl 0,9% 20 gtt/i IVFD NaCl 0,9% 20
Furosemid 1x40 sistol 140-160 mmHg IV levofloxacin 500 gtt/i
Spironolakton 2 x 100 mg Lab/6/5/2017 mg/24 jam IV Ceftriaxon 2 gr/24
Propanolol 2 x 10 mg Lab/6/5/2017 Hb/Ht/E/L/T PCT 3x500 mg jam
Drip albumin 25 % 100 cc/hr Hb/Ht/E/L/T 4,4/14/18/12/2 Nistatin drop 4x2cc IV prosogan 60 mg
Lactulac syr 3 x C1 8,7/23/3,1/6,4/343 MCV/MCH/MCHC ISDN 3x5 Transfusi PRC
Ekstrak telur gabus 3x1 MCV/MCH/MCHC 81/25/31 Valsartan 1x80 mg HD
Balance cairan 74/28/38 Diff: 1/0/0/73/20/6 Bisoprolol: 1x2,5 mg Kalitake 3x1 sachet
Diff: 0/0/0/86/12/2 Transfusi PRC Balance cairan
Lab/2/3/17 GDS : 192 Nistatin drop 4xgtt 2
Hb/Ht/E/L/T Ur/Cr : 383/28,47 Lab/5/5/2017
10,3/26/2,8/8/173 Na/K/Cl : 131/4,3/86 Lab/4/5/2017 Hb/Ht/E/L/T
MCV/MCH/MCHC/RDW Hb/Ht/E/L/T 6,8/19/2,4/16,8/170
94/37/40/21,2 8,5/24/2,7/66,4/8 MCV/MCH/MCHC
Diftel : MCV/MCH/MCHC 79/29/36
3/1/0/44/35/17 86/31/36 Diff: 0/0/0/88/6/6/
Diff: 0/0/0/6/10/84 HbsAg : +
Lab 5/5/2017 GDS: 162 Alb: 2,73
Alb: 2,29 Ur/Cr: 44/1,40 GDS: 115
Na/K/Cl: 132/3,8/104 Na/K/Cl: 131/3,1/99 Ur/Cr: 545/18,70
Na/K/Cl: 133/6,8/102