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Denah Ruang Rawat

AQSHA 2 (Penyakit Dalam Pria)


Hari/Tanggal : Kamis, 15 November 2018
Dokter Jaga : dr. Ahdiah/ dr. Rahmat
Dokter Muda. : Rara/Fitri/Tasnim/ Putri/ Manda
K1B1 K1B2 K1B3 K1B4
DPJP : dr. Krishna, Sp. PD DPJP : dr. Krishna, Sp. PD DPJP : dr. Krishna, Sp. PD DPJP : dr. Krishna, Sp. PD
COW : dr. Yuni COW : dr. Yuni COW : dr. Yuni COW : dr. Yuni
PPDS : dr. Dilla PPDS : dr. Dilla PPDS : dr. Dilla PPDS : dr. Dilla
DM : Indra DM : Indra DM : Indra DM : Indra
Nama : Muhammad Saneh Nama : Basri Abdul Wahab Nama : Mahyuddin Aminuddin Nama : Burhanuddin Umar
TTL : 04/05/1953 (65 th) TTL : 07/11/1977 (41 th) TTL : 01/06/1961 TTL : 19/02/1950 (68 th)
Alamat : Aceh Barat Alamat : Banda Aceh Alamat : aceh selatan Alamat : Kota sabang
Pekerjaan : Pedagang Pekerjaan : Swasta Pekerjaan : PNS Pekerjaan :wiraswasta
CM : 1189924 CM : 0920106 CM : 1-18-94-31 CM :0959335
Hari rawatan : 11 Hari rawatan : 3 Hari rawatan : 1 Hari rawatan : 5

A/ A/ A/ A/
1. Disfagia ec dd/ 1. obs vomitus ec drug induced 1. penurunan kesadaran perbaikan 1. CKD stage V ec dd/
- Akalasia (kemoterapi) dd/ 1. Hipoglikemia -PGOI
-Striktur Esofagus 2. NHL post kemo siklus I regimen 2. Sepsis -PNC
-Ca Esofagus 2. Sepsis ec dd/ Dengan uremic syndrome perbaikan
Th/ 1. Ulkus diabetik pedis sinistra 2.Hiperkalemia
Th/ -Bedrest 2. pneumonia 3. ISK
-Bedrest -Diet MII 1700 kkal/hari 3. Anemia hipokrom mikrositer
-Diet sonde cair 6x200 cc/hari via -IVFD NaCl 0,9% 30 tpm 4. Hiponatremi Th/
NGT -IV Omeprazole 4p mg/12 jam 5. Ulkus diabetik pedis sinistra - bedrest
-IVFD NaCl 0,9% 20 tpm s/s -IV Ondansetron 8 mg/8 jam 6. Hipokalemi ringan -O2 2-4 Lpm via nasal kanul
Dextrose 5% 20 tpm -Domperidon 3x10 mg 7. Tumor paru sinistra - diet ginjal 1700kkal/hari
-IV Lansoprazole 30 mg/12 jam -Sukralfat Syr 3xCII - threeway
-IV Ondansetron 4 mg (k/p) -Graphalac Syr 3xCII Th/ - IV Ceftriaxone 2gr/24j (H5)
-Kaltrofen supp (k/p) -bedrest - Kalitake sch 3x1
-Fosen enema (k/p) Lab 13/11/2018 -diet MII 1700 kkal/hari - IV omeprazole 40mg/12j
Hb/Ht/E/L/Tr -IVFD NaCl 0,9% 20gtt/i - Domperidone 3x10mg
11,7/36/4,3/5,6/41 -IV ceftriaxone 2gr/24 jam - Hemodialisis rabu-sabtu
Lab 9/11/2018 MCV/MCH/MCHC -Clindamycin 3x300mg
Hb/Ht/E/L/T: 13,4/39/4,4/9,8/249 84/28/33 -KSR 1x600mg Lab 12/11/2018
MCV/MCH/MCHC: 89/30/34 Diftell : 0/0/0/70/29/1 Hb/Ht/E/L/T: 8,6/25/3,2/13,5/325
Diftell: 7/0/0/68/20/5 Ur/ Cr : 44/0,71 Lab 14/11/2018 MCV/MCH/MCHC: 88/30/35
Na/K/Cl Hb/Ht/E/L/T: 9,0/26/3,9/34/427 Diftell: 6/0/0/72/9/13
Lab 9/11/2018 142/3,9/97 MCV/MCH/MCHC: 67/23/35 Ur/Cr: 175/13,44
PTT/APTT Diftell: 0/0/0/89/4/7 Anti HCV/ HbsAg : neg/neg
19,4/39,1 GDS: 181 Ca/Na/K/Cl : 9,4/137/5,7/106
