AQSHA 3 (PENYAKIT DALAM WANITA)

Hari/Tanggal : Senin, 26 Juni 2019

Dokter Jaga : dr. Ade / dr. Taufik
Dokter Muda Jaga : Rusdi / Devi

K1B1 K1B2 K1B3 K1B4

DPJP : dr. Abdullah, Sp.PD DPJP : dr. Masralena, Sp. PD DPJP : dr. M. Fuad, Sp.PD
COW : dr. Nadi COW : dr. Aziz COW :
DR : dr. Reyza DR : dr. Riza DR :
Raber : Raber: Raber :
Nama: Fatimahwati Nama : Vanessa Suci Nama : Cut Rahimah
Umur: 46 thn Umur : 29 thn Umur : 69thn
CM: 1-14-14-22 CM : 1-17-94-57 CM :1118120
Alamat: Banda Aceh Alamat : Banda Aceh Alamat : BandaAceh
Hari rawatan: 7 Hari rawatan : 1 Hari rawatan : 1

A/ A/ A/
1. CKD stage V on CAPD 1. Trombositopenia e.c.d.d. - Anemia sedang hipokrom
2. peritonitis associated CAPD - ITP mikrositer ec dd/
3 hipokalemia - TTP 1. Defisiensi besi
4. diare akut e.c 1. infeksi bakteri 2. - Viral infection 2. Penyakit kronis
Infeksi virus - Implant failure post op TKR
Th/ - Hipertensi stage 2
Th/ - Bedrest
- Bedrest - Diet MB 1700 kkal/hari Th/
- O2 2-4 lpm - IVFD NaCl 0,9% 30 tpm - Bedrest
- Diet MB 1500 kkal.hari - Paracetamol 3x500 mg k/p - Diet MB 1700kkal/hari
- Threeway - Iv metilprednisolon 125/2 jam - IVFD NaCl 0,9% 20gtt/i
- IV Ceftriaxone 2 gr/24 jam - Transfusi TC jika trombosit < - Paracetamol 2x1000 mg
- IV omeprazole 40mg/12j 20.000 dengan perdarahan - Transfusi PRC s/d Hb >10gr/dL
- Valsartan 1x40 mg - Valsartan 1x80 mg
- Herbesser CD 1x100 mg Lab 25/06/19
- Inj Cefotaxime 200 mg Hb/Ht/E/L/Tr: 13,7/38/4,3/10,3/10
- Inj gentamisin 20 mg MCV/MCH/MCHC :
- Ksr 2x600 mg 89/32/36
- Alprazolam 1x0,25 mg Diftel: 0/0/0/88/10/2

Lab 24/06/19
Na/K/Cl : 136/2/107
Urinalisis
Leukosit / Protein : - / +1
Glukosa / Keton : +1 / -
Nitrit ; -
Urobilinogen / Darah : - / +
Sedimen
leukosit: 8-10 LPB
Eritrosit : 6-8
Epitel : 10-15

Lab 19/06/19
Hb/Ht/E/L/Tr: 8/22/2,7/7,6/199
MCV/MCH/MCHC : 79/29/37
Difftel: 5/1/0/64/24/6
Ur/Cr : 86/8,64
Na/K/Cl : 138/2,4/102
 K2B1 K2B2 K2B3 K2B4 K2B5
DPJP : dr. Masra lena, DPJP : dr. Diana Erlita, DPJP : dr. M Darma, DPJP : dr. Masra lena,
Sp.PD Sp. PD Sp.PD Sp.PD
COW : dr. Aziz COW : dr. Cut COW : dr. Aziz COW : dr. Aziz
DR : dr. Riza DR : dr. Husna DR : dr. Riza DR : dr. Riza
Raber : Raber : Raber : Raber :
Nama : Wardani M Yusuf Nama : Mirnawati M Adam Nama : Nuraini Ali usman Nama : Andiah M Yusuf
Umur : 35th Umur : 04-05-1977 (42th) Umur : 73 Umur : 18-7-1964 (65 thn)
CM :1206641 CM : 0901205 CM : 1212211 CM : 12124533
Alamat : Bireuen Alamat :Aceh Besar Alamat : aceh besar Alamat : bireun
Hari rawatan: 3 Hari rawatan : 5 Hari rawatan: 5 Hari rawatan: 3

A/ A/ A/ A/
Anemia aplastik 1. Dyspepsia type like 1. Massa right lower 1. Pneumonia
ulcer dd dismotility quadran ec dd/ 2. Hipokalemia
Th/ 2. Susp. Depresi dengan - ca colon 3. Hipoalbuminemia
- Bedrest gangguan somatik - ca renal 4. Geriatri problem
