LAPORAN HARIAN ALERGI imun SELASA 29 januari 2019

Junior : dr.Yuanita Rimadini, dr. Marselya Ulfa Madya : dr. Msy Mutiara, dr. Rini Gita sari Senior: dr. Muhammad Aulia, dr. Yuyun Romaria

Kamar Identitas Diagnosis Pemeriksaan Penunjang Terapi Keterangan

Lantai 2 Sakila Putri /Pr/ 2 tahun PHS dd/ARJ 26-1-2019  Antacid 3x2cc
Kamar 1 7 bulan Hb 10.2 RBC 3.527 WBC 15.31 HT 28 PLT 302.000 MCV 7.9 MCH 29 MCHC 36 RDW-CV  Ibuprofen3x100mg
Bed 1 1104811/RI1900232 12.10 DC 0/3/58/32/7 Ret 2.0 LED 3 CRP kuan 15  metilprednisolone 3x4mg
TL : 16/5/2016 tablet
MRS : 27/1/2019 Urinalisa
Kuning, jernih, BJ 1.005 pH 8.0 protein (-) ascorbic acid (-) glukosa (-) keton (-) darah (-) bilirubin (-)
Alamat : Lorok Pakjo ilir
urobilinogen 1, nitrit (-) lekosit esterase (-) epitel (+) lekosit 5-6 eri 0-1 silinder (-) bakteri (-), mukus
Barat I (-) kristal (-), jamur (-)
Hp 085268643322
BB: 13 kg TB: 97cm
BB/U = 0<Z<2 SD
TB/U = Z = 2 SD
BB/TB : 13/14.25 =
91.22%
Kesan Gizi baik
Perawakan Normal
Lantai 2 Yeni Apriyani / NPSLE + HT stage II 21-1-2019  Stopper Konsul REHAB 
Kamar 2 perempuan / 9 tahun 4 terkontrol + AIHA + anemia Hb 10.6 RBC 3.59 WBC 25.95 HT 32 PLT 358.000 RDW-CV 15.40 DC 0/1/86/9/4 SGOT 44  IVFD D51/2 NS maintanance fisoterapi
Bed 1 bulan (perbaikan) + imbalance SGPT 48 Albumin 3.2 BSS 116 Ureum 71 As Urat 5.4, Kreatinin 0.47 Ca 9.0 Na 139 K 5.3 Cl 105  Ampicillin 3x1.5 gr iv (14)
1089672 / RI 18031863 elektrolit (perbaikan) + CRP 43  Gentamicin 2x55 mg iv (14) PA tgl 19/11/2018
TTL 08-08-2009 aphasia motoric + nepritic Urinalisa  metilprednisolon 3 x 20 mg Kesan : Neutrofilik
Alamat : Pemulutan Ogan lupus Warna kuning, agak keruh , bj 1.010 ph 6.0 protein (++) asam askorbic (-) glukosa (-) keton (-) darah PO  16 mg – 16 mg – 8 mg pleuritis pada
Ilir (++) bilirubin (-) , urobilinogen 1, nitrit (-), lekosit esterase (-), epitel (-) lekosit 0-1 eritrosit 20-25 po  stop selama metilpulse sitologi cairan
MRS: 7-11-2018 TDS TDD silinder (-) Kristal(-) , bakteri (++) mucus(-) jamur(+)  Calcitriol 0,5 mcg 3x/minggu pleura
50th 100 59 20-1-2019  Kalk 1 x 1 tab
BB: 23 kg TB : 132 cm
90th 113 73 Ca 8 Na 140 K 6.2 Cl 107 Ph 6.3 Mg 1.7  Haloperidol 0,5 mg 2x 2 tab Ro thorax
BB/U : P5- P10 14-1-2019
95th 117 77  Entrakid dan nasi biasa 18/11/2018:
TB/U : P10-P25 Hb 11.3 RBC 3.07 WBC 4.3 HT 35 PLT 262.000 RDW-CV 16.00 DC 0/0/68/19/13 SGOT 126
BB/TB ; 23/29 = 79.31%  Fisioterapi - kardiomegali
99th 124 84 SGPT 111 Albumin 3.2 Ureum 98 As Urat , 5 Kreatinin 0.52 Ca 10 Na 144 K 6.6 Cl 123 CRP 41
Gizi kurang, perawakan  Fenitoin 2x75 mg iv disertai efusi
9-1-2019
pendek  R/ MRI kepala dengan kontras pleura kanan,
Hb 11.2 RBC 3.85 WBC 7.04 HT 34 PLT 258.000 RDW-CV 17.40 DC 0/1/71/17/11 Alb 3.3
 CPA tgl 29-1-2019 pneumonia
7-1-2019
DPJP ALIM Hb 9.3 RBC 3.14 WBC 9.8 HT 28 PLT 291.000 RDW-CV 18.40 DC 0/0/77/14/9  Metil pulse 750 mg dalam kanan
RABER Nefro, NPM 5-1-2019 D5% 100ml habis dalam 2
PT 12.4(13.50) APTT 28.4 (29.5) INR 0.90 jam/hari selama 3 hari USG dr. Hasri
2-1-2019 (27/1)(28/1)(29/1) Salwan, Sp.