Ur/Cr: 61/2,11
Ca/Na/K/Cl : 131/3,4/96 Lab 10/11/2018
Hb/Ht/E/L/T
8,3/25/3,0/9,3/151
MCV/MCH/MCHC
84/28/33
Diftell: 1/1/0/80/10/8

Urinalisa(31/10/18)
Kuning
keruh
Ph 6,5
Lekosit: (+)
Protein: (+2)
Glukosa: -
Keton: -
Nitrit: -
Urobilinogen: -
Bilirubin: -
Darah: +
Leukosit: 40-50
Eritrosit: 8-10
Epitel: 6-8
K2B1 K2B2 K2B3 K2B4 K2B5
DPJP : dr. Krishna, Sp. PD DPJP : dr. Krishna, Sp. PD DPJP : dr. Krishna, Sp. PD DPJP : dr. Krishna, Sp. PD DPJP : dr. Krishna, Sp. PD
COW : dr. Yuni COW : dr. Yuni COW : dr. Yuni COW : dr. Yuni COW : dr. Yuni
PPDS : dr. Wahyu PPDS : dr. Wahyu PPDS : dr. Wahyu PPDS : dr. Wahyu PPDS : dr. Wahyu
DM : Reza/ Shinta DM : Reza/ Shinta DM : Reza/ Shinta DM : Riza/ Shinta DM : Reza/ Shinta
Nama : Murni Basyariah Nama : M.Yasin Nama: Samsul Bahri
TTL : 25/05/1984 (34 th) TTL : 06/04/1959 (59 th) Umur:48 tahun
Alamat : Aceh Barat Alamat : Banda Aceh Alamat:Neuheun
Pekerjaan : Petani Pekerjaan : Swasta Pekerjaan: Pedagang
CM : 1190093 CM : 0920106 CM: 0953797
Hari rawatan : 3 Hari rawatan : 5 Hari rawatan: 6

A/ A/ A/ 1.Perbaikan Penurunan
1. CKD Stage V dengan 1. Ikterik ec dd/ Kesadaran ec dd/
uremic syndrome ec dd/ - Ca Ampula Vateri -Stroke
- HN - Ca Caput Pankreas -Sepsis
- PNC - Hepatoma -Imbalance elektrolit
2. Anemia berat hoipokrom - Koledokolitiasis -Uremic ensefalopathy
mikrositer - Cholelitiasis dengan 2.CKD stage 5 ec Urat
cholesistitis nefropati on HD reguler
Th/ 2. Hidronefrosis grade I-II 3.HCAP dd TB Paru dengan
- Bedrest dextra Infeksi Sekunder
- O2 2-4 L/ menit 3. AKI Stage III postrenal dd 4.Gout Atritis
- Diet ginjal 1900 kkal/ hari acute on CKD 5.OA Genu dextra
+ protein 42 gr/hari 4. Hipokalemia ringan
- Threeway (perbaikan) Th/
- Asam Folat 2x400 mg 5. Ileus Paralitik - Bed rest
- Lenal Ace 2x169 mg 6. Hipoalbuminemia (2,2) - Kateter
- Hemodialisa Senin-Kamis - Diet sonde 2x600cc 1800
- Amlodipin 1x10 mg Th/ kkal/hari
- Bisoprolol 1x5 mg -Bedrest - Threeway
- Transfusi on HD 1 kolf on -Kateter - IV meropenem 500mg/12j
HD -Diet hati II 1700 kkal/ hari - Fluimucyl 3x200mg
- Kalitake sach 3x1 -NGT dekompresi - Bisoprolol 1x5mg
- Nystatin drop 4x2cc -IVFD NaCl 0,9% 20 gtt/i - Lenal ace 2x169mg
- IV Ca Glukonas 1 amp -IV omeprazole 40mg/12j - As Folat 2x400mg
- IV D40% 2 fls + 10 IU -Drip albumin 20% 100 - PCT 3x1 tab
insulin cc/hari - Metilprednisolon 3x4mg
-KSR 1x600mg
Lab 13/11/2018 -Paracetamol 500mg extra Lab 13/11/2018
Ur/Cr: 296/27,43 Hb/Ht/E/L/T:
Na/K/Cl: 124/6,5/86 Lab 13/11/2018 7,9/24/3,6/12,2/97
Hb/Ht/E/L/Tr MCV/MCH/MCHC
Urinalisis 8,7/23/3,0/264 80/27/33
Kuning MCV/MCH/MCHC Diftell: 0/0/0/81/12/7
Keruh 76/29/39 Alb: 2,08
Protein +2 Diftell : 2/0/0/85/8/5 Ur/Cr: 122/4,42
Darah +2 Bil tot/Bil direct/Bil Ind: Na/K/Cl: 133/4,7/98