- Diet mb 1700 kkal/hr 3. DM tipe II - ca ovarium
- Threeway 4. ISK 2. anemia ringan hpokrim Th/
- Metyl prednisolon 5. Anemia ringan mikrositer ec dd/ - Bed rest
3x8mg hipokrom mikrositik - peny kronis - Diet lunak 1700 kkal /hari
- Omeprazole 2x40mg - defisiensi besi - IVFD NaCl 0,9% 20 tpm
- Sandimun 2x50mg Th/ 3. Hipoalbuminemia - omeprazole 40 mg
- Iv Metyl prednisolon -Bedrest sedang - iv metokloprmidide amp
125 mg/12 jam -Diet M II 1700kkal/hari 4. Hiponatremia (k/p)
-IVFD NaCl 0,9% 20gtt/i hipoosmolar hipovolemik
- fluimucil 3x200 mg
Lab 25/06/2019 - IV Ondansetron g/8j 5. Geriatri problem
- pct 3x500
Hb/Ht/E/L/Tr: -Iv ceftriaxone 2gr/24j - ksr 3x600 mg
6,4/17/1,7/2,8/44 - IV omeprazole 40mg/12j Th/
MCV/MCH/MCHC : - Kaltropen Supp - bedrest
99/38/38 - Sucralfat syr 3xCI - diet MB TKTP 1700
kkal/hr Lab 25/06/2019
Diftel: 0/1/0/89/7/3 - Diazepam 2,5 mg extra Hb/Ht/E/L/Tr:
- Alprazolam 0,5 mg 1x1 - IVFD NaCl 0,9%
30gtt/i 9110,9/32/3,7/6,2/45194
Lab 22/06/2019 - Haloperidol 0,5 mg 2x1 MCV/MCH/MCHC :
Hb/Ht/E/L/Tr: -sertraline 1x50mg - Paracetamol
3x500mg 85/29/34
3,4/10/0,8/1,8/41 -clobazam 2x1 Diftel: 33/0/1/68/18/10
MCV/MCH/MCHC : -insulin novorapid 6-6-6 - Levofloxacin 1x500
mg Albumin: 2,76
119/43/36 - Gabapentin 2x100 mg GDS : 124
Diftel: 1/0/0/70/20/9 - Drip paracetamol 1 gr/12 Ur/Cr: 15/0,45
jam Na/K/Cl : 138/ 2,6/ 107
- SC Hazelin 0-0-0-8 Lab 22/06/2019
Hb/Ht/E/L/Tr:
Lab 25/06/2019 8,7/26/3,4/8,5/402
Hb/Ht/E/L/Tr: MCV/MCH/MCHC :
9,5/28/3,6/8,4/337 76/26/34
MCV/MCH/MCHC : Diftel: 0/0/0/82/12/6
76726/35 Albumin: 2,54
Diftel: 0/0/0/73/16/11 Ur/Cr: 35/1,12
Na/K/Cl : 125/3,9/99
Lab 22/06/2019 Lab 23/06/2019
GDS : 557 Hb/Ht/E/L/Tr:
Ur/Cr : 92/2,04 0,4/30/3,9/8,0/326
Na/K/Cl : 126/4/114 MCV/MCH/MCHC :
77/26/34
Lab 20/06/2019 Diftel: 0/1/0/83/12/4
Hb/Ht/E/L/Tr:
9,5/28/3,7/25,8/299
MCV/MCH/MCHC :
75/26/35
Diftel: 0/1/0/94/3/2

Lab 21/06/2019
Urinalisa
Glukosa : +3
Leukosit : 10-15
Epitel :2-4
 K3B1 K3B2 K3B3 K3B4 K3B5
DPJP : dr. Diana Erlita, DPJP : dr. Diana, Sp.PD DPJP : dr. Diana Erlita, DPJP : dr. Price Maya, DPJP : dr, M Darma
Sp.PD COW : dr. Cut Sp.PD Sp.PD COW : dr.Aziz
COW : dr. Cut DR : dr. Husna COW : dr. Cut COW : dr. Cut DR : dr.Riza
DR : dr. Husna Raber: DR : dr. Husna DR : dr. Husna Raber:
Raber : Raber : HOM Raber :
Nama : Roswati Nama : Yusriah abd manaf Nama : Wagini Bin tukiman Nama : Salbiah Basyah M Nama : Supiah riswan
Umur: 49 tahun Umur: 47th Umur: 01/107/1967 (51th) Umur : 60thn Umur : 58th
CM: 1-20-23-89 CM: 1212242 CM: 0-80-21-70 CM :0493226 CM : 1181177
Alamat: Aceh Besar Alamat: Pidie Jaya Alamat: Banda Aceh Alamat : Banda Raya Alamat : aceh jaya
Hari rawatan : 3 Hari rawatan : 3 Hari rawatan : 3 Hari rawatan: 6 Hari rawatan : 5

A/ A/ A/ A/ A/