Hb 9.1 RBC 3.07 WBC 4.1 HT 27 PLT 130.000 RDW-CV 18.40 DC 0/0/76/15/9 PT 14.90(13.1) Kesan:
INR 0.96 APTT 33.9 (31.5) Fibrinogen 317 (191) D-dimer 1.04 SGOT 31 SGPT 12 Albumin 2.3  efusi pleura
BSS 77 Kolesterol Total 245 HDL 25. LDL 140 Trigliserida 553 Ureum 49 As Urat 4.9 Kreatinin  Paracetamol 3x250 mg po
massif
 Lactulose 2x5 ml po
0.30 Ca 8.0 Na 143 K3.4 Klor 115  ginjal kanan :
30-12-2018  Clorazepam 2x0.5 mg po
ukuran 10.5
Hb 12.0 wbc 15.9 HT 36 PLT 234.000 LED 3 dc 0/0/81/5/14 PT 12.2 (12.50 INR 0.88 APTT 29.4  Omeprazole 2x0 mg po
(normal). Batas
(31.2) SGOT 32 SGPT 11 protein total 4.2 alb 2.7 ureum 56 creat 0.41 Ca 8.0 phospor 3.9 Na 144 K  Piracetam 3x400 mg po
medulla tidak
3.1 Cl 114 CRP <5  Transfuse WE 1X200 cc
jelas,
27-12-2018  Inj metil prednisolon 1 x 15
1
 LAPORAN HARIAN ALERGI imun SELASA 29 januari 2019
Junior : dr.Yuanita Rimadini, dr. Marselya Ulfa Madya : dr. Msy Mutiara, dr. Rini Gita sari Senior: dr. Muhammad Aulia, dr. Yuyun Romaria
Hb 9.4 eri 3.04 wbc 4.9 HT 27 tro 124.000 dc 0/0/94/2/4 alb 2.9 mg (IV) stop  2 x 25 mg vaskulaisasi
AGD (IV)  stop  buruk.
pH 7.432 pCO2 33.2 pO2 72.1 saO2 94.3 hb 6.5 Na+ 141,7 K+ 2.68 Mg2+ 0.42 Total CO2 23.4  Albumin 25 % 100 cc (20/12)  Ginja kiri :
Beecf -2.1 Beb -1.0 HCO3 22.3 PO2/FiO2 343.3A-aDO2 36.6 1 x order ukuran 12cm
25-12-2018  Aminofusin paed 5% kec 12,5 (membesar)
Hb 8.0 wbc 6.7 HT 25 PLT 171.000 dc 0/0/86/3/11 protein total 3.8 alb 2.5 ureum 56 creat 0.36 Ca cc/jam batas medulla
9.0 Na 141 K 3.4 Cl 110  Ca gluconas 10% 15 cc dalam kortesk tidak
20-12-2018 D5 80 cc tiap 8 jam jelas,
Hb 5.2 leu 6.8 HT 16 PLT 111.000 LED 4 dc 0/0/87/6/7 protein total 4.1 albumin 2.2 ureum 122 creat  Omeprazol 2x 25 mg vaskularisasi
0.75 Ca 7.0 Na 140 K 5.0 Cl 113  Amlodipin 1 x 5 mg
17-12-2018 buruk
 12)  Asites +
SGOT 41 SGPT 34 Protein total 3,6, alb 1.8 ureum 83 AS urat 5.8 creat 0.58 Ca 7.0 Phsopor 3.2 Mg
 PRC 3 x 200 cc (1)(2)  WE  Saran evaluasi
1,30 Na 140 Cl 113 K 4.0 CRP 21 200 cc (1)(2)(3)
13-12-2018 fungsi ginjal
 TC 3 x unit (1)(2)(3)
Urinalisa  Koreksi
Kuning muda, agak keruh 1.015 pH 6.0 protein (++++) ascorbic acid (-) glukosa (-) keton (-) darah hipoalbumin
(+++) bilirubin (-) nitrit (-) lekosit esterase (-) epitel (-) lekosit 3-5 eri 100-104 silinder granular (++)
bakteri (-), mukus (-) kristal (-) PA 12/11/2008
12-12-2018 Kesan : mesoteal
Hb 6.9 leu 3.0 HT 22 PLT 75.000 LED 29 dc 0/2/79/9/10 SGOT 105 SGPT 46 protein total 4.0 alb reaktif pada
2.0 ureum 64 As urat 7.5 creat 0.67 Ca 6.0 Na 143 K 2.3 Cl 115 C3 56 (62-73mg/dl) C4 50.1 (13.0- sitology cairan
46.0mg/dl) CRP 57
pleura
10-12-2018
Protein total 4,1, alb 1.9 Na 143 Ca 8.0 K 2.8 Cl 120
7-12-2018
Kultur darah  steril
29/11/2018
