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Denah Ruang Rawat

AQSHA 3 (Penyakit Dalam Wanita)

Hari/Tanggal : Sabtu/9 Juni 2018


Dokter Jaga : dr.Dedi/dr.Hambali
Dokter Muda : Manda/Ayu/Fara/Muchsal

K1B1 K1B2 K1B3 K1B4


DPJP :dr. M.Riswan, SpPD DPJP :dr. M.Riswan, SpPD DPJP :dr. M.Riswan, SpPD DPJP :M. Riswan, spPD
COW : dr. Al Kautsar COW : dr. Al Kautsar COW : dr. Al Kautsar COW : dr. Al Kautsar
DR : dr. Muchsin DR : dr. Muchsin DR : dr. Muchsin DR : dr. Muchsin
DM : Roji DM : Roji DM : Roji DM : Roji
Nama : Juariah Nama : Ainul Mardiah Nama : Syarifah Nama : Sri Fauziah
Umur : 80 tahun Umur : 53 th Umur : 70 tahun Umur : 70th
CM : 1-09-78-96 CM : 1174061 CM : 1117583 CM : 1112613
Hari rawatan : 3 Hari rawatan :8 Hari rawatan :8 Hari rawatan : 4

A/ A/ A/ A/
1.PSMBA ec DD/ 1. Anemia ringan HM ec dd/ 1. Bisitopenia ec dd/ 1.Penurunan kesadaran ec dd
-ulcus gaster - defisiensi besi -Metastase SSTL -sepsis
-ulcus duodenum - penyakit kronik -Myelofibroma -stroke
-gastritis erosive 2. PSMBA ec Gastritis erosif ar -MDS 2. pneumonia geriatric
-varises esofagus bleeding fundus 2. Massa Acetabulum 3. Ulcus diabeticum grade II
2. pneumonia (CAP) dd/ 3. Pneumonia (perbaikan) 3.AKI stage III renal ec uropati 4. Anemia sedang NN ec dd
- TB Paru dengan sekunder 4. ISK obstruksi -peny kronik
infeksi 5. Hipoalbuminemia sedang (2,76) 4. Hemoroid Interna grade II - defisiensi besi
-mikosis paru 5. Dyspepsia type like ulcer dd type 5.hipoalbuminemia sedang ec
3. Hiponatremia Normoosmolar Th/ mixed renal loss
euvolemik -bed rest 6. High Risk Trombosis 6.hipereosinofilia suspek invasi
.4.Anemia sedang HIkpokrom -diet MII 1700 kkal/hari 7. Pneumonia parasit
mikrositer ec DD/ -IV ceftriaxone 2 gr/ 24 jam 7.geratri problem
- def Fe - IV lansoprazole 30 mg/12 jam Th/ (imobilisasi, instabilitas dan
-perdarahan - sukralfat syr 3x CII - Bedrest jatuh, infeksi, inanisi)
- Penyakit kronik - Diet MII TKTP
5. OMI septal ec CAD Lab 5/6/2018 - IVFD Nacl 0,9% 20 gtt/i Th/
6. DM tipe 2 underweight Hb/Ht/E/L/T - IV lansoprazole 30mg/12jam -bedrest, mika-miki, kasur
7. Dyspepsia tipe dismotility 9,9/27/3,0/3,4/91 - Anti Hemorhoid sup 2x1 decubitus
MCV/MCH/MCHC - Transfusi PRC sd. Hb> 10 gr/dl -NGT,kateter terpasang
Th/ 93/34/36 - Sukralfat syr 3 CII -diet sonde via NGT 6x200cc
- Bed rest Diftell : 1/0/0/66/31/2 - inj cefepim 1 gram/8 jam -IVFD NaCl 0,9%20gtt/i
- NGT, Spooling NaCl 150cc/6 Ur/Cr : 32/0,55 - pradaxa 1x75 mg -IVFD Clinimix+clinoleic 1
jam Na/K/Cl : 134/3,4/110 - laxadyn 3xCII fls/hari
- Diet sonde 6x200 ml - PCT 3x500mg (stop) -IV ceftriaxone 2 gr/24jam(H3)
- IVFD NaCl 0,9 % 20 gtt/i - MST2x1 tab -Flumucyl syr 3xCI
- IV lansoprazole 30 mg/12 jam - drip albumin 20% 100 cc 1fls/hr
- IV ceftriaxone 2 gr/24 jam Lab 04/06/2018 - meropenem 1g/8 jam (skin test)
- flumucyl 3x1 Hb/Ht/E/L/T
- sukralfat syr 3xC1 6,9/21/2,5/10,3/16 Lab 08/06/2018
- sc lantus 0-0-0-10 unit (22.00) MCV/MCH/MCHC Analisa tinja
- transfuse PRC sd HB > 10gr/dl 83/28/34 Warna : coklat
- paracetamol tab 3x 500mg Diftell : 3/1/1/49/27/19 Bau : khas
MDT: Normokrom Normositer, Eritrosit/leukosit : -/-
lab 8/6/2018 Trombositopenia Telur cacing :-
LED : 130 Anti HCV:Negatif Parasite :-
Retikulosit : 1,6 HBsAg:Negatif Konsistensi : lunak
PT/APTT : 0,90/1,10 Biltot/Bildirect/Bilindirect
Feritin : 244,58 0,49/0,26/0,23 Lab 06/06/2018
Anti HCV/HBsAg : -/- SGOT/SGPT: 37/28 Urinalisa
Besi : 12 ALP:120 Warna : kuning
Kolesterol total/LDL/HDL: Albumin:3,20 Kejernihan : keruh
226/31/155/151 BJ/PH : 1,015/6,5
Trigli8serida : 151 Lab 02/06/2018 Leukosit: +
Hb/Ht/E/L/T Protein : + 1
lab 7/6/2018 3,6/11/1,3/9,1/20
Hb/Ht/E/L/T Diftell : 4/1/0/50/30/15 Lab 05/06/2018
8,8/27/3,4/22,8/343 Hb/Ht/E/L/T
MCV/MCH/MCHC Lab 01/06/2018 7,5/24/2,7/24,6/384
78/26/33 Hb/Ht/E/L/T MCV/MCH/MCHC
Diftell : 0/1/0/87/41/8 4,3/14/1,6/11,8/7 90/28/32
GDS : 545 MCV/MCH/MCHC Diftell : 10/0/0/70/15/5
Ur/Cr : 22/0,44 87/28/32 Albumin : 2,36
SGOT/SGPT : 10/11 Diftell : 3/1/1/47/33/15 GDS : 98
Na/K/Cl : 125/4,4/94 SGOT/SGPT: 35/27 Na/K/Cl : 132/4,6/97
GDS: 90
Ur/Cr: 113/3,12
Na/K/Cl: 142/5,3/117