1.Penurunan kesadaran e.c Massa intra abdomen ec 1. Anemia berat hipokrom - OA genu bilateral 1. Pneumonia
dd/ 1. Stroke, 2. sepsis meigs syndrom mikrositer e.c - Dyspepsia type like 2. Susp tumor esofagus
2.sepsis e.c dd/ 1. pneumoni, thalasemia ulcer dd/ 3. Hiponatremia
2. urosepsis Th/ 2. diare akut e.c dd/ 1. Type mixed hipoosmolar
3. post PSMBA e.c dd/ -Bedrest 1.shigella, 2. Infeksi - Geriatri normovolemik
1.uremic bleeding, 2. ulcus - Diet MB 1500 kkal/ hari rotavirus, 3. Intoleransi problem(inanisi,
gaster - ceftriaxone 1gr/12j makanan infeksi, instabilitas Th/
4. anemia ringan NN e.c - furosemid 1 amp/12j 3. penumonia CAP dan jatuh) - bedrest
PGK dd/ perdarahan - omeprazole 1 vial/12j - ISK (perbaikan) - IVFD NaCl 0,9% 20
5. AKI atage 3 prerenal dd/ - drip tramadol 1 amp Th/ Th/ tpm
diabetik nefropati dalam 500 cc NaCl 0,9% -bedrest - Inj omepreaole - Diet lunak 1700
6. trombositopenia e.c dd/ 1. 20 tpm -diet MII 1700kal/hari 40mg/12j kkal/hari
Konsumtion coagulopati -fosen enema (extra) - O2 2 l/i - Inj ondansetron - IV Ceftriaxone 2gr/24j
7. chachor foot dextra -lactulac syr 3xIC - IVFD NaCl 0,9 % 20 gtt/i 4mg/8j - IV Lansoprazole
-IV ceftriaxone 2gr/24jam - Paracetamol 30mg/24j
Th/ Lab 22/06/2019 -Iv omeprazole 40mg/12jam 3x500mg k/p - Curcuma tab 3x1
- Bedrest Hb/Ht/E/L/T -paracetamole 3x10 mg - Sucralfat syr 3 x CI
-NGT kateter 11,5/35/4,1/11,7/867 -domperidon 3x10 mg - Nystatin 3 x 1 cc Urinalisis 25/06/209
- Diet sonde ginjal 1700 MCV/MCH/MCHC -atrapulgite tab - Cetrizine 1x10mg Leukosit / Protein : + / +1
kkl/hari 85/28/33 -synbio 3x1 sach - Iv ceftriaxone 2gr/24j Glukosa / Keton : - / -
- O2 2-4 L nasal kanul Diftel: 1/0/1/77/13/8 - flumucyl 3x2 mg - Fosen enema Nitrit ; -
- IVFD NACL 0,9 % 20 gtt/i GDS: 155 - Attapulgit 2 tab Urobilinogen / Darah : - / -
-iv meropenem gr/8 ajam Ur/Cr: 26/0,78 (extra) Sedimen
(H-7) Na/K/Cl: 133/3,6/106 Lab 23/06/2019 - Attapulgit 1 tab leukosit: 15-20 LPB
Iv omeprazole 40 mg/12 jam Hb/Ht/E/L/T Eritrosit : 2-3
- sc lantus 0-0-0-10 iu 5,0/16/3,1/8,3/129 Lab 25/06/2019 Epitel : 5-6
- sc apidra 3-3-3-3-3-3 MCV/MCH/MCHC Hb/Ht/E/L/T
- mikardis 11x80 mg 51/16/31 11,3/35/4,2/10,6/230 Lab 21/06/2019
-sucralfat syr 3X CI Diftel: 0/0/0/78/14/8 MCV/MCH/MCHC PT pasien.kontrol/INR :
-herbesser CD IX200 mg Ur/Cr: 62/1,46 85/27/32 14,6/13,5/1,1
- nebul ventolin 11 resp /12 Na/K/Cl: 136/3,5/113 Diftel: 1/0/0/78/11/10 APTT pasien/kontrol :
jam GDS : 136 Na/K/Cl: 139/3,3/113 42,9/31,8
- fluimucil syrup 3x C2 Anti HCV : negatif
- citikolin 2X500 HbsAg : negatif
Lab 19/06/2019
Hb/Ht/E/L/T Lab 21/06/2019
Lab 23/06/2019 12,2/37/4,4/13,9/272 Hb/Ht/E/L/T
Hb/Ht/E/L/T MCV/MCH/MCHC 11,9/35/4,3/9,5/265
11,9/35/4,1/10,4/46 83/28/33 MCV/MCH/MCHC
MCV/MCH/MCHC Diftel: 1/0/0/83/7/9 81/28/34
85/29/34 Alb: 2,7 Diftel: 2/1/0/87/6/2