Hb 9.7 eri 3.64 leu 18.1 HT 31 PLT 281 RDW CV 17.30 DC 0/0/75/15/10 prot total 4.5 Alb 2.3 Ur 101
Au 11.2 Cr 0.47 Ca 8.0 Na 146 K 3.3 Cl 110
26/11/2018
Hb 9.5 eri 3.54 leu 9.6 HT 28 PLT 348 RDW CV 14.70 DC 0/1/75/15/16 prot total 5.4 Alb 2.8 Ur 139 Au
9.9 Cr 0.63 Ca 8.0 Na 146 K 3.7 Cl 111 CRP <5
AGD: FIO2 99 ph 7.397 Pco2 34.3 pO2 73.4 BE -3.7 BEb –2.3 HCO3 21.3
25/11/2018
Hb 9.1 eri 3.5 leu 7.0 HT 27 PLT 317 MCV 77.5 MCH 25 MCHC 33 RDW CV 15.60 LED 48 DC
0/0/72/14/14 prot total 5.3 Alb 2.9 Glob 2.4 Ur 111 Au 7.1 Cr 0.77 Ca 8.0 Na 138 K 4.0 Cl 101 CRP <5
AGD: FIO2 90 ph 7.409 Pco2 33.0 pO2 111.0 BE -3.8 BEb –2.4 HCO3 21.1
22/11/18
Hb 6.4 eri 2.53 leu 3.8 HT 20 PLT 2017 MCV 77.5 MCH 25 MCHC 33 RDW CV 15.60 LED 48 DC
0/0/57/30/1.3 prot total 4.9 Alb 2.7 Glob 2.2 Ur 107 Au 7.8 Cr 1.67 Ca 8.0 Na 137 K 4.4 Cl 103 CRP <5
AGD: FIO2 99 ph 7.434 Pco2 29.3 pO2 85.9 BE -4.6 BEb –3.2 HCO3 19.8
21/11/18
23.00 Hb 6.6 eri 2.56 leu 7.0 HT 20 PLT 266 MCV 78.5 MCH 26 MCHC 33 RDW CV 15.50 LED 47 DC
0/0/89/9/2 Prot total 4.9 alb 2.7 glob 2.2 ur 88 Au 7.4 Cr 1.22 Ca 8.0 Na 138 K4.5 Cl 107 CRP 6
AGD: fio2 90 pH 7.423 PCO2 30.0 PO277.5 lactat 0.8 HCO3 19.7 BE -4.9 BEb -3.4
Hb 7.0 eri 2.63 leu 5.8 HT 21 PLT 273 MCV 77.9 MCH 26 MCHC 33 RDW CV 15.50 DC 0/0/67/23/10
prot total 4.5 alb 2.4 glob 2.1 ur 128 CR 0.87 ca 7.0 Na 142 K 3.8 Cl 111 CRP 9 C3 41 (82-73), C4 42.5

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 LAPORAN HARIAN ALERGI imun SELASA 29 januari 2019
Junior : dr.Yuanita Rimadini, dr. Marselya Ulfa Madya : dr. Msy Mutiara, dr. Rini Gita sari Senior: dr. Muhammad Aulia, dr. Yuyun Romaria
(13.0-46.0)
17/11/18
Ferritin 3979.02 SI 21 (61-157) UIBC 70 TIBC 91 (112-346)
16/11/18
Hb 8.0 eri 3.12 leu 8.0 ht 24 trom 209 RDW Cv 15.70 LED 55 DC 0/0/65/23/12 prot total 4.5 alb 2.9 ur
128 creat 1.08 AU 11.0 ca 7.0 Na 141 K 4.6 Cl 115 CRP 33
Kultur cairan pleura: steril
Kultur urin: Candida Sp : yeast cell (+), lekosit 0-1, epitel 0-1, jumlah koloni >100.000
14/11/18
AGD : pH 7.345 pCO2 28.5 pO2 80.8 saturasi O2 95.6 BE -10.2 BEb -8.3 HCO3 15.7 FIO2 384.7
13/11/18
Urinalisa
Warna kuning keruh , bj 1.015 ph 6.0 protein (+++) asam askorbic (-) glukosa (-) keton (-) darah (+++)
bilirubin (-) , urobilinogen 1, nitrit (-), lekosit esterase (-), epitel (+) lekosit 10-20 eritrosit 200-250
silinder granular(+) Kristal(-) , bakteri (-) mucus(-) jamur(+)
12/11/18
Hb 8.9 eri 3.4 leu 5.8 ht 27 PLT 101 MCV 78.2 MCH 26 MCHC 34 RDWCV 15.90 LED 33 DC
0/0/63/29/8/36 SGOT 36 SGPT 6 prot ttal 4.0 alb 2.0 glob 2.0 ur 118 cr 0.72 ca 7.0 na 147 K 4.6 cl
124 CRP 10
10/11/18
Waktu perdarahan 2.0 (1-3), waktu pembekuan 10.0 (9-15), PT 13.1 (14.60), INR 0.97 APTT 38.5
(30.2) Fibrinogen 509.0 (265.0) D dimer 15.09 HbsAg non reaktif, anti HIV non reaktif.