Sedimen : 19/15,24/3,76
Leukosit 8-10 Ur/Cr: 48/5,28 Lab 10/11/2018
Eritrosit: 6-8 Na/K/Cl: 145/3,5/104 Hb/Ht/E/L/T
Epitel: 10-15 7,0/21/2,7/12,1/106
Lab 12/11/2018 MCV/MCH/MCHC
Lab 12 /11/2018 PTT/APTT 78/26/34
Hb/Ht/E/L/Tr 12,7/42,8 Ur/Cr : 62/2,95
7,0/19/2,5/10,9/375 alb: 2,26 Albumin :2,20
MCV/MCH/MCHC ALP: 492 Na/K/Cl : 135/3,4/99
76/28/37 Ca: 8,1
Diftell : 2/0/0/70/17/11 Lab 6/11/2018
Anti HCV/ HBsAg : Lab 11/11/2018 Na/K/Cl/Ca : 131/3.7/99/8.2
Negatif/Negatif pH/pCO2/pO2/Sat.O2 Ur/Cr: 88/3.46
Ur/Cr : 359/30,74 7,519/31,2/48/86,6
Na/K/Cl
116/7,0/74
K3B1 K3B2 K3B3 K3B4 K3B5
DPJP : dr. Fauzi yusuf, DPJP : dr. Fauzi yusuf, DPJP : dr. Fauzi yusuf, DPJP : dr. Fauzi yusuf, DPJP : dr. Fauzi yusuf,
Sp.PD Sp.PD Sp.PD Sp.PD Sp.PD
COW : dr. Andi COW : dr. Andi COW : dr. Andi COW : dr. Andi COW : dr. Andi
DR : dr. Hambali DR : dr. Hambali DR : dr. Hambali DR : dr. Hambali DR : dr. Hambali
DM : Rezeky Aulia DM : Rezeky Aulia DM : Rezeky Aulia DM : Rezeky Aulia DM : Rezeky Aulia
Nama: Adnan Daud Nama : Zakaria Nama: Hamzah Maskum Nama: Toimin Katimin Nama: Ismail Haji
Umur : 1/07/1967 (51 thn) TTL : 12/06/1962 (56thn) Umur: 01/07/1945 (73thn) Umur: 04/08/1962 TTL: 01/07/1940
Alamat : Sabang Alamat : Aceh Barat Alamat: Aceh Tengah Alamat: aceh tamiang Alamat: Aceh besar
Pekerjaan: Wiraswasta Pekerjaan : Petani Pekerjaan: Petani Pekerjaan: tani Pekerjaan: petani
CM: 1128409 CM : 1189596 CM: 1190377 CM: 1190728 CM: 0-97-82/81
Hari rawatan: 3 Hari Rawatan : 14 Hari rawatan: 7 Hari Rawatan: 3 Hari rawatan:

A/ A/ A/ A/ A/
1. HE grade I dengan 1. CKD stage V ec dd/ 1. Hepatomegali ec dd/ 1. PSMBA ec dd/ 1. penurunan kesadaran ec
pencetus - HN - Hepatoma dengan - Gastritis erosif dd/
-infeksi - PNC cancer pain - Ulkus gaster 1. SDA
-imbalance elektrolit 2. HHD - Metastase proses - Ulkus duodenum 2. Sepsis
2. Sirosis hepatis 3. Pneumonia (HAP) 2. Massa Intra Abdomen 2. Anemia berat ec 3. hyponatremia
decompensate related Hep perbaikan ec dd/ Perdarahan 2. SDA dengam pencetus
C - HCC 3. OA geno sinistra infeksi, perdarahamn,
3. Pneumonia Th/ - Ca Gaster 4. Fracture collum femur hiponatremi
4. Anemia hipokrom - Tirah baring - Limfoma Hodgkin sinistra 3. ulkus decubitus gr I a/r
mikrositik ec dd - O2 2-4 liter/menit - Ca. Pankreas 5. Geriatri problem ec dd/ - sacrum
-penyakit kronik - Threeway 3. Asites ec dd/ immobilisasi, - 4. PSMBA ec dd/
-def. FE - Diet ginjal 1700/kkal - Metastase proses instabilitas dan jatuh, - 1. stress ulcer
5. Hipoalbumin dengan protein 62gr/hari - Sirosis hepatis impairment of vision 2. ulkus gaster
6. SBP - IV ceftriaxone 2gr/24 jam 4. Pneumonia (HAP) dd/ Th/ 3. gastritis erosive
7. Hiponatremi Hipoosmolar (H3) TB paru dg infeksi - bed rest 4. hyponatremia
Hipervolemik - Lenal Ace 2x169mg sekunder - mobilisasi ringan hipoosmolar euvolemik
8. Varises Esofagus gr II - Asam folat 2x400mg 5. Susp tumor paru dd - diet MII 1700kkal 5. hipertensi terkontrol
9. ulkus gaster a/r antrum - Amlodipin 1x10mg (Pagi) metastase proses - IVFD NaCl 0,9% 20tpm 6. geriatric problem (inanisi,
- Bisoprolol 1x5mg (malam) 6. Efusi Pleura - IV ceftriaxone 2g/24 jam infeksi, instabilitas, dan
Th/ - HCT 1x25 mg (pagi) (H3) jatuh, immobilisasi, dan
- Bed rest - Kalitake 3x1 Sachet Th/ - Drip omeprazole impairment of vision)
- Diet hati 700kkal/hr + - ISDN 3x5mg - Tirah baring 6,25mg/jam, 5 cc/jam 7. keratitis OD
hepatoseluler - Tanapres 1x10 mg tab - Diet hati 1700 kkal /hari - PCT 3x500mg 8. retensio urine ec susp
- IVFD comafussin hepar (malam) - Threeway - Sukralfat Syr 3xCII stricture uretra
2fl/hari -Adalat Oros 1x30 mg tab - IV aminofusin hepar 1 - Catarlect ED 4xgttI 9.dd/ bladder neck contracur
- IV Levofloxacin 750mg/hr fl/hari - Vitrolenta ED 4gtt I post TURP
(H3) Lab 13/11/2018 - Iv omeprazole 40mg/12j - Citicolin 1x500mg 10. stroke iskemik
- IV Furosemid 1amp/12j Hb/Ht/E/L/T: - IV Furosemid 1 amp/12 11. ulkus decubitus grade II
- IV omeprazole 40ml/24j 7,7/23/2,7/13,4/262 jam Lab 12/11/2018 12. Pneumonia geriatric
- Drip albuminer 25% MCV/MCH/MCHC: - Curcuma 3x1 Hb/Ht/E/L/T 13. Iskemia anterolateral
100ml/hr (H2) 85/28/33 - Spinorolacton 2x100mg 3,2/9/1,1/165/6
- Spinorolakton 2x100mg Diftell: 7/0/075/11/7 - Graphalac syr 3xCII MCV/MCH/MCHC Th/
- Sucralfat syr 3xCII Koles tot: 251 - Fosen enema extra 83/29/36 -bedrest dengan Kasur
- Propanolol 2x10mg HDL/LDL/TRI:35/140/248 - Tramadol 50mg 3x1 Diftell: 2/0/0/61/28/89 decubitus
- Domperidon tab 3x10mg GDS: 91 - Fosen Enema (k/p) PT/APTT : 10,4/38,1 -mobilisasi passive
- Curcuma 3x1 tab Ur/Cr: 259/12,22 - IV Cefepime 1 gr/ 8 jam HbsAg : neg -NGT, Kateter
- Lactulac Syr 3xCII Na/K/Cl: 143/5,0/102 (H3) SGOT/SGPT : 14/9 -diet sonde 6x100ccnaik
- Endostein 3x1tab Urinalisis: GDS : 97 bertahap
Kuning Lab 14/11/2018 Ur/Cr: 41/0,92 -IVFD NaCl 0,9%20gtt/i
Lab 12/11/2018 Keruh Hb/Ht/E/L/T Na/K/Cl: 137/3,6/111 -IV cefepime 1gr/8jam (H1)
Hb/Ht/E/L/T Leukosit + 10/28/3,8/17,2/347 -drip omeprazole 80 mg dl
7,5/22/3,0/4,9/45 Protein +2 MCV/MCH/MCHC 24 jam (5cc/jam)
MCV/MCH/MCHC Glukosa +1 75/27/36 -clindamicin 3x300mg
75/25/34 Darah + Diftell: 0/0/0/92/3/5 -sucralfat syr 3xCII
Diftell: 4/0/1/62/15/18 Mikros: Leu:20-30, Eri: 20- Na/K/Cl: 136/4,6/93 -rawat luka
Bilirubin total/dir./indir. 25, epitel: 8-10 -decubalt zalf 3x appl
1,90/0.92/0,98 Lab 12/11/2018 -spooling NGT dg NaCl
SGOT/SGPT : 38/29 Lab 06/11/2018 AFP: 2,40 0,9% 150cc smpai
Albumin : 2,15 Na/K/Cl: 142/5,8/101 Prot total: 6,50 bersih/8jam
GDS : 114 Alb/Glo: 3,02/3,48
Ur/Cr : 21/1,09 Urinalisa 02/11/18 Lab 13/11/2018
Na/K/Cl : 130/3,5/98 Kuning Lab 09/11/2018 Hb/Ht/E/L/T
Keruh PT/Aptt: 1,02/1,23 12,3/33/4,3/17,2/108
Lab 1-11-2018 pH 6,5 AFP: 2,18 MCV/MCH/MCHC
CK-MB 38 Lekosit: positif Alb: 2,91 76/29/37
Protein +2 Diftell: 1/0/0/86/5/8
Urinalisa 14/11/2018 Keton: - Lab 08/11/2018 GDS: 126
Kuning Nitrit: - PT/APTT : 11,0/41,1 Ur/Cr: 55/1,06
Jernih Urobilinogen: - AFP(alfa feto protein) : 2,18 Na/K/Cl: 124/3,5/86
Ph 7,0 Bilirubin - Albumin : 2,91
Leukosit – Darah: +
Protein –
Glukosa –
Keton –
Nitrit –
Urobilinogen –
Bilirubin –
Darah –
K4B1 K4B2 K4B3 K4B4 K4B5
DPJP : dr.Fauzi yusuf, DPJP : dr.Fauzi yusuf, DPJP : dr.Fauzi yusuf, DPJP : dr.Fauzi yusuf, DPJP : dr.Fauzi yusuf,
Sp.PD Sp.PD Sp.PD Sp.PD Sp.PD
COW : dr. Andi COW : dr. Andi COW : dr. Andi COW : dr. Andi COW : dr. Andi
DR : dr. Hambali DR : dr. Hambali DR : dr. Hambali DR : dr. Hambali DR : dr. Hambali
DM : Siti Maghfirah DM : Siti Maghfirah DM : Siti Maghfirah DM : Siti Maghfirah DM : Siti Maghfirah
Nama :M. Jamal Daud Nama : Zainal Abidin Nama :M. Nur Ali Nama : Rasman Ibrahim Nama : M. Yusuf
TTL : 01/07/1956 (62th) TTL : 06/08/1969 TTL : 1/7/1952 (66tahun) TTL : 10/12/1970 (47 tahun) TTL : 01/01/1955 (63 tahun)
Alamat : Aceh Besar Alamat : aceh tamiang Alamat : Banda Aceh Alamat : Banda Aceh Alamat : Pidie
Pekerjaan : Petani Pekerjaan : wiraswasta Pekerjaan : Wiraswasta Pekerjaan : Buruh harian Pekerjaan : Petani
CM : 0-79-97-21 CM : 1-19-02-75 CM : 1-18-23-06 CM : 0-95-33-94 CM : 1-18-95-03
Hari rawatan : 4 Hari rawatan : 7 Hari Rawatan : 20 Hari Rawatan : 18 Hari Rawatan : 12
A/
A/ A/ A/ 1. Cholelitiasis A/
1. CKD stage V on HD 1. Ulkus gaster ar antrum 1.CKD Stage V On HD 2. Anemia berat hipokrom 1. CKD stage V dengan
Reguler ec PNC dengan 2. Esofagitis grade II Reguler ec PNC mikrositer ec dd/ uremic syndrome ec
edema paru akut 3. CKD stg V ec DD 2.Geriatri Problem (inanisi, - Def. Fe polikistik kidney disease
2. CHF FC NYHA III-IV ec - urat nefropati impairment of vision, - Perdarahan 2. Hipertensi stage 2
dd/ - HN infeksi) 3. Hepatitis B kronik 3. ISK
- HHD - PNC 3. Nefrolitiasis bilateral 4. Skizofrenia Paranoid 4. Anemia sedang
3. Pneumonia (HAP) 4. HT stg II 4. CHF Fc NYHA II-III ec 5. Early sirosis hipokromik mikrositer ec
4. HHD 5. Gout Arthritis dd/ 6. HT st 2 dd/
5. Chest Pain ec dd/ - HHD 7. Hipokalemia ringan - Penyakit kronik
- UAP Th/ - IHD 8. Hyponatremi - Perdarahan
- NSTEMI - tirah baring 5. wrist tendinitis 9. Hypernatremia
6. Dispepsia Tipe like Ulcer - mobilisasi Th/
- diet DM 1900 kkal dengan Th/ Th/ - Bedrest
Th/ 60 gr protein /hari - Bedrest - Tirah baring - Diet ginjal sonde 1900
- Tirah baring - threeway - O2 2 ltr/menit - Diet lunak 1700kkal/ hr kkal + 65 gr protein/hari
- O2 2-4 lpm -IV ceftriaxone 2g/24j (H8) - Threeway - IVFD sol 2:1 20 tpm - 02 2-4 lpm
- Threeway -valsartan 1x160mg - Diet MII ginjal 1700kkal - IV. Levofloxacin - Three way
- IV Cefepime 1gr/12j (H4) -amlodipin 1x10mg dengan protein 60gr/hari 750mg/24j (H7) - IV Levofloxacin 500
- IV furosemid 20mg/8 jam -lenal ace 2x169mg - IV Meropenem 500 gr/8j - IV.Omeprazole 40 mg/ 48 jam (H2)
- IV lansoprazole -as. Folat 2x400 mg (H13) mg/12jam - IV Omeprazole 40
30mg/12jam - Bisoprolol 1x5mg - Lenal ace 2x169 mg - Curcuma 3x1 mg/12 jam
- As.folat 2x400 mg -sucralfat syr 3xCII - asam folat 2x400 mg - UDCA 2x500 mg - Lenal ace 2x169 mg
- lenal ace 2x169 mg -Recolfar 3x0,25 mg - flumucyl syr 3XCI - Valsartan 1x160 (pagi) - As.Folat 2x400 mg
- Bisoprolol 1x5 mg -paracetamol 3x500mg - curcuma 3x1 tab - KSR 1x600mg - Valsartan 1x160 mg
- Spironolakton 1x100mg - PCT 500 mg 3x1 tab - Sucralfat syr 3xCI - Bisoprolol 1 x 5 gr
- Sukralfat Syr 3xCI Lab 14/11/2018 - Lansoprazole 30 mg/12 jam - Kaltrofen supp (k/p) - Citicholin 1000 mg 2x1
- ISDN 3x5 mg tab Hb/Ht/E/L/T - hemodialisa senin-kamis - thriflouperazin 1x5mg
- CPG 1x 75 mg tab 9,4/28/3,1/10,1/448 - lorazepam 1x2mg Lab 08/11/2018
- Aspilet 1x80 mg MCV/MCH/MCHC Lab 6 /11/2018 - try hexyphenidil 2x2mg Asam urat : 7,4
- Amlodipin 1x10mg 88/30/34 Hb/Ht/E/L/T
Diftell: 3/1/0/66/20/10 6.2/18/2,2/101/3,2 lab 14/11/2018 Lab 05/11/2018
Lab 13/11/2018 Ur/Cr: 153/14,41 MCV/MCH/MCHC bil total/ bil direct/ bil Hb/Ht/E/L/T
CKMB: 22 As. Urat: 12,6 82/28/34 indirect:4,17/2,65/1,52 8,7/25/3,2/14/119
Na/K/Cl: 141/4,9/100 Diftell: 3/1/0/65/23/8 SGOT/SGPT:72/20 MCV/MCH/MCHC
Lab 11/11/2018 Na/K/Cl: 136/3,9/105 ALP: 152 77/27/35
Hb/Ht/E/L/T: Lab 11/11/2018 Diftell: 1/0/0/84/6/9
8,4/23/3,0/4,4/124 PT/APTT Lab (01/11/2018 ) Lab 8/11/2018 MDT: anemia NN dgn
MCV/MCH/MCHC: 10,3/39,8 Hb/Ht/E/L/T Ferritin : 691,21 trombositopenia
79/28/36 8,5/25/3,1/10,3/125 Bi. Tot/dir./Indir. : Feritin 460,64
Diftell: 6/1/0/65/17/11 Lab 08/11/2018 MCV/MCH/MCHC 5,12/2,74/2,38 serum FE: 6
Ur/Cr: 141/12,82 Ca : 5,8 82/28/34 Ca: 8,0
Na/K/Cl: 135/4,9/100 Asam urat : 17,1 Diftell: 6/1/0/56/21/16 Ur/Cr : 20/0,91 Lab 04/11/2018
Urinalisa: Alb: 2,92 Na/K/Cl: 147/3,5/111 Hb/Ht/E/L/T
Lab 09/11/2018 Protein : +1 Ur/Cr: 78/8,32 8,0/22/3,0/11,8/128
Hb/Ht/E/L/T: Glukosa :+1 Na/K/Cl: 138/3,8/106 Lab 3/11/2018 MCV/MCH/MCHC
8/22/2,8/4,5/109 Darah : positif Hb/Ht/E/L/T 73/27/37
MCV/MCH/MCHC: Urinalisa (1-11-2018) 7,4/21/2,9/6,2/223 Diftell: 1/0/0/88/4/7
78/29/36 Kuning MCV/MCH/MCHC Ca: 7,6
Diftell: 4/1/0/67/18/10 Keruh 74/26/35s Ur/Cr: 173/11,88
Ur/Cr: 155/13,90 pH 7,5 Diftell: 1/0/0/84/12/3 Na/K/Cl: 141/3,3/105
Na/K/Cl: 140/5,4/95 Lekosit: - Bil tot/direct/indirect:
Protein +2 6,68/4,28/2,40 Lab 1/11/2018
Keton: - SGOT/SGPT: 43/54 Hb/Ht/E/L/T
Nitrit: - Ur/Cr: 44/1,13 6/17/2,3/10,3/133
Urobilinogen: - Na/K/Cl: 146/3,1/111 MCV/MCH/MCHC
Bilirubin - 72/26/36
Darah: + Lab 1-11-2018 Diftell: 0/0/0/88/5/7
ALP 341 Ca: 6,9
Lab (31/10/2018) Amilase 146 Ur/Cr: 267/17,64
Procalcitonkin: 8,75 Lipase 147 Na/K/Cl: 141/3,7/109
HbSag: negatif
Kolesterol
tot/LDL/HDL/trigli:
151/25/92/160
K5B1 K5B2 K5B3 K5B4 K5B5
DPJP : dr. Azhari Ghani, DPJP : dr. Azhari Ghani, DPJP : dr. Azhari Ghani, DPJP : dr. Azhari Ghani, DPJP : dr. Azhari Ghani,
Sp.PD Sp.PD Sp.PD Sp.PD Sp.PD
COW: dr. Alkausar COW: dr. Alkausar COW: dr. Alkausar COW: dr. Alkausar COW: dr. Alkausar
Dr : dr. Riza Dr : dr. Riza Dr : dr. Riza Dr : dr. Riza Dr : dr. Riza
DM : Suci/Entan DM : Suci/ Entan DM : Suci/ Entan DM Suci/ Entan DM : Suci/ Entan
Nama: M. Amir R Nama: Mahyuddin Abdul Nama: Mahendra M Jafar Nama: Saprizal Nama : Ilmi Setiawan
TTL: 01/05/1970 (48 thn) Gani Umur: 08/07/1988 (30th) TTL: 01/02/1998 (20 th) TTL. : 27/05/1978 (40 thn)
Alamat: Aceh Besar TTL: 21/09/1989 ( th) Alamat:Pidie Alamat : Aceh Singkil Alamat: Banda Aceh
CM: 1029127 Alamat: Tangse, Pidie CM: 1060745 CM : 1-19-06-24 Cm. : 1190680
Hari rawatan: 4 CM: 1190216 Hari rawatan: 4 Hari rawatan:4 Hari rawatan: 5
Hari rawatan: 8
A/ A/ A/ A/
1. Ascites terkontrol ec TB A/ 1. dd 1. HAP 1. DHF grade II 1. AKI stg III post renal dd
ec dd/ 1. Pansitopenia ec dd/ 2. TB paru dengan acute on CKD
-kardiomiopati -mielofibrosis infeksi sekunder Th/ 2. Striktur uretra
-hipoalbuminemia -MDS 2. Reaktif Hiperglikemia dd - Bed rest 3. Ruptur uretra post
- non alkoholik steatohepatis -Leukimia akut -DM tipe II - Diet MB 1700kkal/hari uretroskopi dan sistotomi
-hepatitis -Anemia aplastik -Drug Induced - Sucralfat syr 3xCII 4. Hipertensi grade I
2. DM tipe 2 overweight 2. Post PSMBA perbaikan ec 3. Penigkatan enzim - IVFD RL 30gtt/i 5. Hiperurisemia
3. peningkatan enzim dd/ transferase ec dd - IV omeprazole 40mg/12j
transaminase ec dd/ -gangguan koagulopati -drug induced - Domperidon 3x10mg Th/
-sirosis hepatis -stress ulcer -viral infection - PCT 3x500mg - Tirah baring
-hepatitis -ulcus gaster 4. Polisitemia vera - Psidii 100mg tab 3x2 - Diet Ginjal 1700kkal/hr
4. Hipoalbumin 5. Penyakit jantung bawaan + 40 gr per hari
5. Heart Failure ec Th/ sianotik ec dd Lab 13/11/2018 - Threeway
Kardiomiopati diabetik -Bedrest -TOF Hb/Ht/E/L/Tr - IV ceftriaxone 2gr/24j
6. STEMI Inferior late onset - Diet MII 1700 kkal/hr -VSD 13,2/36/4,3/5,2/13 (H1)
7. Insomnia - Threeway - RVH MCV/MCH/MCHC - IV omeprazole 40 mg
- IVFD NaCl 0,9% 20 gtt/ i 83/31/36 /24j
Th/ - IV Omeprazole 40mg/12j Th/ Diftell : 1/1/0/31/56/11 - Valsartan 1x80mg
- Bed rest - Paracetamol 3x500mg - Diet Jantung 1700kkal/hr Urinalisis - Amlodipin 1x10mg
- Diet MB 1700 kkal/hari + -Sukralfat syr 3xCI - 02 2-4 lpm/24j Kuning - Lenl ace 2x169mg
ekstra putih telur - IVFD NaCl 0,9 20 TPM Keruh - As. Folat 2x400mg
- Threeway Lab 13/11/2018 - Propanolol 1x10mg Protein +1 - Resfar 1 fls/ hari
- O2 2-4 lpm Hb/Ht/E/L/Tr - IV furosemid 20mg/8j Glukosa negatif - Ondansentron 1 amp
- Omeprazole 2x20mg 8,9/32/3,6/4,7/109 - Sildenafil2x5mg Keton negatif extra
- Domperidon 3x10 mg tab MCV/MCH/MCHC - KSR 1x600mg Nitrit negatif - Hemodialisa
- IV Furosemide 20 mg/12 88/25/28 - Digoxin 2x0,25mg Urobilinogen negatif - Balace cairan
jam Diftell : 2/0/0/58/35/5 - PCT 3x500 mg Bilirubin negatif
- Spironolakton 2x100 mg Pt/Aptt: 0,96/1,11 - Flumucyl syr 3xCI Darah negatif Lab 13/11/2018r
- Lactulac Syr 3xCI Anti HCV: negative Kuning
- Curcuma 3x2 tab HbsAg: negative Lab 13/11/2018 Lab 12/11/2018 Keruh
- Novomix 16-14 Kuning Hb/Ht/E/L/Tr Leukosit +
- Nitrokaf 2x6,25 mg Lab 12/11/2018 Keruh 13,2/36/4,3/6,2/13 Protein +1
- Lovenox Inj 2x0,6 Hb/Ht/E/L/Tr 1,020 MCV/MCH/MCHC Darah +
- Clobazam 1x5 mg 8,1/28/3,3/91 7,0 83/31/37 Leukosit 10-15
(malam) MCV/MCH/MCHC leukosit negatif Diftell : 1/0/0/29/60/10 Eritrosit 4-6
- Dulcolax supp II (extra) 87/25/29 protein +2 Epitel 3-5
Diftell : 2/0/0/51/39/8 bil positif Lab 10/11/2018
Lab 14/11/2018 darah positif Hb/Ht/E/L/T Lab 11/11/2018
Feses rutin: warna coklat, Lab 09/11/2018 18,7/51/6,1/4,2/16 Hb/Ht/E/L/Tr
bau khas Hb/Ht/E/L/T: Lab 11/11/2018 MCV/MCH/MCHC 9,9/27/3,7/12,6/311
Mikroskopik: eritrosit: 8,3/29/3,3/3,6/75 Hb/Ht/E/L/T 83/31/37 MCV/MCH/MCHC
negative, telur cacing, telur MCV/MCH/MCHC 23,3/66/9.2/2,4/41 Diftell: 1/1/0/52/35/11 73/27/37
cacing-, parasite -, 86/25/29 MCV/MCH/MCHC Anti dengue IgG/IgM Diftell : 7/0/1/65/18/9
konsistensi lunak Diftel 1/0/0/56/36/7 72/25/35 Positif/positif Anti HCV/ HBsAg (Negatif)
HbsAg : neg Diftell: 0/2/0/69/23/6 Ur/Cr : 48/1,42 SGOT/SGPT
Lab 12/11/2018 SGOT/SGPT : 38/29 SGOT/SGPT : 103/56 Na/K/Cl : 135/4,2/93 52/57
Billirubin Total 0,94 Bi. Tot/dir/indir : CKMB : 26 Ur/Cr : 153/13,92
Billlirubin Direct 0,36 1,47/0,45/1,02 GDS :583 Na/K/Cl
Billirubin Indirect 0,58 Ur/Cr : 12/0,57 Bi. Tot/dir/indir : 136/4,8/97
Hb-A1c 11,90 Na/K/Cl : 143/4,0/101 1,47/0,45/1,02
Urinalisis : Ur/Cr : 40/0,87 Lab 10/11/2018
Protein (+1) Na/K/Cl : 143/4,0/101 Hb/Ht/E/L/T:
Glukosa (+3) Na/K/Cl/Ca:125/4.3/92 9,7/27,9/3,74/12/289
Anti dengue IgG/IgM MCV/MCH/MCHC:
Lab 10/11/2018 Negatif/negatif 74,6/25,9/34,8
13,6/37/4,4/13,2/141 Diftel 0,1/6,2/66/17,4/10,3
MCV/MCH/MCHC SGOT/SGPT : 36/39
84/31/37 Led : 37
Diftell: 0/0/0/68/23/9 As. