Denah Ruang Rawat

AQSHA 3 (Penyakit Dalam Wanita)

Hari/Tanggal : Jumat/20 Juli 2018

Dokter Jaga : dr. Munawar/dr. andri
Dokter Muda : Fitri, salsa, fira, sagita, ade
K1B1 K1B2 K1B3 K1B4
DPJP : dr. Agustia, Sp.PD DPJP : BEDAH DPJP : dr. Agustia, Sp.PD DPJP : dr. Agustia, Sp.PD
COW : dr. M haris RABER : endokrin COW : dr. M haris COW : dr. M haris
DR : dr. Muchsin DR : dr. Muchsin DR : dr. Muchsin
DM : Suha DM : suha DM : suha
Nama : Maimunah Nama : Sukaisi Nama : Asiah
Umur : 68 tahun Umur : 42 tahun Umur : 89 thn
CM : 0-84-25-48 CM : 1178276 CM : 0-94-66-45
Alamat : Kota sabang Alamat : Aceh tamiang Alamat :aceh besar
Pekerjaan : IRT Hari rawatan :6 Hari rawatan : 5
Hari rawatan : 5
A/ A/
A/ 1. sirosis hepatis stadium DC 1.penurunan kesadaran
1. .Dispepsia tipe child pugh B (perbaikan) ec SDA
dismotility dd gastropati 2. pneumonia 2.SDA dengan pencetus
diabetik 3. Hipoalbuminemia berat infeksi
2.Hipertensi on terapi 4.hiponatremi hiposmolar 3. PSMBA (perbaikan) ec
3.Stroke iskemik hipervolemia stress ulcer
4.Hipokalemia ringan 4.pneumonia geriatric
5.Febris ec dd/ Th/ 5.Hipoalbuminemia ringan
-Dehidrasi -Bedrest 6.Hipokalemia ringan
-infeksi - Diet hati MB 1700 kkal/hari
6. DM tipe 2 - IVFD aminofusin hepar 1 fls/ Th/
7. ISK asimtomatik hari -bed rest dengan mobilisasi
8. Cholelithisis multipel - iv furosemid 20mg/ 8 jam nyeri, miring kanan dan
- spironolakton 3 x 100 kiri/3 jam
Th/ - drip albumin 25% 100 cc 1 -NGT & cateter
- Bedrest fls/ hari -O2 2-3 liter/mnt
- Diet MII 1700 - IV cefotaxim 1 gr/ 8 jam (h6) - diet sonde via NGT 6x200
kkal/hari - Lactulac syr 3x30cc cc + ekstra putih telur
- IVFD RL 30 gtt/menit - Inj Vit K 1 amp/6jam -iv ceftriaxone 2gr/24 jam
- Iv omeprazole 40 -Propanolol 2x10 mg (h6)
mg/12 jam - Iv omeprazole 40 mg/12 j
Lab 18/7/2018 -Ksr 1x600 mg
- Sucralfate syr 3x30cc
Hb/Ht/E/L/T -Sucralfate 3xcII
- Amlodipine 1x10 mg
9,7/26/3,1/15,9/139
- Ramipril 1x5mg MCV/MCH/MCHC Lab 18/7/2018
- Domperidon 3x10 mg 84/31/37 Hb/Ht/E/T/L
- Iv Ceftriaxone 2 gr/24j Bil. Total : 4,98 10,3/31/3,7/186/6,6
(h3) Bil. direk/indirek: 1,66/3,32 MCV/MCH/MCHC
Ur/Cr: 127/1,03 83/28/34
Lab 18-07-2018 Na/K/Cl
Hb/Ht/E/Tr/Leu 125/4.4/88 Lab 17/07/2018
11,6/33/4,3/195/12,0 Albumin : 2,57
MCV/MCH/MCHC Urinalisa : Na/K/Cl :
77/27/35 Leukosit + 148/3,5/114
Diftel: 1/0/1/64/26/8 Darah +
HbA1c : 10,80 Lab 14/7/2018
Lab 17/7/2018 Hb/Ht/E/T/L
Urinalisa Albumin : 2,42 13,3/39/4,8/378/11,4
Leukosit + USG abdomen : asites masif MCV/MCH/MCHC
Protein +2 82/28/34
Urobilinogen + Lab 14/7/2018 Ur/Cr: 19/1,13
Bilirubin + Hb/Ht/E/L/T Na/K/Cl
Darah + 10,4/28/3,4/133/20,0 133/3,3/102
Lab 14-07-2018 MCV/MCH/MCHC PT/APTT: 11,7/52,1
Echo : disfungsi diastolik 84/31/37 SGOT/SGPT: 34/10
dengan EF 77% Ur/Cr: 79/0,89 Gds: 139
LVH konsentris Na/K/Cl Ur/cr: 79/0,89
Sesuai dengan HHD 120/4,0/96 Na/k/cl: 120/4,0/96
PT/APTT: -/1,6
Lab 16-07-2018 Anti HCV: negatif
Hb/Ht/E/Tr/Leu Hbsag : negatif
13,9/41/5,3/210/13,0 SGOT/SGPT: 100/56
MCV/MCH/MCHC Prot