BTA 1 (-) BTA 2 (-) TCM not detected
08/11/18
C3 31 C4 27. Kol total 132 HDL 10 LDL 52 TG 339 ASTO non reaktif
Analisa cairan pleura: warna kekuningan ph 8.0, jumlah leukosit 10.0 PMN sel 10 MN sel 90 glukosa
101.0
BTA cairan pleura (-)
Kultur urin steril
GDT: Eritrosit normositik normokrom
Leukosit jumlah normal, bentuk normal
Trombosit jumlah normal bentuk besar
Kesan: anemia normositik normokrom ec susp penyakit kronis
Saran monitor darah tepi CRP
Urinalisis :
Warna kuning muda, Kejernihan Keruh, bj 1.010 ph 6.0 protein (++) asam askorbic (-) glukosa (-)
keton (-) darah (+++) bilirubin (-) , uro 1, nitrit (-), Lekosit esterase (-), Epitel (+), Lekosit 180-200,
Eritrosit 30-40, Silinder (silinder), Kristal (-), Bakteri (-) mucus(-), jamur(-)
07/11/18
Hb 9.6 Eri RBC 3.64 Leu WBC 5.1 Ht 29 PLT 166 MCV 78.6 MCH 26 MCHC 34 RDW-CV 15.70 LED 57
Bas 0 Eos 0 Net 61 Lim 29 Mon 10 Ret 1.3 PT+INR 14.80 (13.8) INR 1.03 APTT 30.3 (38.2) Fe 10 TIBC
120 AST/SGOT 42 ALT/SGPT 9 Pro tot 3.8 Alb 1.7 Glob 2.1 Ur 120 Kre 1.25 Ca 6.3 Mg 1.80 Na 142 K
4.9 Cl 123 Ferr 1979.50 CRP-K 25
Lantai 2 Ririn Nurdianti / Pr /13 SLE + AIHA + nefrotik 28-1-2019  IVFD D51/2 NS gtt XV makro Konsul DV
Kamar 3 tahun 10 bulan lupus Urinalisa  Methylprednisolone 3x12 mg Ass : Susp
Bed 4 Kuning, jernih, BJ 1.005 pH 7.0 protein (-) as. ascorbat (-) glukosa (-) keton (-) darah (-) bilirubin (-) po Discoid Lupus
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 LAPORAN HARIAN ALERGI imun SELASA 29 januari 2019
Junior : dr.Yuanita Rimadini, dr. Marselya Ulfa Madya : dr. Msy Mutiara, dr. Rini Gita sari Senior: dr. Muhammad Aulia, dr. Yuyun Romaria
1103903/RI19002353 Sis Dias urobilinogen 1 nitrit (-) lekosit esterase (-) epitel (+) lekosit 0-2 eritrosit 0-1 silinder (-) bakteri (-),  Antacid 3x5 ml po Eritematosus
TL : 2/03/2005 P50 109 66 mukus (+) kristal (-)  Ibuprofen 3x200 mg po (DLE)
MRS : 22/1/2019 21-1-2019  Aseptic gargle 2x1 ue Saran 
P90 121 75
Alamat : Bengkulu P95 125 78
Comb test Direct / Indirect (+/+)  Ceftazidin 3x1.6 gr iv (7) Pemeriksaan
21-1-2019  Sulfat ferrous 3x1 tab po biopsy kistoPA
Hp P99 132 83 Hb 9.1 RBC 3.47 WBC 2.35 HT 28 PLT 265.000 MCV 80.1 MCH 26 MCHC 33 RDW-CV 15.40 Konsul Psikiatri
BB: 33 kg TB: 150 cm  Kalk 1x1 tab po
LED 35 DC 0/0/58/35/5 Ret 0.7 Fe 141 TIBC 255 BT 0.6 BD 0.3 BI 0.3 SGOT 53 SGPT 35 Alb 3.8  Calcitriol 1x0.5 mcg po  pada saat
BSS 113 Kolt tot 178 Ur 45 Kreat 0.63 Ca 9 Na 149 K 4.0 Cl 117 Ferritin 1664.70 C3 60 C4 12.4 diperiksa
BB/U : P <5 ANA test 1/1000 pola cytoplasmic (negative <1/100) anti ds-DNA 230.97 (equivocal 201-300, positif emosional tetap
TB/U : P10 – P25 301-800, positif kuat > 800) CRP < 5 stabil
BB/TB : 35/41 = 85 % Urinalisa Saran : Konsul
Kesan Gizi kurang Warna kuning, jernih, bj 1.005 ph 7.0 protein (-) asam askorbic (-) glukosa (-) keton (-) darah (++) ulang bila ada
bilirubin (-) , urobilinogen 2, nitrit (-), lekosit esterase (-), epitel (-) lekosit 0-1 eritrosit 2-3 silinder keluhan
granular(-) Kristal(-) , bakteri (++) mucus(-) jamur(-) Therapy sesuai TS
GDT:
Eritrosit normositik normokrom, poikilositosi (fragmentosit, ovalosit)
Leukosit jumlah menurun, limfosit atipik (+)
Trombosit jumlah normal bentuk normal
Kesan: anemia normositik normokrom dan leukositosis ec inflamasi kronis / pengaruh obat-obatan /
depresi sumsum tulang
Saran monitor darah tepi
Lantai 2 M. Anggada / Lk /6 Juvenile Idiophatic Artritis 22-1-2019  IVFD D5 ¼ NS gtt XV/m
Kamar 4 tahun 2 bulan Poliarthritis Hb 9.8 RBC 4.27 WBC 19.94 HT 32 PLT 958.000 MCV 75.9 MCH 23 MCHC 30 RDW-CV 16.70 (makro)
Bed 6 1104164/RI19001935 DC 0/0/84/13/3 SGOT 19 SGPT 6 ALB 3.3 UREUM 13 AS.URAT 4.7 KREAT 0.43 Ca 9 Na 145 K  MTX 1x3 tab po @2.5 mg tiap
Sis Dias 4.5 Cl 111 CRP 74 jumat saat perut kosong
TL : 16/11/2012
P50 98 60 perminggu
MRS : 22/1/2019
P90 108 68  Aspilet 1x80 mg po  aspilet
Alamat : Banyuasin 4x250 mg
Hp P95 111 71
 Ibuprofen 3x150 mg po
BB: 15 kg TB: 117cm P99 117 75  As folat 1x5 tab po
 B Komplek 2x1 tab po
BB/U = p<5  Tablet penambah darah 3x1
TB/U = P 50-P75 tab
BB/TB : 15/22 = 66%
Kesan Gizi buruk
Lantai 3 Siti Ratna Isnariah / 12 SLE + syndrome metabolic 26-01-2019  IVFD D5 ½ NS 15 tpm makro Konsul DV 
Kamar 6 tahun 1 bulan / (DM type II+ Dislipidemia + Ca urine 60.0 Na Urine 32, K Urine 11.12 4.1 Cl 114  Omeprazole 2x 20mg iv Frichone uron dd/
Bed 1 perempuan Hipertensi Stage II Ca 9.0 Na 138 K 4.1 Cl 114 BSS 162  D-Vitamin 1x10ml po ulkus+ miliaria
1026164 / RI 19031415 terkontrol) + Peningkatan AGD: Temp 36.5, FiO2 40 pH 5.0 pCO2 37.8 pO2 139.9 saturasi O2 99.6 Hct 36 Hb 11.9 NA+ 133.6 K+  Fluconazole 1x350 mg po (11) dishloe + stria
TTL: 4 desember 2006 SGOT/SGPT + 2.33 Ca 1.08 Laktat 1.6 pHtc 7.517 PCO2 tc 37 PO2 tc 136.9 TCO2 31.5 HCO330.4 Kelebihan Basa 7.1  Amlodipin 1x2.5 mg po alba
NRS : 14-1-2019 Hipoalbuminemia + 25-01-2019 pukul 13.00 (malam) Saran : Pelembab
Palembang Imbalance elektrolit (selesai) Ca 10 Na 141 K 3.9 Cl 112  Lisinopril 1x2.5 mg po (pagi) amiclair 2x/hr pd
No telp : 082182870783 + Oral Monoliasis Urinalisa kulit kering,
 Paracetamol 500mg kp
(perbaikan) + Erupsi Kuning, jernih, BJ 1.010 pH 7.0 protein (-) as. ascorbat (-) glukosa (-) keton (-) darah (-) bilirubin (-) Kulit sehat :
 OAT
BB: 38 gr TB: 140 cm Acneformis + miliaria urobilinogen 2 nitrit (-) lekosit esterase (-) epitel (+) lekosit 2-4 eritrosit 0-1 silinder (-) bakteri (-), compres terbuka
BB/U : P25-50 pustula + Limfadenitis Tb + mukus (+) kristal (-)  Ceftriaxon 1x1,5 gr (15) dg NaCl 0,9% 3x
TB/U : P5-10 ulcus aksila dx et sin et 25-01-2019 pukul 03.00  Cetirizin 1x5 mg po k/p ½ cc
BB/TB 38/37 =102,7% gluteasinistra + limfadenitis Hb 11.2 RBC 3.74 WBC 9.52 HT 30 PLT 155.000 MCV 81 MCH 30 MCHC 37 RDW-CV 14.80  Ambroxol 3x1cth po Intrasic gel setelah
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 LAPORAN HARIAN ALERGI imun SELASA 29 januari 2019
Junior : dr.Yuanita Rimadini, dr. Marselya Ulfa Madya : dr. Msy Mutiara, dr. Rini Gita sari Senior: dr. Muhammad Aulia, dr. Yuyun Romaria
Kesan : gizi baik, TB DC 0/0/90/8/2 LED 23 Bitot 0.50 Bidek 0.40 Bi Ind 0.10 Chol Tot 242 SGOT 88 SGPT 152 Prot tot  Betadine gargle 2x/hr kering
perawakan pendek _ 4.9 ALB 3.0 BSS 200 UREUM 15 KREAT 0.43 As Urat 2.3 Ca 9.0 Na 124 K 2.5 Cl 86 Phospor 2.2  Metil prednisolone 2x8mg iv
Sis Dias Mg 2.00 CRP 230 1x12 mg po (S/K/S) Konsul Mata 
Raber Infeksi, P50 103 61 24-1-2019  Sucralfat 3 x 7.5 ml po Anomaly refraksi
Nephrologi, NPM,
P90 116 75
Hb 12.8 RBC 4.22 WBC 8640 HT 34 PLT 171.000 RDW-CV 14.90 DC 0/0/96/2/2 LED 21 Chol  Asam fusidat 2xue ODS
Endokrin Tot 242 HDL 31 LDL 90 TG 701 SGOT 139 SGPT 178 ALB 2.8 UREUM 24 KREAT 0.51 Ca 8.0  Cellcept 500mg pagi 1 tab sore Saat ini tidak
P95 120 79 Na 121 K 1.9 Cl 83 CRP 220 C-peptide 2.37 ditemukam tanda
1 ½ tab
P99 127 86 21-1-2019 uveitis
 Susu F100 3X200 ML
Hb-A1c 9.6 (4-6.5) Saran: kontrol
 Diet nasi bubur
21-1-2019 ulang ke poli
 Kompres wajah dengan NaCl
Hb 13.7 RBC 4.46 WBC 3.60 HT 36 PLT 136.000 RDW-CV 14.60 DC 0/0/90/6/4 SGOT 184 refraksi mata
0.9%
SGPT 270 Ca 8 Na 140 K 4.0 Cl 115 untuk koreksi kaca
 Ibuprofen 300 mg KP  2x200
Urinalisa mata.
Kuning, agak keruh, BJ 1.005 pH 7.0 protein (-) as. ascorbat (-) glukosa (++++) keton (-) darah (-) mg
bilirubin (-) urobilinogen 1 nitrit (-) lekosit esterase (-) epitel (+) lekosit 3-5 eritrosit 0-1 silinder (-)  Klorokuin 2x1/2 tab po Konsul Neuro 
bakteri (+), mukus (+) kristal (-)  Calamin lotion 150 cc + NPSLE belum
18-1-2019 hidrocortison 20 gr/ 12 jam ue dapat ditegakan
Protein esbach 0.2 (Normal : 0.5)s  Metformin 3x500mg po saran : EEG
15-1-2019  OAT (INH Etambutol) po
Kultur darah : steril  KSR 1x2 tab  KCL pulv 3 x Konsul DV  dd/
14-1-2019 500mg cap po milaria psikoriasis
Hb 16.0 RBC 5.19 WBC 11.2 HT 46 PLT 182.000 MCV 88.4 MCH 31 MCHC 35 RDW-CV 15.50  Drip KCl 10 meq + D5 100cc Saran : calamine
DC 0/0/90/7/3 LED 27 C3 173 C4 15.2 SGOT 193 SGPT 168 ALB 4.4 UREUM 26 KREAT 0.52 Ca habis dalam 2 jam lotion 150 cc +
9 Na 140 K 4.2 Cl 103 ANA (1/320) positif kuat, Anti dsDNA (158.49)  negative, CRP 5 C3 173  Koreksi ca gluconas 15 cc hidrocortison 20
(82-73) C4 15.2 (13-46), Koltot 382 HDL 62 LDL 253 Tg 311 dalam D5 75 cc habis dalam 30 gr / 12 jam
Urinalisa menit/ 8 jam
Kuning, agak keruh, 1.020 pH 5.0 protein (+) glukosa (-) darah (-) bilirubin (1) nitrit (-) lekosit  Koreksi calcium 17 meq + D5 Konsul Infeksi 
esterase (-) epitel (-) lekosit 0-1 eri 0-1 silinder (-) bakteri (+), mukus (+) kristal (-) 100cc drip 30 menit tiap 8 jam Acc Rawat
 Koreksi Albumin 25% 140cc bersama
habis dalam 4 jam (1)(2)(3)
 D5 ½ NS 400cc + 176 NS 3% Konsul
+ KCL 17 cc kec 60cc/Jam Nehprologi  acc
 Domperidone 3x2 cth po rawat bersama
 Nifedipin 1x 5mg po (kp)
 Captopril 2x 25 mg po Konsul GEH 
 Furosemid 2x40 mg saran ; omeprazole
2x20 mg
 Antasid syr 3x10m po
Sucralfate 3x 2,5
mg

Konsul Endokrin -
 DM type II
Metformin
3x500mg
Da Vit 3x 1 cap
Diet 2000-
2200kkal
Cek BSS pagi-
siang-malam
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 LAPORAN HARIAN ALERGI imun SELASA 29 januari 2019
Junior : dr.Yuanita Rimadini, dr. Marselya Ulfa Madya : dr. Msy Mutiara, dr. Rini Gita sari Senior: dr. Muhammad Aulia, dr. Yuyun Romaria
Konsul ulang 3
hari lagi
Lantai 3 Muhammad Kenzo PHS Relaps (Perbaikan) + 26-1-2019  Sucralfat 3x7,5 ml po Konsul gigi dan
Kamar 10 Hakim / lk/ 3 tahun 5 Perdarahan gastrointestinal Hb 11.6 RBC 4.26 WBC 16.97 Ht 36 PLT 312 RDW-CV 16.00 DC 0/0/53/39/8 MCV 83.6 MCH 27 MCHC  Metil prednisolon 2x4 mg iv mulut 28-1-19
Bed 1 bulan (perbaikan) + oral 33 LED 30 CRP Kuant <5 (8) gangrene radiks
1095350 / RI 18037265 monoliasis + Gangren radiks 21-1-2019  B complex syr 3xcth I konservatif, pro
TL: 29 juli 2015 + Pulpitis Kultur urin  Betadine gargle 2x/hari ekstraksi bila
MRS 27-12-2018 Kuman : E Coli, gram (-) basil (+), leukosit 0-1/lp, epitel 0-1/lp  Asam Folat 1x1mg sudah persistensi
Sukarame, Palembang Sis Dias Kultur Darah : Steril  Ranitidine 2x10 mg po (usia5-6thn)
No HP 085267357182 P50 89 47 Urinalisa  Ceftriaxone 1x800 mg iv (9)
Kuning, jernih, BJ 1.010 pH 6.0 protein (-) ascorbic acid (-) glukosa (-) keton (-) darah (-) bilirubin (-) USG Abdomen
P90 103 62
BB: 11 kg TB 94 cm 18-1-2019 
P95 107 66 urobilinogen 1, nitrit (-) lekosit esterase (-) epitel (+) lekosit 0-1 eri 0-1 silinder (-) bakteri (-), mukus  Omeprazol 1x20 mg iv
BB/U : -3SD dalam batas
TB/U : -1 SD < Z < 0 P99 114 74
(-) kristal (-), jamur (-)  Asam fusidat 2xue normal
FR : kehitaman, encer, amoeba (-), eritrosit 5-6, leukosit 1-2, bakteri (+), jamur (-), telur cacing (-),  Metotrexate 5 mg po tiap
BB/TB -3 < Z < -2 lemak (-), darah samar (+) Saran : PPI dan
Kesan gizi kurang hari Jumat sucralfat, bila
perawakan normal
18/1/19  Ibuprofen kp masih BAB hitam
Hb 13.4 RBC 4.88 WBC 25.17 Ht 42 PLT 271 RDW-CV 17.90 DC 0/0/60/32/8 PT 13.6 (13.5) INR 1.01  Ceterizin 1x1 cth po dan muntah
APTT 24 (31.6)  Domperidone 3x1/2 cth po direncanakan
FR : coklat, keras, amoeba (-), eritrosit (0-1), leukosit (0-1), bakteri (+), jamur (-), lemak (-), darah  Drip methylprednisolone endoskopi.
samar (+) 300 mg dalam D5 100 cc
9-1-2019 habis dalam 2 jam selama 3 Ro toraks tgl 31 -
FR : coklat, keras, amoeba (-), eritrosit (0-1), leukosit (0-1), bakteri (+), jamur (+), lemak (-), darah hari (18/1, 19/1,20/1) 12 – 2018
samar (-)  Eritromicin 1x400mg po (6)  Limpadenitis
Kultur urin menuuggu  ga ditampung2  Cetirizin 1 x cth 1 hilus Kiri
 Ampicillin IV 3 x 750 mg
8-1-2019 (14) --> stop
Urinalisa  Gentamisin IV 1 x 60 mg Konsul gigi 15-1-
Warna kuning keruh , bj 1.000 ph 9.0 protein (-) asam askorbic (-) glukosa (-) keton (-) darah (-) (14) --> stop 2019  ganggren
bilirubin (-) , urobilinogen 1, nitrit (+), lekosit esterase (-), epitel (-) lekosit 0-2 eritrosit 0-2 silinder  Fluconazole 1x 30 mg radix
granular(-) Kristal(-) , bakteri (+++) mucus(-) jamur(-)  Fe syr 1x10mg (13) Saran : tindakan
BTA 1 (-)  Metil prednisolon 4 mg poli
3-1-2019 1 – 0- 1 tab(10/1/19 s/d
Hb 9.7 RBC 3.73 WBC 24.5 Plt 718 RDW-CV 14.80 LED 41 DC 0/0/75/19/6 CRP kuant <5 15/1/19)
28-12-2018
Kultur Urine steril
26-12-2018
Hb 10.2 wbc 21.0 HT 32 PLT 230.000 LED 52 dc 0/3/55/36/6 CRP <5
Urinalisa
Kuning, jernih, 1.010 pH 6.0 protein (-) glukosa (-) darah (-) bilirubin (-) nitrit (-) lekosit esterase (-)
epitel (-) lekosit 0-1 eri 0-1 silinder (-) bakteri (-), mukus (+) kristal (-)
13/12/2018
Kultur urin  klebsiella pneumoniae ssp pneumoniae
Sensitif: cipro, genta, kotrim, nitrofurantoin, tigeciclin, ceftri, amikasin, aztreonam, cefazolin,
cefepim, ceftazidim, ertapenem, meropenem, tazobactam
Resisten:ampi
Lantai 3 Wahyu Reza Pratama / Psoriasis +ichiosis + arthritis 28-1-2019  Mtx 1x2.5 tab po tiap minggu Konsul Mata
Kamar 10 Lk /15 tahun 8 bulan septik + oral trust + anemia Hb 9.9 RBC 4.88 WBC 9.90 HT 29 PLT 785.000 MCV 68.2 MCH 20 MCHC 30 RDW-CV 17.00  Asam folat 2x1 mg po senin-  Ektropion OD
DC 0/1/83/10/6 LED 90 retikulosit 2.6 ferritin 262.10 SI 23 UIBC 205 TIBC 228 Saran kompres
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 LAPORAN HARIAN ALERGI imun SELASA 29 januari 2019
Junior : dr.Yuanita Rimadini, dr. Marselya Ulfa Madya : dr. Msy Mutiara, dr. Rini Gita sari Senior: dr. Muhammad Aulia, dr. Yuyun Romaria
Bed 2 1028525/RI19002355 Sis Dias 25-1-2019 sabtu kassa basah 2x10
TL : 10/05/2003 P50 110 67 Hb 8.7 RBC 4.23 WBC 5.71 HT 29 PLT 654.000 MCV 67.6 MCH 21 MCHC 30 RDW-CV 17.00  Ibuprofen 2x500 mg po Kp menit palpebral
MRS : 22/1/2019 P90 122 76
DC 0/0/78/14/8 LED 89 SGOT 488 SGPT 33 ALB 3.2 UREUM 3.1 KREAT 0.57 Ca 9.0 Na 140  Cefixime 2x200 mg po dextra,
Alamat : Sukarami
K5.2 Cl 104 CRP 170  Mometason krim 2x ue Chloramphenicol
P95 126 79
Palembang Hp
24-1-2019  Kompres NaCl 0.9% EO/8jam
P99 134 84 Kultur : steril  Methylprednisolone 1x8 mg Cendo lyters /
BB: 35 kg TB: 143 cm Kultur : Basilus SP gram (+) basil (+) leukosit 10-15/lp epitel 0-1/lp 6jam ODS
po
BB/U = p< 5 Analisis Cairan Sendi : Ro thorax
 Ceftriaxon 1x2gr iv (9) (drip
TB/U = p<5 Vol 7.0 ml kekuningan, keruh, tidak berbau, BJ 1.005 Bekuan (-) pH 7.0 Jumlah Leukosit 140432 24-01-2019
15 menit + NaCl 0.9% 50 cc)
BB/TB : 35 /36 PMN Sel 92 MN Sel 8 Rivalta (-) Glukosa 5.0 Prot 0.9 LDH 2899 Kesan
 Oleum coccos 2x ue
Kesan Gizi baik Analisis Cairan Sendi : Cardiomegaly
 Candistatin oral 4x1ml
Vol 5.0 ml kekuningan, keruh, tidak berbau, BJ 1.005 Bekuan (-) pH 7.0 Jumlah Leukosit 113525 (mild), pelebaran
 Transfusi PRC 2x 200 ml
PMN Sel 95 MN Sel 5 Rivalta (-) Glukosa 17.5 Prot 3.5 LDH 2315 mediastinum
(1)(2) superior dd/
21-1-2019
Hb 10.2 RBC 5.02 WBC 9.96 HT 34 PLT 923.000 MCV 68.5 MCH 20 MCHC 30 RDW-CV 18.30  Cendo lyters/ 6jam ODS limphadenophati ;
LED 84 DC 0/2/71/19/8 ferritin 229.40 serum iron 15 UIBC 223 TIBC 238 BT 0.4 BD 0.2 BI 0.2  Cloramphenicol EO/8jam vaskuler, pulmo
SGOT 12 SGPT 13 Alb 3.8 Ur 13 Kreat 0.61 Ph 4.6 Ca 9 Na 145 K 4.3 Cl 106 CRP 80 ASTO reaktif tak tampak
kelainan.