Diftel: 0/1/0/86/9/4 Ur/Cr: 22/0,41 CT/BT: 7/2
GDS : 373 Na/K/Cl: 136/4,2/107 GDS: 106
Alb: 2,7 Ur/Cr: 30/0,56
Ur/Cr: 147/3,67 Lab 21/06/2019 Na/K/Cl: 126/3,9/98
Na/K/Cl: 147/4,5/122 Urinalisa
PTpasien/kontrol/INR: Protein : +1
13,5/13,4/1 Nitrit :Positif
APTTpasien/kontrol: Bakteri :Positif
25,9/33,7
AGDA
Ph: 7,501
pCO2 : 25,7
pO2 : 245
HCO3 : 20,3
total CO2 : 21,1
BE: -1,2
Saturasi O2 : 99,1
 K4B1 K4B2 K4B3 K4B4 K4B5
DPJP : dr. Abdullah, Sp.PD DPJP : dr. Mahriani, DPJP : dr. Darma, Sp.PD DPJP : dr. Masra, Sp.PD DPJP : dr. Price Maya,
COW : dr. Nadi Sp.PD COW : dr. Aziz COW : dr. Aziz Sp.PD
DR : dr. Reyza COW : dr. Nadisyah DR : dr. Riza DR : dr. Riza COW : dr. Cut
Raber : DR : dr. reyza Raber: Raber: GH, Kardio DR : dr. Husna
Raber: GH, GEH, EMD, Raber :
PTI
Nama: Ramlah Abbas Nama: Salbiah Hamdan Nama: Ummiah Bransyah Nama: Sairah Matsyah Nama: Irawati M Ali
Umur: 01/07/1947 (71th) Umur: 50th Umur:01/07/1950 Umur: 59th Umur: 48 th
CM: 1-21-21-06 CM: 1-21-66-79 CM:1082645 CM: 1211036 CM: 1-14-07-80
Alamat: Aceh Besar Alamat: aceh besar Alamat: Banda aceh Alamat: Aceh Timur Alamat: Aceh Besar
Hari Rawatan: 5 Hari rawatan: 18 Hari rawatan: 4 Hari rawatan: 15 Hari Rawatan: 3

A/ A/ A/ A/ A/
1.Konstipasi e.c dd 1. penurunan kesadaran ec 1.geriatric Problem 1. Penurunan kesadaran ec 1. Syok hipovolemik ec.d.d.
-Neurogenic dd/ -insabilitas dd/ perdarahan akut
-Tumor colorectal - uremic sensefalopati ,jatuh,immobilisasi -Sepsis 2. PSMBB e.c.d.d.
-Striktur colon - HE Grade III 2.Dyspepsia tipe mixed dd -SDA - Colitis i48unfeksi
2.stroke iskemik - Sepsis tipe like ulcer -Stroke - Crohn disease
3. anemia ringan NN e.c 2. CKD Stage V ec PNC 3. hiponatremia eufolemik -uremic ensefalopati - anemia sedang normokrom
peyakit kronik dd perdarahan dengan uremic syndrome normoosmolar 2. sepsis ec dd : normositer ec perdarahan
akut 3. Hepatosplenomegali ec dd/ 4. DM tipe II -pneumonia
4.geriatric Problem - SH std DC Childpugh C -urosepsis Th/
(imobilisasi,konstipasi,inanisi) dgn Hepatoma Th/ 3. SDA dengan pencetus - Bedrest
5. Pneumonia geriatri - Acute viral hepatitis -Bedt rest -infeksi - Diet MII 1700 kkal/hari
- Septikemia -Diet MII 1700kkal/hari -konstipasi - IVFD NaCl 0,9% 30 tpm
4. sepsis e.c urosepsis -IVFD NaCl 0,9% 20tpm 4. Pneumonia (HAP) dd - Salofalk 2 x 500 mg
Th/ (jamur) -IV Omeprazole20mg/12jam TB paru dengan infeksi - Grafalac syr3XCI
- Bedrest 5. DM Tipe 2 dgn critical ill -Sucralfat syr 3XCI sekunder - Sucralfat syr 3xCI
- Diet MII 1600kkal/hari 6. Efusi pleura (D) ec dd/ -ceftazidimn 1gr/12j 5. CHF FC NYHA II-III ec
- IVFD NaCl 0,9% 20tpm - Asites -ondansetron 1 amp/12j dd Lab (25/6/19)
- fosen enema/24 jam - Hipoalbuminemia -attapulgite 1 tab tiap - IHD Hb/Ht/E/L/T:
- lactulac syr 3 x 30 cc mencret - HHD 79,2/9/2,2/9,2/362
- IV Omeprazole 40 mg/12jam - DCM MCV/MCH/MCHC: 82/28/32
- KSR1x 600mg Th/ Lab (23/6/19) 6.AKI stage III ddacut on Diftel: 4/0/0/75/3/8
- iv ceftriaxone 2gr/24j -bedrest hba1c : 1,70 CKD
- paracetamol 3x500mg -diet sonde 2x600cc/hari Na/K/CL : 138/3,3/114 7. ISK
- O2 2-4l/i 8. hiperurisemia Lab (23/6/19)
Lab (24/6/19) - IVFD NaCl 0,9% 30tpm Lab (23/6/19) Hb/Ht/E/L/T:
Hb/Ht/E/L/T: - lactulac syr 3xCI PT pasien/kontrol/INR : Th/ 7,2/22/2,7/25,6/542
10,1/29/3,4/4,4/298 - sukralfat syr 3xCI 15,7/13,5/1,2 -Bedrest MCV/MCH/MCHC: 82/27/33
MCV/MCH/MCHC: 86/30/34 - comafusin hepar 1fls/hari APTT pasien/kontrol : -O2 via NK 2-4 lpm Diftel: 1/1/0/88/6/4
Diftel: 4/1/0/49/36/11 - IV meropenem 1gr/8 jam 35,1/31,8 -Diet sonde ginjal 1700 GDS : 148
Ur/Cr : 11/0,49 - IV Transamin 500mg/8jam HbsAg/Anti HCV : -/- kkal/hari Ur/Cr : 28/0,49
Na/K/CL : 134/2,7/106 - IV Fluconazol 200 cc/24 Albumin : 1,96 -Aspilet 1x80mg Na/K/CL : 136/4,2/109
jam GDS : 100 -CPG 1x75mg
- IV Ca Glukonas 1 amp/12 -Atorvastatin 1x40mg
Lab (21/6/19) jam Lab (21/6/19) -Flumucyl 3x1
Hb/Ht/E/L/T: Hb/Ht/E/L/T: -bicnat 3x1
11,8/34/4,0/8,6/444 Lab urinalisis (24/6/19) 9,0/26/3,3/13,5/282 -Allupurnol 1x300mg
MCV/MCH/MCHC: Protein : +1 MCV/MCH/MCHC: -Valsartan 1x160mg
87/30/3463/22/grr/2 79/27/35 -IV Ranitidin 1 amp/12jam
Diftel: 3/1/0/44/40/12 Lab (20/6/19) Diftel: 1/0/1/53/41/4 -IV lansoprazole 30 mg/8j
GDS : 136 Hb/Ht/E/L/T: GDS : 79 -sucralfat syr 3xcII
Ur/Cr : 22/0,95 9,8/26/3,2/9,4/173 Ur/Cr : 15/0,59 - IV furosemid 20mg/8j
Na/K/CL : 137/3,3/102 MCV/MCH/MCHC: Na/K/CL : 128/3,6/121 - Nebule combivent
82/31/37 1resp/12 jam
Diftel: 1/0/0/76/11/12 -cilostazol 1x100 mg
Ca : 8,9 - paracetamol 3x500mg
Ur/Cr : 140/4,77 - IV Meropenem 500mg/8j
Na/K/CL : 137/3,8/99 - drip hidonac 1000 mg
Dlam 200 cc NaCLhabis
Lab 19/6/19 dalam 4 ajam dalam 2 hari
AFP : 1,28
BilTot/Dir/Ind:1,18/0,79/0,39 Lab (24/6/19)
pH; 7,370
Lab 18/6/19 PCO2: 66,50
Urinalisis PO2: 65
Leukosit / Protein : + / +1 HCO3: 38,8
Glukosa / Keton : +1 / + CO2: 40,9
Urobilinogen / Darah : + / + BE 11,2
Sedimen : 20-30 LPB SaO2: 90,6
Eritrosit : 10-15
Epitel : 4-6 Lab (22/6/19)
pH; 7,462
Lab 18/06/2019 PCO2: 52,60
Hb/Ht/E/L/T : PO2: 45
9,8/26/3,2/9,4/173 HCO3: 37,9
MCV/MCH : 82/31/37 CO2: 39,5
Diftell : 1/0/0/76/11/12 SaO2: 81
Ur/cr: 140/4,77 Lab 20-6-2019
Na/K/Cl: 137/3,8/99 Hb/Ht/E/L/T :
LED: 112 8,2/22/2,5/9,3/169
Ca: 8,9 MCV/MCH : 90/33/37
Diftell : 3/0/0/82/3/7

K5B1 K5B2
DPJP : dr. Diana Erlita, DPJP : dr. Masralena,
Sp.PD Sp.PD
COW : dr. Cut COW : dr. Aziz
DR : dr Husna DR : dr. Riza
Raber: Raber :
Nama : Rubama M. Saman Nama: Salbiah Harun
Umur : 61 thn Umur: 09/11/1965 (53 th)
CM : 0697674 CM: 1-21-1-8-49
Alamat : aceh besar Alamat: Aceh Tamiang
Hari rawatan : 2 Hari Rawatan: 2
A/ A/
- Anemia berat e.c dd/ . ulcus 1. Pansitopenia e.c.d.d.
gaster, 2.. defisiensi besi, 3. - Anemia aplastik
Penyakit kronik - MDS
- PSMBA e.c dd/ . 1. Ulcus
gaster 2. Ulcus duodenum, Th/
3. Gastritis erosif, 4. Sress - Bedrest
ulcer - Diet MB 1500 kkal/hari
- IVFD NaCl 0,9% 20 tpm
Th/ - paracetamol drip 1 gr
- Bed rest (ekstra)
- Diet MII 1700kkal/hari - vectrin 3x1
- IVFD RL 20 gtt/i - metilpednisolon 3x4 mg
- IV omeprazole 2x40 mg - iv omprazole 40 mg/12 jam
- domperidon 3x10 mg tab
Lab 23/06/2019
Lab 24/06/2019 Hb/Ht/E/L/Tr:
Hb/Ht/E/L/T: 3/10/1,5/6,/183 9,8/29/3,4/4,1/17
MCV/MCH/MCHC : 67/20/30 MCV/MCH/MCHC :
Diftel: 0/0/0/84/10/6 85/29/34
Ur/Cr : 28/0,56 Diftel: 2/1/0/49/40/8
Na/K/Cl : 135/3,5/111
Anti HCV : negatif Lab 21/06/2019
HbsAg : negatif Hb/Ht/E/L/Tr:
GDS : 144 11/31/3,6/5,7/10
MCV/MCH/MCHC :
86/31/36
Diftel: 1/0/0/64/29/6
Retikulosit : 1,7
Anti HCV : negatif
HbsAg : negatif
K5B3
DPJP : dr. Diana Erlita,
Sp.PD
COW : dr. Cut
DR : dr Husna
Raber: neuro
Nama: Ruqaiyah Usman
Umur: 011/07/1953 (65 th)
CM: 1212418
Alamat: Aceh Pidie
Hari Rawatan: 2
A/
1. SDA e.c.d.d.
- infeksi
- imbalance elektrolit
-. hipertensi stage 1
- susp pneumonia
2. tension headache
Th/
- omeprazolle 80 mg bolus
(ekstra)
- iv omprazole 40 mg/12 jam
- amlodipin 1 x 5 mg
- sucralfat syr 3xCII
- iv ceftriaxone 2x i gr
Lab 24/06/2019
Hb/Ht/E/L/Tr:
12,8/38/4,7/14,1/356
MCV/MCH/MCHC :
82/28/33
Diftel: 1/1/0/80/11/7
Anti HCV : negatif
HbsAg : negatif
SGOT/SGPT : 3/11
GDS : 127
UR/CR : 37/0,58
Na/K/Cl : 134/4,2/109
LED: 50
Lab 19-6-2019
Hb/Ht/E/L/T :
7,9/24/2,6/8,0/185
MCV/MCH : 90/30
Diftell : 3/1/0/78/11/7
Ur/Cr: 111/3,83
Na/K/Cl: 147/2,2/106
K5B4 K5B5
DPJP: dr. Price maya, DPJP : dr. Mahriani,
SpPD Silvawani, Sp.PD-KR
COW: dr. Cut COW : dr. Nadi
DR: dr. Husna DR : dr. Reyza
Raber:
Nama: Irdawati Zikrillah Nama : Risma Saragih
Umur: 13/06/1986 (32 thn) Umur : 56 th
CM: 1-21-21-14 CM : 1-02-11-30
Alamat: lhoksemawe Alamat : Banda Aceh
Hari Rawatan: 6 Hari rawatan : 2
A/ A/
1.anemia berat hipokrom 1. Obs Febris e.c.d.d.
mikrositer e.c dd - Tifoid fever
- thalasemia - Demam dengue
-defisiensi besi - ISK
-sideroblastik 2. Dyspepsia type like ulcer
dd type dismotility
Th/ 3. Hipokalemia ringan
- Bedrest
- Diet MII 1700kkal/hari Th/
- IVFD NaCl 0,9% 20tpm -bedrest
- diet MB 1700 kkal/hari
Lab 21/06/2019 - IVFD RL 30 gtt/i
Hb/Ht/E/L/T: - Omeprazole 2x40 mg
6,3/21/3,2/4,2/187 - Sucralfat syr 3xCI
MCV/MCH/MCHC : - KSR 2 x 600mg
65/20/30 - Paracetamol 1 gr/8 jam
Diftel: 1/1/0/47/46/5 - Lactulosa 3x30 cc
Ur/Cr : 12/0,41 - Alprazolam 1x0,25 mg
Na/K/Cl : 142/3,0/112 (malam)
- iv ciprofloxacin 500
Lab 21/06/2019 mg/12j
Hb/Ht/E/L/T: - lactulac supp (extra)
6,1/21/3,2/4,4/195 - domperidon 3x10 mg
MCV/MCH/MCHC :
66/19/30 Lab 20/06/2019
Diftel: 1/1/0/45/49/4 IgM/IgG Anti dengue :
neg/neg
Widal test
S. Typhi H : 1/80
S. paratyphi CH : 1/320
Lab 20/06/2019
Hb/Ht/E/L/T:
13/35/4,1/5,5/133
MCV/MCH/MCHC :
84/32/38
Diftel: 0/0/1/75/21/3
GDS : 107
Ur/Cr : 10/0,46
Na/K/Cl : 136/3/99
 K6B1 K6B2 K6B3 K6B4 K6B5
DPJP : dr. M. Darma, DPJP : dr. Abdullah, SpPD DPJP : dr. Mahriani,Sp.PD DPJP : dr. Price Maya, DPJP : dr. Masra Lena,
SpPD COW : dr. Nadi COW : dr. Nadi Sp.PD Sp.PD
COW : dr. Aziz DR : dr. Reyza DR : dr. Reyza COW : dr. Cut COW : dr.Aziz
DR : dr. Riza Raber: Kardio, Obgyn Raber : DR : dr. Husna DR : dr. Riza
Raber: Raber : Jiwa Raber :
Nama: Jasmani Abdullah Nama: Wardiana Abd Samad Nama : Rukiah Yahya Nama : Roslina M Husen Nama : Nurmiana Mahyiddin
Umur: 04/08/1959 (59 thn) Umur: 31-12-1959 (60 thn) Umur : 1-7-1956 (62 thn) Umur : 43 thn Umur : 08-10-1978 (40th)
CM: 1-21-22-90 CM: 1-21-03-71 CM : 1-21-18-47 CM : 1176011 CM : 1093352
Alamat: Aceh Besar Alamat: Aceh Tamiang Alamat : Bireuen Alamat : aceh besar Alamat : aceh timur
Hari rawatan: 2 Hari rawatan: 9 Hari rawatan : 6 Hari Rawatan : 2 Hari rawatan : 1

A/ A/ A/ A/ A/
1. CKD stage V dengan 1. CKD Stage V dgn Uremic 1.Penurunan kesadaran e.c dd 1.dispepsia type like ulcer -Dispepsia tipe mixed dd tipe
uremic syndrome e.c.d.d. Syndrome - Sepsis (perbaikan) 2.psikogenic pain ulcer
- DN 2. Hipertensi terkontrol - Uremic ensefalopati -Colitis ulceratif
- GNC 3. Ca Cervix 2.Sepsis e.c dd - multipel ulkus
2. DM tipe II NW 4. AF NVR - urosepsis Th/ - anxietas
3. Anemia sedang e.c. PGK - pneumonia -Bedrest
5. Hiponatremia Th/ 3.CKD stage V dengan -Diet M II 1700 kkal/hr Th/
- Bedrest uremicsyndrome HD reguler - IVFD NaCl 0,96 % 20 gtt/i 1. Bedrest
Th/ - Diet ginjal 1700kkal/hari E.c dd - IV Omeprazole 40 mg/12 2. Diet lunak 1700kkal/hari
- Bedrest - Three way - PGOI jam 3. IV Omeprazole 40 mg/12
- O2 2-4 lpm - Asam Folat 3 x 1 tab - HN - sukralfat syrup jam
- Diet ginjal 1700 kkal/hari + - Lenal Ace 2 x 1 tab 4. Anemia ringan HM ec - alprazolam (extra) 4. ondasentron 4 mg/8 jam
0,6 gr protein/kgBB/hari - Valsartan 1 x 80 mg penyakit kronik dd def. Fe - kaltropen sup (extra) 5. haltropen supp h/d
- IVFD NaCl 3% 15 tpm - IV Asam Tranexamat 500 5. Nefrolitihiasis Sinistra 6. sucralfat 3xCI
- SC novorapid 8-8-8 mg/12 jam
- Lenal ace 2x169 mg - Amlodipine 1 x 10 mg Th/ Lab 24/6/19
- asam folat 2x400 mcg - Salbutamol 3 x 4 mg - Bed rest Hb/Ht/E/L/T: Lab 25/06/2019
- IV Ca Gluconas 1 amp - Sucralfat syr 3 x CI - Diet sonde 6x200 cc/hari 10/27/3,5/8,/360 Hb/Ht/E/T/L:
(extra) - IV Methcohlorpramide 1 - O2 2-3 lpm MCV/MCH: 78/29/37 12,5/40/6,9/635/22,2
- Kalitake sachet 3x1 amp/8jam - IVFD NaCl 0,9% 10 gtt/i Diftel: 1/1/0/ 64/29/5 MCV/MCH/MCHC: 58/18/31
-lasix 20 mg/8 jam iv - Lactulac 3x30 cc - IV Omeprazole 40 mg/12 j GDS : 121 Diftel: 42/1/0/38/16/3
-. IV Omeprazole 40 mg/12 - Asam folat 2 x 400 mcg Ct/Bt : 7/3 Kgds 162
jam Lab 20/06/19 - Bicnat 3 x 500 mg Ur/Cr : 59/1,64 Ur/Cr : 25/1,13
-. ondasentron 4 mg/8 jam Hb/Ht/E/L/T - IV Meropeem 1 gr/8jam Na/K/Cl/Ca : 133/3,7/108 Na/K/Cl: 132/4,2/109
- iv ceftriaxone 1x 2 gr 7,5/23/2,8/6,3/185
MCV/MCH/MCHC Lab 24/6/19
Lab 24/06/19 82/27/27 Hb/Ht/E/L/T :
Hb/Ht/E/L/T Diftel: 9/1/0/63/17/10 9,1/28/3,6/11,4/30
8,1/23/3/278/21,3 Ur/Cr: 106/13,75 MCV/MCH : 76/25/33
MCV/MCH/MCHC Na/K/Cl: 141/4,8/106 Difftell : 1/1//0/83/8/7
79/27/35 Ca: 9,0 Ur/Cr : 230/7,33
Diftel: 1/1//0/85/8/5 Na/K/Cl : 143/5,1/115
Ur/Cr: 197/12,89 Lab 18/6/19
Na/K/Cl: 120/5,5/97 Hb/Ht/E/L/T:
HbA1C 14,9 7,3/22/2,7/8,0/167
MCV/MCH: 79/27 Lab 20/06/19
Lab 20/06/19 Diftel: 7/0/0/76/9/8 Berat jenis 1,005
Na/K/Cl: 116/5,7/94 Ur/Cr : 73/11,71 pH 6,0
GDS : 494 Na/K/Cl/Ca : 138/4,4/105/9,8 nitrit (-)
Ca : 9,7 protein (+)
Anti HCV : negatif Lab 15/6/19 keton (-)
HbsAg : negatif Hb/Ht/E/L/T: glukosa (-)
6,0/18/2,3/6,0/118 urobilinogen (-)
MCV/MCH: 76/26 epitel 4-6
Diftel: 6/1/0/69/18/6 warna kuning
Ur/Cr : 125/18,33 darah (+)
Na/K/Cl/Ca : 138/6,0/108/9,2 leu 120-130
Albumin : 3,09 eri 3-5
lekosit (+)
Lab 14/6/2019 bilirubin (-)
Na/K/Cl/Ca : 136/8,6/110/9,3
Lab 19/6/19
Lab 13/6/2019 Hb/Ht/E/L/T :
Anti HCV / HbsAg : (-)/ (-) 9,2/27/3,6/15,1/16
SGOT/SGPT : 14/7 MCV/MCH : 76/26
GDS : 232 Difftell : 0/0/0/94/3/3
Ur/Cr : 171/6,9
Na/K/Cl : 145/5,2/115
GDS L 33