K2B1 K2B2 K2B3 K2B4 K2B5


DPJP :dr.M.Riswan,Sp.PD DPJP :dr. M.Riswan, SpPD DPJP :dr. M.Riswan, SpPD DPJP :dr. M.Riswan, SpPD DPJP :dr. M.Riswan, SpPD
COW : dr. Al Kautsar COW : dr. Al Kautsar COW : dr. Al Kautsar COW : dr. Al Kautsar COW : dr. Al Kautsar
DR : dr. Muchsin DR : dr. Muchsin DR : dr.Muchsin DR : dr. Muchsin DR : dr. Muchsin
DM : Ayu DM : Ayu DM : Ayu DM : Cut harvina DM : Cut harvina
Nama : sumiati Nama :Nurlina Nama : Cut Agusdiana Nama: Ummiah Isa Nama: Nursaina Bancin
Umur : 57th Umur : 45tahun Umur : 27 tahun Umur: 69 tahun Umur:47 th
CM : 1-02-26-53 CM: 1174178 CM : 1055754 CM: 1-17-45-46 CM:1174192
Hari rawatan : 16 Hari Rawatan : 5 Hari rawatan : 19 Hari Rawatan: 3 Hari Rawatan: 5

A/ A/ A/ A/ A/
1. AF NVR (perbakan) 1.Massa esophageal gastro 1. Thalasemia Beta Mayor 1.CKD stage V dengan 1. penurunan kesadaran ec
2.CKD stage V on HD junction suspek Cag aster 2. Asites ec susp SBP uremic syndrome ec DD/ DD/
reguler 2. Sarkopenia ec 3. Anemia sedang ec -DN -uremic ensefalopati
3. compartemen sindrom malignancy thalasemia GNC -imbalance cairan
ar brachialis sinistra post 4. Dyspepsia Tipe 2. Anemia ringan hipokrom - hepatic ensefalopati
fasciotomi Th/ dismotility mikrositer ec DD/ 2. edema paru (perbaikan)
-Bedrest 5. Amenore sekunder ec -Def Fe akut ec acute decompesata in
Th/ -Diet bubur saring Hipogonad -peny.kronik chronic HF
-bedrest 1500kkal/hari 3. Pneumonia (CAP) 3. elevated liver enzym ec
-O2 2-4liter -IVFD Clinimix 1fls/hari + Th/ 4. DM tipe 2 normoweight dd
-diet ginjal 1700kkal clinolice 20 gtt/mnt -Bedrest 5.Trombositopenia -hepatik hepatopati ec liver
protein 65mg - IVFD NaCl 0,9% 20 -Three way 6. LVH suspek kardiomiopati congestive
-threeway gtt/mnt -IV omeprazole 40mg/12j - iskemik liver
- iv cefoperazone 1 gr/12 -IV furosemide 1 amp/12 Th/ 4. cardiorenal syndrome tipe
jam (H10) Lab 31/5/2018 jam (1-1-0) -bedrest 2 dengan akut on CKD
Hb/L/T : 9,8/9,8/555 - domperidone 3x tab 1 -O2 2-4L/I NL 5. CHF FC NYHA IV
Lab 6/06/2018 GDS : 94 -exjade 1x500mg -Diet ginjal II 1700 kkal/hari 6. MR severe
Hb/Ht/E/L/T Na/K/Cl : 137/2,39/88 -Vit E 1x1 tab + 60 gr protein/hari 7. TR moderate
8,8/25/2,5/9,1/169 Ur/Cr : 46/0,6 -asam folat 1x400mcg -threeway 8. suspek CAP
Ur/Cr : 97/12,43 - KSR 2x 600mg - pasang NGT 9.HHD on terapi
Na/K/Cl : 140/4,7/104 - PCT 3x500 mg (k/p) -IV ceftriaxone 1 gr/ 12 jam 10. ISK asimptomatik