77/26/34 total/alb/globulin:5,92/1,6/4,32
Diftel: 0/0/0/61/29/10 Gds: 143
GDS 211 Ur/cr: 79/0,89
Ur/Cr Na/k/cl: 120/4,0/96
46/0,91
Na/K/Cl
136/3,3/101
 K2B1 K2B2 K2B3 K2B4 K2B5

DPJP : dr. Agustia, DPJP : dr. Agustia, DPJP : dr. Agustia, DPJP : dr. Agustia, Sp.PD DPJP : dr. Agustia,
Sp.PD Sp.PD Sp.PD COW : dr. M haris Sp.PD
COW : dr. M haris COW : dr. M haris COW : dr. M haris DR : dr. Muchsin COW : dr. M haris
DR : dr. Muchsin DR : dr. Muchsin DR : dr. Muchsin DM : zati DR : dr. Muchsin
DM : zati DM :zati DM : zati DM : jaja
Nama: Fauziah Nama: Sakyan Nama : Ummi Kalsum Nama :Ernidar Nama :Ainsyah H Aji
Umur: 55 tahun Umur: 52 tahun Umur : 82 tahun Umur : 46 tahun Umur :60 tahun
CM: 1163797 CM: 1-17-79-64 CM : 1178713 CM : 1128303 CM : 1177989
Alamat : Lhokseumawe Alamat : Aceh Barat Alamat : Kuta malaka Alamat : Bireun Alamat : Peureulak,
Pekerjaan : IRT Pekerjaan: IRT Pekerjaan : IRT Pekerjaan : IRT A.Timur
Hari rawatan: 9 Hari rawatan: 9 Hari rawatan : 3 Hari rawatan : 6 Pekerjaan : IRT
Hari rawatan : 8
A/ A/ A/ A/
1. CHF FC NYHA 1. CKD stage V on HD 1. Anemia berat HN ec dd/ 1. Syok Sepsis (perbaikan) A/
III-IV ec dd/ reguler ec dd/ - def. Besi ec dd 1. Penurunan kesadaran ec
- IHD -HHD -PNC - peny. Kronis - Urosepsis dd/ 1.Hepatitis ensefalitis
2. CKD Stage 5ec. -Urat Nefropati 2. Stroke iskemik - Pneumonia 2.Imbalance elektrolit
Dd/ 2.Anemia normokrom 3. Pneumonia dd/TB paru 2. CKD Stage 5ec dd 3. Meningoensefalopati
– HN - DN normositik ec dd/ relaps - DN On HD regular 2.Early sirosis hepatis
- PGK 4. geriatri problem - DNC 3. CHF Stage NYHA I-II
On HD regular
3.HAP dd/ 5. Hipertensi stage I - HN ec dd
(Selasa-Jum,at)
-TB paru 3. ISK Asimtomatik - IHD - HHD
3. Failure AV Shunt -mikosis paru Th/ 4. DM Tipe 2 overweight 4. Hipertensi on terapi
(D) -NGT, kateter 5. Pneumonia 5. Hipernatremia
4. HHD Th/ -Diet sonde 6x200 cc 6. Anemia sedang ec dd/ 1. 6. Hepatitis B stage I
5. ISK asimtomatis -Bedrest -IVFD RL 20 gtt/i PGK 2. Defisiensi besi 7.dispepsia tipe like ulcer
-diet ginjal 1500 -IVFD Clinimix + clialoic 7. Hipoalbuminemia berat dd/ tipe mixed
Th/ kkal/hari + 50gr protein 1 fls/hari 8.dermatitis atopic
-Bedrest - Three way -IV ceftriaxone 2 gr/24j Th/ 9.diare akut
- O2 2 L/i - lansoprazole 2x20 mg - IV omeprazol 40 mg/12 - Bed Rest 10.Prolong fever ec dd/
- Threeway - lenal ace 2x 169 mg jam - NGT -Malaria
- Diet Ginjal 1700 kkal -As folat 2x400 mg IV citicolin 200 mg/12j - Three way -Tiphoid fever
+ rendah garam -Ostriol 2x0,5 mg -ramipril 1x5 mg - Diet Ginjal 1700 kkal/hari 11. ISK
- IV furosemide 1 amp/8 - iv ceftriaxone 2 gr/24 -amlodipin 1x10 mg - IV Metocloparamide -FUO
jam jam(H5) -SF 3x200 mg 1amp/8jam 12. Hipokalemia
- Valsartan 1x160mg -vectrin 3x200 mg Transfusi PRC 1 kolf/hr - drip levofloxacin 500mg/24
- Lenal Ace 2x1 tab jam H3 Th/
-Asam Folat 2x400 tab Lab (17/07/2018) Lab (17/07/2018) - SC Novorapid 8-8-8 iu -Bedrest
-Bisoprolol 1x10mg Hb/Ht/E/L/T : Hb/Ht/E/L/T : - Sc lantus 0-0-0-14 unit - Diet hati 1700 kkal/hari
-Alprazolam 10,1/31/4/8,1/202 1,9/8/1,5/5,5/202 - Asam folat 2 x 400 mg - IVFD Dex 5% 20gtt/i
1x0.5mg(K/P) MCV/MCH/MCHC MCV/MCH/MCHC - Lenal ace 2 x 169 mg - IVFD comafusin hepar
-Herbesser CD 78/25/33 54/13/24 - lactulac 3xcII 1fls/24jam
1x200mg Diftell : 9/1/0/56/24/10 Diftell : 6/0/0/64/22/8 -Tanapres 1x2.5mg - IV ceftriaxone 3 gr/hr
-Domperidon 1x200 mg Ur/Cr : 51/0,92 GDS 142 - albumin 25% 100 cc 1 fls dalam 50 cc NaCl
- balance cairan negatif Na/K/Cl : 144/3,6/109 Ur/Cr : 81/7,52 - flukonazol 1x200 mg -Drip PCT 1gr/8jam
Na/K/Cl : 144/4,5/115 - Hemodialisis Rabu-Jum’at - IV omeprazol 40 mg/12
Lab (18/07/2018) jam
Hipokinetik inferior Lab 17/07/2018 - Tanapres 1x 5 mg
LVH kosentris Hb/Ht/E/L/T : - Amlodipin 1x 5 mg
Disfungsi diastolik 7,2/22/2,7/7,3/190 -Bisoprolol 1x10 mg
dengan EF 45% MCV/MCH/MCHC -Attapulgit 1 tab setiap bab
Sesuai dengan CAD, 82/26/32 cair
CHF Diftell : 0/0/0/81/12/6 - Sucralfat syr 3xCII
Albumin : 2,28
Lab (17/07/2018) Na/K/Cl:135/3,9/104 Lab 18-07-2018
Hb/Ht/E/L/T : Ur/Cr : 63/3,65 Hb/Ht/E/L/T :
11,0/32/4,0/8,2/147 12,5/34/3.7/6/56
MCV/MCH/MCHC Urinalisis MCV/MCH/MCHC
82/28/34 Protein +3 94/34/36
Diftell : 2/1/0/72/12/13 Glukosa +1 Diftell : 1/1/1/0/63/20/15
Ur/Cr : 87/5,97 Nitrit + D dimer : 3581,58
Na/K/Cl : 141/4,3/107 Darah + Ur/Cr : 50/0,60
Na/K /Cl: 150/2,6/108
Lab (09/07/2018) Lab 13/7/2018 S.Typhy O : 1/320
Hb/Ht/E/L/T : Urinalisis S.Paratyphi AO : 1/320
7,2/23/2,7/11,5/162 Protein +2 S.Paratyphi AH : 1/320
MCV/MCH/MCHC Glukosa +3 S.Paratyphi BH : 1/320
85/27/32 Leukosit PENUH MDT
Diftell : 0/1/0/74/16/9 Eritrosit : 10-15 = Eritrosit : Normokrom
SGOT/SGPT : 10/7 Epitel 8-10 Anisopoikilositosis :
GDS : 137 Ur/Cr : Target Cell Eosinofilia
100/6,71 Lab 12/07/2018 = Lekosit : Eosinofilia,
Na/K/Cl : 141/4,8/111 Hb/Ht/E/L/T : Monositosis
8,1/25/3,1/13,4/276 = Trombosit : Jumlah
MCV/MCH/MCHC Kurang Tersebar Bentuk
81/26/32 Normal
Ca: 7,7 Kesimpulan : Normokrom
Na/K/Cl:136/4,5/107 Normositer
Lab 10/07/2018 Trombositopenia
Hb/Ht/E/L/T :
8,1/25/3,1/15,2/356 Urinalisis :
MCV/MCH/MCHC Leukosit : positif
80/26/32 Nitrit : positif
Ca/Mg : 8,3/1,4 Darah : positif
Na/K/Cl:129/4,9/103
 K3B1 K3B2 K3B3 K3B4 K3B5
DPJP :dr. M. Darma, DPJP :dr. M. Darma, Sp.PD DPJP :dr. M. Darma, Sp.PD DPJP :dr. M. Darma, DPJP : dr. M. Darma,
Sp.PD COW : dr. Muldani COW : dr. Muldani Sp.PD Sp.PD
COW : dr. Muldani DR : dr. Fadhila DR : dr. Fadhila COW : dr. Muldani COW : dr. Muldani
DR : dr. Fadhila DM :jaja DM :jaja DR : dr. Fadhila DR : dr. Fadhila
DM :jaja DM :icha DM :icha
Nama: Saidah Ubit Nama: Rabuyah Nama: sabarani Nama: Fatimah piah Nama : Samini
Umur: 69 th Umur: 61 tahun Umur : 63 thn Umur: 63 th Umur : 38 tahun
CM: 1177898 CM: 0996802 CM : 1178200 CM: 1-17-57-45 CM : 1178863
Alamat: Lampaseh Banda Alamat: lambaro skep Alamat: aceh besar Alamat: Pidie Alamat: bener meriah
Aceh Pekerjaan: IRT Pekerjaan: IRT Pekerjaan: IRT Pekerjaan: pekebun
Pekerjaan: IRT Hari rawatan: I Hari rawatan : 2 Hari rawatan: 4 Hari rawatan : 1
Hari rawatan: 9
A/ A/ A/ A/
A/ 1. Diare akut ec dd/ 1.Ileus paralitik dd/partial 1.Ca esophagus dd metastase 1. CHF fc NYHA III-IV ec
1. PSMBA (perbaikan) -intoleransi makanan MBO proses dd/
ec dd/ -inf.bakteri 2. DM tipe 2 normoweight 2. Sarkopenia -HHD
-Gastritis Erosif -inf.virus 3. AKI stage III dd DN -Peny. Jantung katup
-ulcus gaster 2. AKI stage I prerenal 4. Hiponatremia hipoosmolar Th/ 2. AKI stage 3 prerenal
-ullcus duodenum 3. pneumonia dd/TB paru dg 5. AF NVR -Bed rest 3. Hiperkalemia
2. OA Genu dextra inf.sekunder 6. Anemia ringan HM ec dd -diet sonde cair via 4. Gross hematuri ec dd/
3. Hipertensi terkontrol 4. DM tipe II -def. besi gastrotomi tube 6x40cc - nefritis akut
4. Hiperkalemia (perbaikan) -peny.kronik -IVFD nacl 0,9% - IgA nefropati
5. Hipoalbunemia (2,98) Th/ 20 ,mmgtt/menit - malignancy
6. Anemia sedang NN ec dd - bedrest Th/ -IVFD Clinimix 1 fls/hari
- Perdarahan - Diet DM MII 1700 kkal/hr -Bedrest, kateter Th/
- penyakit Kronik -IV ceftriaxone 2gr/24 j -Diet DM II 1700 kkal/hr Lab 19/07/2018 - bedrest
7.Oral candidiasis - attapulgite 2 tab selanjutnya 1 -IVFD NaCl 0,9% 20 tpm Albumin : 2,93 -Diet MB 1700 kkal/hr
8. PPOK stabil tab per BAB cair -IVFD clinimix + clinoleic 1fls Protein total : 6,80 -threeway
9. Pneumonia (perbaikan) -IV omeprazol 40 mg/12j Globulin : 3,87 -IV furosemid 30 mg/jam
10. selulitis ar gluteal sinistra Lab 19-07-2018 -IV metoklopramid 10 mg/8j
11. SDA dengan pencetus Hb/Ht/E/L/T - IV ceftriaxone 2 gr/24 jam Lab 17/07/2018 Lab 19/07/2018
infeksi 10,0/31/4/11,4/242 - SC lantus 0-0-0-10 IU Hb/Ht/E/L/T Hb/Ht/E/L/T
12.Obese grade II MCV/MCH/MCHC - CPG 1x75 mg 9,3/29/3,3/337/7,4 14,4/45/5,1/9,9/142
79/25/32 -Digoxin 1x0,25 mg MCV/MCH/MCHC MCV/MCH/MCHC
Th/ Diftel : 0/0/0/76/11/13 -fluimucyl 3x200 mg 88/28/32 88/28/32
-Bedrest GDS : 201 -bicnat 3x1 HbsAg : neg HbsAg/anti HCV: neg/neg
- Diet M II 1500 kkal/hari Ur/Cr: 56/1,66 Ur/Cr: 26/0,62 Alb/GDS : 2,78/135
- IVFD NaCl 0,9% 20 gtt/i Na/K/Cl: 138/4,1/109 Lab 18/07/2018 Na/K/Cl: 143/3,9/108 Ur/Cr: 111/2,08
- Iv Ceftriaxone 1 gr/12 jam Hb/Ht/E/L/T Na/K/Cl: 141/5,4/108
(H10) 10,7/32/4,2/8,6/286
- iv omeprazole 40 mg/12 jam MCV/MCH/MCHC
- Sucralfat syr 3xCII 76/26/34
- Nystatin Drop 4x2cc Ur/Cr: 97/1,81
- domperidone tab 3x10 mg Na/K/Cl: 130/3,5/88
- clindamycin 3x300 mg
- symbicor inhaler 2x1 Lab 17/7/2018
- fusidex zalf Ur/Cr/As. Urat:
- nebule combivent 1 113/1,97/14,1
resp/8jam Na/Cl : 136/78
- compress Nacl 0,9% Urinalisis :
-kin mouth wash Leukosit +
Protein +
Lab 18/07/2018 Darah +
Hb/Ht/E/L/TR
9,6/28/3,4/8,2/243 Lab 13/07/2018
MCV/MCH/MCHC Hb/Ht/E/T/L
84/29/34 10,7/32/4,2/318/8,4
Diftell: 2/0/0/73/14/11 MCV/MCH/MCHC
Albumin:2,47 76/25/33
Ur/cr: 34/0,61 Ur/Cr: 163/4,92
Na/k/cl: 135/4,5/111 Na/K/Cl: 119/3,9/67
Albumin: 3,75
Lab 16/07/2018 GDS: 215
Kalsium : 8,4
Na/K/Cl : 136/4,3/113

Lab 15/07/2018
Hb/Ht/E/L/T
9,4/29/3,4/11,3/257
MCV/MCH/MCHC
85/28/33
diftell: 1/0/0/83/9/7
Ur/cr: 85/1,08

Lab 12/07/2018
Kolestrol total : 155
Kolestrol hdl : 20
Kolestrol ldl : 92
Retukulosit : 1,7
Morfologi darah tepi :
Kes: hipokrom mikrisiter
Leukositosis
 K4B1 K4B2 K4B3 K4B4 K4B5
DPJP :dr. M. Darma, Sp.PD DPJP :dr. M. Darma, Sp.PD DPJP :dr. M. Darma, Sp.PD DPJP :dr. M. Darma, DPJP : BEDAH DIGESTIF
COW : dr. Muldani COW : dr. Muldani COW : dr. Muldani Sp.PD COW : dr. Muldani
DR : dr. Fadhila DR : dr. Fadhila DR : dr. Fadhila COW : dr. Muldani DR : dr. Fadhila
DM :icha DM : icha DM :gadis DR : dr. Fadhila DM :gadis
DM :gadis
Nama: Halimah Nama: Aminah Sarung Nama: Kasmawati Nama: Hanisah Mahmud Nama: Jamaliah
Umur: 78th Umur: 75 th Umur: 44 th Umur: 66 tahun Umur: 82 th
CM: 1177037 CM: 1-17-59-10 CM: 1177674 CM: 1-17-77-82 CM: 1-17-61-09
Alamat : Nagan Raya Alamat: Peusangan, Bireuen Alamat: Dusun Putro Labu Alamaat: Pidie Jaya Alamat: aceh Besar
Pekerjaan : IRT Pekerjaaan: Petani Pekerjaaan: IRT Pekerjaan: IRT Pekerjaaan: IRT
Hari Rawatan: 7 Hari Rawatan: 25 Hari Rawatan: 10 Hari rawatan: 10 Hari Rawatan: 3
A/
A/ A/ A/ A/ 1.Cholelitiasis denhan
1. Pansitopenia ec dd/ 1.Penurunan kesadaran ec dd/ 1.(PSMBB) Hematoskezia ec 1. Syok sepsis ec dd/ cholesistitis
- Anemia Aplastik -Sepsis massa tumor reg - Pneumonia 2. HHD
- Myelofibrosis - Imbalance elektrolit anocutanjunction dd ca rectum - Urosepsis
- MDS - stroke 2. Anemia sedang HM ec 2. Pneumonia Th/
2. Pneumonia Geriatri 2.Sepsis ec dd 1. Pneumonia 2. - perdarahan 3. CKD stg 5 on HD - Bedrest
3. Dispepsia tipe dismotility urosepsis reguler ec dd/ - Diet MII 1700kkal/hri
4. Konstipasi 3.CKD stage IVec PNC Th/ - PNC - Kasur dekubitus jika tersedia
4.High risk trombosis -Bedrest - PGOI -IVFD RL 20 gtt/menit
Th/ 5. Ulkus Dekubitus grd II -Diet MII 1700 kkal 4. ISK - lansoprazole 2x30 mg
- Tirah baring 6. DM tipe II NW dengan -IVFD NaCl 0,9% 20 gtt/i 5. Hipoalbumin ec - urda falk 2x250 mg
- O2 2-4 L/hari critical ill - Transfusi PRC s/d Hb>10 Proteinuria - herbeser 1x100 mg
- IVFD futrolit 20 gtt/mnt - Anti hemoroid supp 1x Th/ - tanapres 1x2,5 mg
- IV ceftriaxone 2 gr/ 24 j(H16) Th/ (malam) - Bedrest
- IV omeprazol 40 mg/12 jam - Bedrest -MST 3x10 mg - O2 2-4 l/i
- Drip Paracetamol 1g/8jam jika - Kasur dekubitus jika tersedia - IVFD NaCl 0,9 % 10
suhu ≥ 38,5 - Mobile pasif mika-miki/2 j Lab: 15/7/2018 gtt/i
- Azitromicin 1 x 500mg - O2 8-10 L/i Hb/Ht/E/L/Tr - Diet sonde ginjal via
- Acetyl sistein tab 3x1 - NGT, kateter urin terpasang 10,2/31/4,1/5,9/323 NGT 6 x 200 ml
- Graphalac syr 3xCII - Diet sonde6x200cc MCV/MCH/MCHC - Iv ceftazidin 1gr/12 jam
1700 kkal/hari + 0,6 gr 79/25/32 (H5)
Lab 17/7/2018 protein /kgbb/ hari DIFTEL: 13/0/0/58/21/8 - Drip Levofloxacin
Hb/Ht/E/L/T - IVFD 2:1 30 gtt/i 500mg/24jam (H5)
7.9/24/2.6/4/80 - IV meropenem 500mg/12 j Lab: 14/7/2018 - Drip NE mulai dari 0,05
MCV/MCH/MCHC - IV. Citicoline 500 mg/12 jam Hb/Ht/E/L/Tr meq, titrasi dosis, target
93/30/33 - Drip fosfomycin 1 gr/12 jam 9,0/29/3,7/5,6/326 TDS >100 mmHg atau
(H13) MCV/MCH/MCHC MAP > 65 mmHg
Lab 14/7/2018 - Drip albumin 25% 100 cc 78/25/32 - Drip flukonazole
Hb/Ht/E/L/T (H2) DIFTEL: 8/1/0/63/21/7 400mg/24j
8,0/23/2,5/4,8/17 - Lenal ace 2x169 mg -Iv dipenhidramin 0,5
MCV/MCH/MCHC - Asam folat 2x400 mg Lab 12/7/2018 mg/24 jam (malam)
90/32/35 - Fluimucyl tab 3x1 Hb/Ht/E/L/T - Lenal Ace 2x169 tab
- Pradaxa 1x75 mg 7/23/3/5/343 - Asam folat 2x400 mg tab
Lab 13/7/2018 - SC apidra 5-3-5-3-5-3 MCV/MCH/MCHC - Hemodialisa (selasa-
Hb/Ht/E/L/T - SC lantus 0-0-0-12 iu 78/24/30 jumat)
7,9/23/2,6/4,2/5 - balance cairan Diftell : 7/0/0/54/31/8 - Balance cairan
MCV/MCH/MCHC MDT: hipokrom mikrositer
89/30/34 Lab 19/07/2018 Lab 14/7/2018
Diftell : 2/1/0/51/40/6 Hb/Ht/E/Tr/L Lab 10/07/2018 Hb/Ht/E/L/T
9,5/30/3,2/325/10,8 Hb/Ht/E/Tr/L 10,4/30/3,7/10,3/253
Lab 10/7/2018 MCV/MCH/MCHC 7,4/24/3,2/321/4,8 MCV/MCH/MCHC
Hb/Ht/E/L/T 95/30/31 MCV/MCH/MCHC 81/28/35
5,2/16/1,6/4,2/22 Diftell : 6/1/0/71/15/7 77/24/31 Diftel: 8/1/0/65/16/10
MCV/MCH/MCHC Albumin : 2,36 Diftell : 6/0/1/64/24/8 Ur/Cr: 66/3,56
98/32/33 Ur/cr : 70/1,81 PT/aptt: 0,8/0,96 Na/K/Cl: 137/3,5/111
Diftell : 0/0/0/80/17/3 Na/k/cl : 143/3,8/114 GDS: 111
Anti HCV/HbsAg negatif Lab 12-07-2018
Lab: 18/07/2018 Ur/cr : 18/0,67 Urinalisa
AGDA Na/k/cl : 147/3,9/104 Leukosit + (20-25) LPB
pH : 7,39 Protein +2
pCO2 : 36,40 Lab 11-07-2018
pO2 : 106 Urinalisa
HCO3 : 22,4 Leukosit + (40-50) LPB
Total Co2 : 23,6 Protein +2
BE :-1,5 Lab 10/7/2018
SpO2 : 97,1 Hb/Ht/E/L/T
6,6/20/2,5/13,6/303
Lab: 16/07/2018 MCV/MCH/MCHC
Na/K/Cl : 147/4,4/112 82/27/33
Diftel: 6/0/0/75/14/5
Lab: 14/07/2018 Anti HCV (-)
Hb/Ht/E/L/T HbsAg (-)
10,2/31/3,4/12,8/389 GDS: 106
MCV/MCH/MCHC Ur/Cr: 131/4,78
92/30/32 Na/K/Cl: 146/3,7/124
Diftel: 3/0/0/80/12/5
Ca:7,9
Ur/Cr: 69/1,79
Na/K/Cl: 145/4,0/114
 K5B1 K5B2 K5B3 K5B4 K5B5

DPJP : dr. Hendra, Sp. PD, DPJP : KARDIO DPJP :dr. Hendra, Sp.PD- DPJP : dr. Hendra, DPJP dr. Hendra, Sp.PD-
KEMD KEMD Sp.PD-KEMD KEMD
COW : dr. suheir COW : dr. suheir COW : dr. suheir COW : dr. suheir
DR : dr. Hambali DR : dr. Hambali DR : dr. Hambali DR : dr. Hambali
DM : syech DM : sifa DM : sifa DM : sifa
Nama:Masyitah Nama : Malahayati Nama: Zuraidah Nama: Mardiana
Umur: 33 th Umur : 24 th Umur: 61 tahun Umur: 32 th
CM: 1178732 CM : 1017996 CM: 1062552 CM: 1-17-76-52
Alamat: Aceh selatan Alamat: Sawang Alamat: sabang Alamat: Alue Dama, Aceh
Pekerjaan: Guru Pekerjaan: Mahasiswa Pekerjaan: IRT Barat Daya
Hari rawatan: 2 Harirawatan : 2 Hari rawatan: 1 Peekerjaan: IRT
Hari rawatan: 12
A/ A/ A/
1. CKD stage V ec dd/1. 1. CKD stage V on HD 1. Ca mammae S pro A/
HN 2. PNC dengan reguler ec dd PNC kemoterapi siklus V 1. Edema anasarka ec dd/
uremic sindrom 2. Anemia berat ec PGK 2. Anemia sedang NN ec - SN -GNC
2. Anemia berat NN ec dd 3. Hipertensi on terapi dd drug induced - Ig A Nefropati
1. Peny kronis 4. Post op aff AV Shunt 2. Anemia berat NN ec dd/
3. HHD Th/ - penyakit kronis
4. Hiponatremia Th / -Bedrest -perdarahan
hipoosmolar euvolomik Bedrest - Diet MB 1700kkal- 3. Hipoalbuminemia (1,68)
5. HAP Diet ginjal 1700 kkal/hari + threway
45 gr protein/hari - IVFD NaCl 0,9% 20 tpm Th/
Th/ Lenal ace 2x169 mg - transfusi PRC sd >10 -Bedrest
- Bed rest Asam folat 1x10 mg - kemoterapi siklus V -Diet ginjal 1700 kkal/hari
- Diet ginjal 1500 kkal/hari + 30 Valsartan 1x60 mg + ekstra putih telur
gr protein / hari Amlodipin 1x10 mg Lab 16/07/2018 -Kateter
- Threeway HD reg (senin-kamis) Hb/Ht/E/L/T: -Lenal ace 2x169 mg
- IV cefixim 1 gr/8j 7,2/22/2,5/10.8/210 -Flumucyl 3x200mg
- Lenal ace 2x169 m Lab 18/7/2018 MCV/MCH/MCHC: -Valsartan 1x160mg
- Asamfolat 2x400 mg Hb/Ht/E/L/T: 85/28/33 -Drip albumin 25%
- Fluimucyl 3x200 mg 6,9/21/2,6/11,5/133 Diftell:0/0/0/62/27/11 100cc/24 jam
- Ramipril 1x5mg MCV/MCH/MCHC: -As folat 2x400 mg
- Bisoprolol 1x5 mg 80/27/33 -Spironolactone 1x200 mg
- Amlodipin 1x5mg Diftell:10/0/0/69/14/7 - methyl prednisolon
- HCT 1x25 mg Ur/Cr : 84/6,97 24-20-20 mg
- HD Ca/Mg : 7,3/1,4
Na/K/Cl: 136/4,3/103 Lab 19/07/2018
Lab 19-7-2018 Hb/Ht/E/L/T
Leukosit 7,4/22/2.6/14,5/186
Protein +1 MCV/MCH/MCHC
Glukosa +2 86/29/34
Darah +
Lab 18/07/2018
Lab 18/7/2018 Albumin : 1,68
Hb/Ht/E/L/T:
5,1/14/1,7/20/226 Lab 14/07/2018
MCV/MCH/MCHC: Hb/Ht/E/L/T
83/29/35 6,2/18/2,1/9,0/156
Diftell:0/0/0/88/7/5 MCV/MCH/MCHC
Ur/Cr : 212/11,51 86/29/34
GDS : 102 Albumin: 1,60
Na/K/Cl: 126/4,5/100 Ur/Cr: 23/0,40
Na/K/Cl: 137/3,1/103

Lab 12/07/2018
Retikulost : 2,8
Albumin : 1,23
LDH : 278
Kolestrol total : 243
Kolestrol hdl : 10
Kolestrol ldl : 155
Trigliserida : 259
 K6B1 K6B2 K6B3 K6B4 K6B5

DPJP dr. Hendra, Sp.PD-KEMD DPJP dr. Hendra, Sp.PD- DPJP dr. Hendra, Sp.PD- DPJP dr. Hendra, Sp.PD- DPJP dr. Hendra, Sp.PD-
COW : dr. suheir KEMD KEMD KEMD KEMD
DR : dr. ishak COW : dr. suheir COW : dr. suheir COW : dr. suheir COW : dr. suheir
DM : sifa DR : dr. ishak DR : dr. ishak DR : dr. ishak DR : dr. ishak
DM : dwiki DM : dwiki DM : dwiki DM : dwiki
Nama : Faridah Iriani
Umur : 53 tahun Nama: Nurul Aflah Nama : Fitrica Nama : HJ Asnah Nama : Salbiah taher
CM : 1171416 Umur: 87 tahun Umur :54 tahun Umur : 66 th Umur :67 thn
Alamat: Lhokseumawe CM: 1178953 CM : 0813704 CM : 1178657 CM : 1177439
Pekerjaan: IRT Alamat: Jeunieb Alamat:Banda Aceh Alamat: Aceh selatan Alamat: bireuen
Harirawatan :7 Pekerjaan: IRT Pekerjaan: IRT Pekerjaan: IRT Pekerjaan: IRT
Hari rawatan: 1 Hari rawatan :7 Hari rawatan :3 Hari rawatan : 11
A/
1. Penurunan Kesadaran ec A/ A/ A/ A/
-Syok sepsis 1. Pneumonia (CAP) dd/ TB 1.Ca Mamae post kemoterapi 1. CKD stage V 1.PSMBB ec colitis infeksi
-Stroke paru dg inf. Sekunder 6 siklus dengan uremic 2. - CAP (perbaikan )
2. Syok Sepsis ec dd 2. selulitis supuratif ar cruris 2/Dispepsia tipe like ulcer dd sindrom - TB paru dgn infeksi sekunder
-Urosepsis sinistra tipe like dismotility 2. 2. Anemia berat - mikosis paru
-Pneumonia 3. geriatri problem ( inanisi, 3. anemia sedang HM ec dd/ NN ec PGK - Bronkiektasis
3. Urosepsis infeksi, instabilitas, dan jatuh) peny. Kronis 3. HT stage II 3. anemia ringan ec perdarahan
4. DM Tipe 2 normoweight 4. candidiasis oral 4. Konstipasi (perbaikan )
5. Anemia Sedang NN ec dd Th/ 4. Hipokalemia
-Penyakit kronis -bedrest Th/ Th/
-Perdarahan -diet lunak 1700 kkal/hr -Bedrest -bedrest Th/
6. Hipokalemia (2,4) -IVFD NaCl0,9% 20 tpm -diet MB 1700kkal/hari + -diet MII rendah garam -Bedrest
7. Hipoalbuminemia (2,2) -IV ceftriaxone 1 gr/12 j ekstra putih telur 1800 kkal degan 40 gr - diet M II 1700 kkal/hri
8.Disfagia ec dd/ -flumucyl 3x200 mg -IVFD Nacl 0,9% 20 gtt/i protein / hari -drip metronidazole 500 mg/8
-candidiasis esophagus - PCT tab 3x500 KAEN 3B 20gtt/i Threeway jam (H12)
-GERD -gentamisin zalf -Curcuma 3x1 Iv omeprazole 40 mg / 12 - levofloxacim 1x 500 mg(H12)
9.Dyspepsia type dismotility dd/ -Tamoxifen 2x10mg jam - iv lansoprazole 30 mg/12 jam
-dyspepsia type mixed Lab 19-07-2018 -Lactulac syr 3xCII -amlodipin 1x10 mg - transamin 2x500 mg
-gastropati diabetik Hb/Ht/E/L/Tr -Domperidon 3x10mg -Valsartan 1x80 mg -iv Vit K 1 amp/ 8 jam
12,1/36/4,5/15,0/198 -nystatin 4x2cc -Lenal ace 2x169 mg -salofalk 4x500 mg
Th/ MCV/MCH/MCHC -Asam folat 2x400 mg
-bed rest , mobilisasi pasif/3 jam 80/27/34 Lab:18/07/2018 -Iv furosemid 1 amp/8 jam Lab 19/07/2018
mika miki Diftell: 0/1/0/84/9/6 Hb/Ht/E/L/Tr -lactulac 3xcI Hb/Ht/E/L/Tr
-NGT , kateter GDS : 171 8,7/27/3,7/8,4/322 -HD intermitten 10,5/32/3,6/8,1/367
-Diet Sonde 1700 kkal/hr + ekstra Ur/cr: 36/0,78 MCV/MCH/MCHC -Transfusi PRC sd Hb > 10 MCV/MCH/MCHC
putih telur Na/K/Cl : 143/3,6/109 72/23/33 89/29/33
- IVFD Nacl 0,9% 20 gtt Diftell: 1/1/0/57/33/8 Lab 19/07/2018 Diftell: 2/1/0/72/18/7
- Iv omeprazole 40 mg/12 jam LED : 107 Urinalisa Na/K/CL: 144/2,9/109
-Nistatin drop 4x1cc Ur/cr: 11/0.56 Leukosit +
-Drip Albumin 25% 1 fls/hri (H7) SGOT/SGPT: 63/14 Protein +1 Lab 16-07-2018
-drip norepineprin mulai dengan Anti HCV negatif Hb/Ht/E/L/Tr
dosis 0,05 meq, titrasi dosis target Lab:15/07/2018 Ur/Cr : 108/6,58 9.3/28/3,1/10,5/435
MAP . 65 mmhg Hb/Ht/E/L/Tr MCV/MCH/MCHC
-balance cairan per hari 9.4/28/4/8.2/359 Lab 18/7/2018 89/31/34
MCV/MCH/MCHC SGOT/SGPT : 14/7 GDS:117
Lab 19/07/2018 70/23/34 Protein Ur/cr: 17/0,84
Na urine : 882 Diftell: 1/1/0/63/28/7 total/albumin/globulin Na/K/CL: 143/3.2/112
K urine : 12,00 GDS:161 6,4/3,81/2,59
Alb / Ca : 2,4/6,1 Ur/cr: 10/0.63 Kolesterol tot/HDL/Trigli Lab 14/07/2018
Na/K/Cl : 144/3,1/104 Na/K/CL: 134/3.1/95 234/53/100 PT/APTT: 1,04/1,06
Ca: 8.3 Asam urat : 8,1
Lab 17/07/2018 SGOT/SGPT: 109/11 Lab 12/7/2018
Hb/Ht/E/L/T Albumin: 2.67 Lab 17/7/2018 Hb/Ht/E/T/L
6.7/19/2.3/108/16.4 Hb/ht/e/t/l 9/26/2,9/474/11
MCV/MCH/MCHC 6,7/20/2,2/239/8,1 Mcv/mch/mchc
84/29/35 Mcv/mch/mchc 88/31/35
Diftel :0/0/0/88/10/2 93/31/33
Albumin : 2,24 Diftell : 5/0/1/70/18/6 Lab 10/07-2018
Ur/Cr : 36/0.79 Hbsag negatif Anti HCV negatif
Na/K/Cl :138/2,4/107 GDS/Ur/Cr : 153/111/6,44 HbsAg negatif
Na/K/Cl : 148/5,3/119
- Lab 8/7/2018
Hb/ht/e/t/l
10.1/30/3,5/444/10,4
Mcv/mch/mchc
87/29/34
Diftell : 0/1//0/75/28/6
PT/aptt : 10.5/32.9
GDS/Ur/Cr : 126/61/1,50
Na/K/Cl : 139/4,7/94