-IV furosemide 20 mg/ 12 11. Hipernatremia
Lab 4/06/2018 Lab 8/6/2018 jam hipovolemia
Hb/Ht/E/L/T Hb/Ht/E/L/T -asam folat 2x400mg 12. diare akut ec intoleransi
9,5/28/2,7/9,5/207 7,0/20/2,5/7,7/140 -IV ondansetron 4gr (K/P) susu
MCV/MCH/MCHC MCV/MCH/MCHC: - lenal ace 2x169 mg 13. Hipokalemia sedang ec
103/35/34 82/29/35 - bicnat tab 2x1 tab iatrogenic (induced insulin)
Diftel : 2/0/0/68/18/12 Diftell : 0/1/0/47/43/9 -fluimucyl 3x20mg
PT/APTT 1,13/1,301 Albumin : 2,72 -HD Th/
Na/K/Cl : 132/3,5/94 -balance cairan/hari - Bedrest semifowler
Lab 29/05/2018 LED: 140 -diet DM 1700 kkal+ protein
Albumin : 3,76 Lab 06/06/2018 0,8/kgBB (40-45 gr/mnt)
Ca : 8,3 Lab 5/6/2018 Urinalisis rendah garam < 2gr/hari
Na/K/Cl : 149/4,9/107 Hb/Ht/E/L/T Warna : kuning - O2 2-4 liter via nasal kanul
7,9/23/2,7/6,3/196 Kejernihan : keruh -IVFD Nacl 10 gtt/mnt
Lab 27/05/2018 LED : 130 BJ/pH :1,010/6,5 -IV Furosemide 40 mg/6 jam
Hb/Ht/E/L/T Feritin : 4707,33 Leukosit/protein : +/+1 -IV Ceftriaxone 2 gr/24 jam
9,0/25/2,6/5,2/139 Albumin : 2,31 -IV Lansoprazole
MCV/MCH/MCHC Lab 06/06/2018 30mg/12jam
98/35/36 Lab 2/6/2018 Hb/Ht/E/L/T -Tanapres 1x5mg
Diftel : 1/0/0/72/21/6 Anti HCV / HbsAg: 10,3/31/4,3/52/12,6 -ISDN 3x5 mg
Ur: 85 negative/negative MCV/MCH/MCHC -Clopidogril 1x75mg
Na/K/Cl : 143/4,7/109 Bilirubin 73/24/33 -bisoprolol 1x5mg
total/direct/indirect: Diftel : 0/0/1/93/3/3 -valsartan 1x40mg
Lab 25/5/2018 3,74/2,29/1,45 Anti HCV : negative -allopurinol 1x100mg
Urinalisa SGOT 54 HbsAg : negative -Curcuma 3x2 tab
Protein (+1) Albumin/globulin : GDS : 144 -Sukralfat 3xCII
Darah (+) 1,95/6,47 Ur/Cr : 125/3,51 - insulin drip  tunda, ganti
Ca: 6,7 Na/K/Cl : 136/3,6/105 dengan insulin basal bolus
Na/K/Cl : 133/3,6/101 - apidra 6-6-6
-levemir 0-0-0-10 unit
Lab 29/05/2018 - KSR 3x 600mg
Hb/Ht/E/L/T -balance cairan
8,8/25/3,1/6/154 -drip insulin 3 unit/jam
MCV/MCH/MCHC :
82/29/35 Lab 6/6/2018
Diftel : 1/1/0/50/38/10 Procalcitonin : 23,03
Ca : 7,9
25/5/208 Ur/cr :240/6,72
GDP : 122 Na/K/Cl : 142/4,8/116
G2PP : 255 Lab 6/6/2018
Hb/Ht/E/L/T
144/42/5/108/19,3
MCV/MCH/MCHC
84/29/34
Diftel : 0/0/0/93/3/4
Ur/Cr : 299/6,75
Na/K/Cl : 137/6,9/96

MDT : kesimpulan
Normokrom normositer
Leukositosis
trombosiopenia

Lab 5/05/2018
Bil Tot/dir/indir :
1,22/0,81/0,41
SGOT/SGPT : 474/554
Asam urat : 18,2

Lab 4/05/2018
Troponin I 1,00
CKMB 40

Lab 3/05/2018
Hb/Ht/E/L/T
11,9/33/4.1/22,9/87
MCV/MCH/MCHC
81/29/36
Diftel : 0/0/0/94/3/3
Ur/Cr: 141/ 4,25
PT/APTT 1,54/1,55
Anti HCV –
HbsAg –
SGOT/SGPT 866/564
Albumin 3,21
Gds 350
Na/K/Cl 139/4,9/110

K3B1 K3B2 K3B3 K3B4 K3B5


DPJP :dr. Fauzi Y, Sp.PD DPJP :dr. Fauzi Y, Sp.PD DPJP :dr. Fauzi Y, Sp.PD DPJP :dr. Fauzi Y, Sp.PD DPJP :dr. Fauzi Y, Sp.PD
COW : dr. Laura COW : dr. Laura COW : dr. Laura COW : dr. Laura COW : dr. Laura
DR : dr. Fadhila DR : dr. Fadhila DR : dr. Fadhila DR : dr. Fadhila DR : dr. Fadhila
DM : Cut harvina DM : uyun DM : uyun DM : uyun DM : Naso

Nama : Nama : Sabidah Nama : Bukhniar Nama : Suryani Nama : Sabar Liana
Umur : Umur :67th Umur : 53 th Umur : 49 th Umur :24th
CM : CM :1174315 CM : 1131466 CM : 1172087 CM :0980042
Hari Rawatan : Hari rawatan :4 Hari rawatan : 1 Hari rawatan :2 Hari rawatan :5

A/ A/ A/ A/
1. CKD stage V on Hd 1. CKD stage V ec DN on 1.penurunan kesadaran ec 1.prolonged fever ec dd
regular ec HN HD regular dengan edema dd -pneumonia
2. HCAP dd/ TB paru paru -syok hipovolemik -TB Paru
sekunder infeksi8 2. Anemia sedang NNec -sepsis -ISK
3. Penurunan kesadaran ec PGK -imbalance elektrolit -Faringitis kronis
dd/ -infeksi viral -ISK
- hipotensi induce dialysis T/ 2. diare akut ec dd/
- imbalance elektrolit -bedrest -intolerasni makanan Th/
-O2 4-6 L/mnt -infeksi bakteri -bedrest
Th/ -Diet ginjal 1700kkal + 60 3. CAP dd TB paru -diet MB TKTP 1700kkal/hari
-bedrest gr prot/hr 4. Anemia berat NN ec DD/ -IVFD RL 20gtt/i
- O2 via nasal kanul 4L/mnt -IV furosemide 40mg - peny .kronis -drip PCT 1 gr/8jam
- diet sonde 6x 200 cc + 60 (extra) -occult bleeding -IV ceftriaxone 2 gr/24 jam
gr protein/hari -Transfusi PRC s/d Hb 9 5. AKI stage 1 (pre renal) (skin test)
- threeway gr/dl
- Iv cefepim 1 gr/ 24 jam -Asam folat 2x400mg Th/ Lab 7/6/2018
-PCT 3x500 mg -Lenal ace 2/169mg -Bed rest LED : 40
- vectrin 3x20 mg -HD (hariini) bila Hb ≥ 6 -IVFD 20 gtt/i Malaria : negative
- lenal ace 2x169 mg gr/dl dengan back up PRC2 -ciprofloxacin drip
- asam folat 2x400 mg kolf 400mg/12jam Urinalisis :
-amlodipin 1x10mg -attapulgit 2 tab (inisial) Protein : +1
Lab 7/6/2018 -valsartan 1x80mg selanjutnya 1 tab tiap BAB Darah: Positif
Hb/Ht/E/L/T cair. Leukosit : 20-25
9,3/28/3,4/12,6/294 Lab (8/6/2018) -Transfusi PRC sd Hb > 10 Eritrosit : 10-15
MCV/MCH/MCHC Hb/Ht/E/L/T: gr/dl Epitel : 8-10
82/27/33 4,8/14/1,7/8,0/193 -PCT 1 gr/8jam
Diftel : 4/0/0/76/14/6 MCV/MCH/MCHC: -lacbon 3x1 Lab 5/6/2018
GDS : 119 85/28/33 Hb/Ht/E/L/T
Ur/Cr : 98/8,06 Diftell: 12,1/3,7/4,9/10/333
Na/K/Cl : 143/3,9/110 3/1/0/75/16/5 lab 7/6/2018 Na/K/Cl : 138/3,9/110
LED 95 Ur/Cr : 16/0,5
Bilirubin total 0,54
Direct/indirect : 0,34/0,20
SGOT/SGPT : 142/53
HbA1c : 9.2

Lab 6/6/2018
Hb/Ht/E/L/T
6,1/17/2,2/7,5/97
MCV/MCH/MCHC
81/28/35
Diftell : 0/0/1/87/8/4
GDS : 193
Ur/Cr : 68/1,84
Na/K/Cl : 133/5,1/111

K4B1 K4B2 K4B3 K4B4 K4B5


DPJP :dr. Fauzi Y, Sp.PD DPJP :dr. Fauzi Y, Sp.PD DPJP :dr. Fauzi Y, Sp.PD DPJP :dr. Fauzi Y, Sp.PD DPJP :dr. Fauzi Y, Sp.PD
COW : dr. Laura COW : dr. Laura COW : dr. Laura COW : dr. Laura COW : dr. Laura
DR : dr. Saddam DR : dr. Saddam DR : dr. Saddam DR : dr. Saddam DR : dr. Saddam
DM : Naso DM : Naso DM : Alex DM : Alex DM : Alex
Nama: Marhamah Nama : rahyuni Nama:Zakiah Yahya Nama :warnidar Nama: Hamidah
Umur: 30 th Umur : 23 th Umur:44 th Umur : 30 th Umur: 72 tahun
CM: 1043225 CM : 1174539 CM: 0951404 CM : 1147515 CM : 0-88-76-09
Hari Rawatan: 1 Hari rawatan : 3 Hari rawatan : 1 Hari rawatan :3 Hari Rawatan:9

A/ A/ A/ A/ A/
1. edema anasarka ec DD 1.prolonged fever ec dd 1. STEMI anterior late 1. CML 1.penurunan kesadaran e.c
-sindrom nefritik -SLE onset 2. Dyspepsia tipe like DD
-sindrom nefrotik -TB paru 2. CKD stage V ec dd/ mixed - SDA
-hipoalbumin -malignancy - diabetic nefropati -stroke
2. Hipertensi stage 1 2. Hiponatremia - GNC Th/ - Imbalance elektrolit
3. Anemia sedang hipoosmolar euvolemik 3. DM type 2 normoweight - Bedrest -sepsis
normokrom normositer ec dd 3.anemia sedang HM ec dd 4. Massa a/rcolli dextra ec - Diet MII 1700kkal/hari 2. SDA dengan pencetus
- penyakit kronik -def Besi dd/ - IVFD NaCl 0,9%20gtt/i gangguan elektrolitdan infeksi
- perdarahan -penyakit kronik - limfoma maligna - IV prosogan 30 3. ISK
4. hipokalemia ringan 4. status hipokoagulasi - limfadenitis Tb mg/12jam 4. pneumonia (CAP)
5. Diare akut ec dd/ - limfadenitis infeksi -Sucralfat syr 3xCI 5. Hipokalium
Th/ -infeksi virus -Curcuma tab 3x1 6. Hiponatremia hipoosmolar
- bedrest -infeksi bakteri T/ - Transfusi trombosit jika hipovolemik
- threeway -intolerasni makanan. -bedrestsemifowler Trombosit <20.000 dengan 7. Hipoalbumin
- IV furosemide 1 amp/8 jam -O2 2-4 L/hari perdarhan, trombosit 8.Hemiparesis dextra
- valsartan 1x 80 mg Th/ -Diet ginjal15oo kkal+ 42 <10.000 tanpa perdarahan ec.Stroke Iskemik
- KSR 1 x 600mg -Bed rest graprotein/hari 9. Anemia sedang NN ec DD/
-O2 2-4L/i -threeway Lab 6/6/2018 -penyakit kronis
Lab 8/6/2018 -IVFD NaCl 0,9% 20gtt/i -aspilet 4 tab 1x80mg Hb/Ht/E/L/T -perdarahan
Hb/Ht/E/L/T -Diet MII 1700kkal/hari -CPG 4 tab 1x75mg 6,7/19/2,4/14,7/20
9,7/28/3,5/7,8/396 -IV lansoprazole -ISDN 3x5mg MCV/MCH/MCHC Th/
MCV/MCH/MCHC 30mg/12jam -IV furosemide 1 amp/8 79/28/35 - bedrest + mobilisasi mika
81/28/34 -PCT 3x500mg jam Diftell : 0/0/0/7/77/16 miki/2jam
Diftel : 2/1/0/52/37/8 -nyatatin drop 4x2cc -Atorvastatin1x20mg - O2 2-4 liter/hari
Na/K/Cl : 141/3,1/115 -IV Vit K 1 amp/8 jam -Rmipril 1x5mg Lab 6/6/2018 - IVFD clinimix + clenoleic
Ur/Cr: 21/1,30 -Drip metilprednisolon -SC lovenox 6cc/12 jam  Hb/Ht/E/L/T 1000 mg/hr
GDS :91 (kompromi divisi tunda 6,7/20/2,4/33,9/4 - IVFD NaCl 20gtt/i
Albumin:1,01 reumatologi) -SC arixtra 2,5cc/24 jam  MCV/MCH/MCHC - diet sonde 6x200 + ekstrak
-IV ondansetron 4mg/8jam tunda 82/28/34 putih telur
-Attalpulgite 2 tab - coditam tab 2x1 Diftell:0/0/0/4/56/40 - inj ceftriaxone 2gr/24 jam
selanjutnya 1 tab/BAB cair, -gabapentin tab 1x1 -IVFD Aminoleban 1 fls/hari
max 12 tab Lab 4/6/18 -drip albumin 25 % 100cc
- IV metilprednisolon Lab(8/6/2018) Hb/Ht/E/L/T /hari
250mg/12 jam Hb/Ht/E/L/T : 9,1/27/3,4/67,7/6 - IV prosogan 30 mg/12 jam
9,0/28/3,6/9,5/257 MCV/MCH/MCHC - IV CIticolin 500mg/12jam
Lab 6/6/18 MCV/MCH/MCHC: 81/27/34 - IV Mecobalamin
LED : 25 77/25/33 Diftell: 0/0/0/4/50/46 500mg/12jam
PT/APTT : 0,97/ 1,10 Diftell: 1/0/0/83/10/6 -drip PCT 1 gr/8 jam
CRP kualitatif/ RF: +/- PT/APTT: 0,84 /1,08 - burnazin salep
Anti HCV/HbsAg: -/-
Lab 6/6/18 Albumin : 2,90 Lab 7/6/2018
Hb/Ht/E/L/T GDS: 126 Hb/Ht/E/L/T
9,5/22/3,1/4,8/133 Ur/Cr : 161/8,50 7,7/22/2,6/10,9/84
MCV/MCH/MCHC Na/K/Cl : 135/5,5/106 MCV/MCH/MCHC
72/31/43 85/30/35
Diftel : 0/0/083/14/3 Diftell:1/0/0/80/14/5
SGOT/SGPT : 109/48 Albumin : 2,32
GDS : 110 Na/K/Cl : 128/3,3/103
Ur/Cr : 23/0,83
Na/K/Cl : 122/3,9/100 Lab 05/06/2018
Hb/Ht/E/L/T
7,9/24/2,7/12/81
LED : 45
Na/K/Cl : 138/3,6/106

Lab 04/06/2018
Na/K/Cl 139/3,9/109

Lab 03/06/2018
Albumin: 2,46
Na/K/Cl: 146/4,1/113
Lab 01/06/2018
Hb/Ht/E/L/T
10,3/31/3,5/22,1/174
MCV/MCH/MCHC
89/29/33
Diftel : 1/0/1/86/9/3
Ca: 7,0
Na/K/Cl : 150/3,6/119

Lab 30/05/2018
Albumin : 2,81
Na/K/Cl : 159/2,8/123

K5B1 K5B2 K5B3 K5B4 K5B5

DPJP :dr. Krisna, Sp.PD DPJP :dr. Krisna, Sp.PD DPJP :dr. Krisna, Sp.PD DPJP :dr. Krisna, Sp.PD DPJP :dr. Krisna, Sp.PD
COW : dr. Ganis COW : dr. Ganis COW : dr. Ganis COW : dr. Ganis COW : dr. Ganis
DR : dr. Hambali DR : dr. Hambali DR : dr. Hambali DR : dr. Hambali DR : dr. Hambali
DM : Halim DM : Halim DM : Halim DM : Fara DM : Fara
Nama: Revina Amalia Nama : Nurhasanah Nama: Asniati M. Daud Nama : Sarwati Nama: Ummiah
Umur: 22th Umur : 30th Umur: 57 tahun Umur : 45 th Umur: 67 tahun
CM : 1016104 CM : 1171094 CM: 1-17-42-87 CM : 1174561 CM : 1-08-26-45
Hari Rawatan:4 Hari rawatan :4 Hari rawatan : 3 HAri rawatan : 3 Hari Rawatan:5

A/ A/ A/ A/ A/
1.Prolonged fever ec dd/ 1. CKD stage V Cardiorenal 1.CKD Stage V on HD ec 1. Prolonged fever ec dd 1. Dyspepsia type like lucer
- autoimmune syndrome DD/ - autoimmune DD 1. Tipe mixed
- TB paru 2. Anemia berat hipokrom - DN - immunocompromise 2. Type dismotility
- malignancy mikrositer ec DD ? - GNC 2. Penurunan kesadaran 3. GERD
2. Lymphadenopathy ec DD/ - PGK 2.Anemia sedang NN ec -NPSLE 4. ulkus gaster
-limfaadenitis TB -Def Fe PGK -CVD 2. TB Paru
-Lympoma 3.CHF Fc NYHA I-II ec DD 3.DM tipe 2 normoweight - Sepsis 3.DM TIpe 2 NW
3.SVT - penyakit jantung katup 4. Hipertensi stage II 4. Geriatri problem (Inanisi,
4.Anemia sedang HM ec dd 4.PDA 5.Closed fracture 1/3 distal Th/ Immobilisasi, Infeksi,
-penyakit kronis 5.hiponatremia hipoosmolar femur dextra Tirah baring Instabilitas dan jatuh)
-def besi 6. ISK asymptomatik Diet sonde 6x200 cc via
5.hipoalbuminemia Th/ NGT Th/
6. hipokalemia ringan Th/ -Bedrest IVFD Nacl 0,9% 20 -Bed rest
-bedrest -Diet Ginjal 1700 kkal/hari + gtt/mnt -Diet DM Lunak 1700 kkal
-O2 2-4 L/I NL 60 gram protein/hari IV omeprazole 40 mg/ 12 -IVFD Nacl 0,9% > 20gtt/i
Th/ - pasang DC -Threeway jam -IV Ceftriaksone 2gr/24 jam
-bedrest -Threeway -IV ceftriaxone 2 gr/24 jam Candesartan 1x16 mg -IV Lansoprazole
-diet MII TKTP _ NGT dan kateter ( Pasien -SC Apidra 0-0-6 unit Amlodipin 1x5mg 30mg/12jam
-IVFD RL 30gtt/i menolak) (malam) Paracetamol 3x500mg -Paracetamol 3x500mg
-IV ceftriaxone 1 gr/12jam - adalat oros 1x30mg -Lenal ace 2x169 mg -Flumucyl 3x1 tab
-paracetamol 3x500mg -sildenacyl 3x50mg -Asam folat 2x400 mg Lab ((7/6/2018) -SC Levemir 0-0-0-6 unit
-flumucyl 3x1 -Oscal 2x1 -Valsartan 1x160 mg Hb/Ht/E/L/T: (jam 22.00)
-digoxin 2x0,125 mg -lenal ace 2x169 -Bisoprolol 1x5mg 9,0/26/3,0/5,0/103
-drip albuminae 25% -lansoprazole 2x30mg MCV/MCH/MCHC : Lab 7/6/2018
100/hari -IV furosemide 40 g /8 jam Lab 6/6/-2018 87/30/34 LED : 125
- bisoprolol 1x 1,25mg -transfusi PRC sd HB >7 Protein : +2 Diftell : 1/0/0/66/17/16 Bil. total/direct/indirect:
-transfusi PRC Hb>10gr/dl - bisoprolol 1x5 mg Glukosa : +1 GDS : 108 0,23/0,15/0,08
Leukosit : 15-20 LPB Ur/Cr : 23/0,46 SGOT/SGPT : 17/15
Lab 8/6/-2018 Lab 7/6/2018 Eritrosit : 6-8 LPB Na/K/Cl : 134/3,6/101 Hb-A1c : 9,20
PT/APTT: 1,66/1,41 Urinalisis Epitel : 4-6 LPK
Bil.total/direct/indirect: Protein +1 Lab 6/6/2018
1,09/1,05/0,04 Darah + Lab 4/6/-2018 Kolesterol total : 125
SGOT/SGPT : 21/20 Leukosit 10-15 Hb/Ht/E/L/T HDL: 18
Kolesterol total/HDL/LDL: Eritrosit 20-25 8,4/23/2,9/10,2/180 LDL: 66
31/5/3 Epitel 6-8 MCV/MCH/MCHC Triglesirida : 145
Trigliserida : 74 78/29/37
Cr/asam urat :0,38/ 2,2 Lab 6/6/-2018 Diftel : 2/0/0/79/13/6 Urinalisis :
Na/K/Cl : 137/2,3/112 Hb/Ht/E/L/T Protein +1
Ca/Mg : 6,0/1,0 4,8/14/1,9/7/165 HBsAg negative Glukosa +1
MCV/MCH/MCHC antiHCV negative Darah +
Urinalisa 6/6/2018 72/26/35 Leukosit 20-30
Protein +1 Diftel : 3/0/0/88/6/3 Gds/Ur/Cr : 323/147/7,31 Eritrosit 8-10
Leukosit 20-25 GDS : 86 Na/K/Cl: 131/4,2/95 Epitel 6-8
Eritroist 1-2 Na/K/Cl : 122/4,5/91
Epitel 4-6 Lab 04/06/2018
Hb/Ht/E/T/L
10,7/32/4,0/378/18,0
Lab 5/6/-2018 MCV/MCH/MCHC
Hb/Ht/E/L/T 81/27/34
8/23/3/18,9/279 Diftel : 0/0/0/78/14/8
MCV/MCH/MCHC GDS:182
78/27/34 Ur/Cr : 19/0,61
Diftel : 0/1/0/78/14/7 Na/K/Cl : 131/4,4/100
Albumin : 1,6
GDS : 102
Ur/Cr : 10/0,43
Na/K/Cl : 132/3,1/108

K6B1 K6B2 K6B3 K6B4 K6B5


DPJP :dr. Krishna, Sp.PD DPJP :dr. Krishna, Sp.PD DPJP :dr. Krishna, Sp.PD DPJP : dr.Krisna Sp.PD DPJP :dr. Krisna, Sp.PD
COW : dr. Ganis COW : dr. Ganis COW : dr. Ganis COW : dr.Ganis COW : dr. Ganis
DR : dr. Ishak DR : dr. Ishak DR : dr. Ishak DR : dr. Ishak DR : dr. Ishak
DM : Fara DM : Tina DM : Tina DM : Tina DM : Tina

Nama :hj.Syarifah Chairiah Nama : Lilis Suriani Nama : Nama : Nama : Fauziah
Umur :67th Umur :27 tahun Umur : Umur : Umur : 65 tahun
CM :0934539 CM :1-17-41-47 CM : CM : CM : 1-13-68-18
Hari rawatan :5 Hari rawatan :4 Hari rawatan : Hari rawatan : Hari rawatan : 2

A/ A/ A/
1.CKD stage V ec dd 1.Poliarthritis ec dd/ 1.Hipertensi emergency
-PNC 1. SLE (perbaikan)
-urat nefropati 2. Juvenile RA 2. Hipoglikemia (perbaikan)
Dengan uremic syndrome 3. Fibromyalgia 3. DM tipe 2 Normoweight
2.Anemia sedang HM ec 2.Bisitopenia ec dd 4. Bronchiectasis
penyakit kronik 1.SLE 5. HHD
3. ISK komplikata 2.Malignancy hematologic 6. AKI stage 2
4. hiperuremia 3.ITP
5. Dislipidemia 3.hiperuresemia Th/
6. Asidosis metabolic 4.Hipokalemia ringan -Bedrest
(perbaikan) 5.AKI stage I renal -IVFD Dex 5%
6. cholelithiasis -drip perdipine , 0,3
Th/ 7. Limfadenopati a.r colli meq/KgBB/jam target TD
-bed rest ec dd/ 160 mmHg
-O2 2-4 L/i - limfadenitis TB - nebule combivent 1 resp/8
-diet ginjal 1700kkal +30 - metastase proses jam
protein/hari 8. TB diseminata - nebule pulmicort 1 resp/12
-threeway 9. Efusi pleura dekstra ec jam
-asam folat 2x400`mcg dd/ - pleuritis TB -valsartan tan 1x80 mg
-lenal ace 2x169mg - pleuro pneumonia -flumucyl tab 3x1
-IV ceftriaxone 2 gr/24jam - metastase proses -Amlodipine tab 1x10 mg
-HD (rabu-sabtu) -IV ceftriaxone 2g / 24 jam
-transfusi PRC 1 kolf/hari Th/ - clopidogrel 1x80 mg
-Bedrest - aspilet 1x80 mg
Lab 5/6/2018 -Diet MB 1500 kkal/hari
Hb/Ht/E/L/T - IVFD RL 20gtt/menit Lab 8/6/2018
7,6/24/4,1/19,6/352 -Paracetamol tab 3x500mg Urinalisis
MCV/MCH/MCHC -Allupurinol 1x100 mg Warna :kuning
58/19/32 - curcuma 3x1 Kejernihan : keruh
Diftel : 0/0/1/83/9/7 - piridoxin 2x1 BJ/ pH : 1,015/ 7,0
PT/aPTT : 0,9/1,3 - fluimucyl syr 3xCI Leukosit: +
Anti HCV/HbsAg : (-)/(-) - pro TB4 FDC 1x3 tab Protein/glukosa : +2/+1
GDS : 96 (pagi) Keton/nitrit: -/-
Ur/Cr : 199/6,38 - Lansoprazole 1x30 mg Urobilinogen/bilirubin : -/-
Na/K/Cl : 142/4,8/122 - Sukralfat syr 3xCI Darah : +
Ca: 7,7 Leukosit/eritrosit/epitel:
Na/K/Cl : 145/3,0/1116 Lab 05/06/2018 30-35/10-20/8-10
Analisa cairan pleura
Lab 31/05/2018 Warna : kuning Lab 7/6/2018
Kalium : 2,9 Kejernihan : keruh Hb/Ht/E/L/T
Bekuan : negative 10,5/31/3,7/11,6/282
Lab 30/05/2018 PMN/ MN sel : 20/80 MCV/MCH/MCHC
Na urin : 1236 Leukosit : 10500 83/28/34
Kalium Urin : 12,60 Totatl protein/glukosa : Diftell: 1/0/0/87/8/4
4,4/87 Ur/Cr : 66/ 2,59
Hb/Ht/E/L/T GDS : 207
9,2/24/3/7,3/435 Lab 05/06/2018 Na/K/Cl : 139/4,9/113
Ur/Cr : 16/1,13 Hb/Ht/E/T/L
Kalium : 2,2 9,5/29/3,8/89/9,5
MCV/MCH/MCHC
Lab 29/05/2018 76/25/33
Na/K/Cl : 144/2,6/113 CRP kualitatif : Positif
RF:Negatif
Lab 28/05/2018 AntiHCV/HBsAg
Na/K/Cl : 141/2,2/112 Negatif/Negatif
Biltot/Bildirect/bilindirect
0,54/0,31/0,23
SGOT/SGPT:81/49
Protein Total:8,00
Albumin:3,43
Globulin:4,57
LDH:883
Asam Urat: 12,7

Lab 04/06/2018
Hb/Ht/E/T/L
9,5/30/4,0/118/11,3Ur/Kr :
27/1,47
Na/K/Cl : 138/3,1/105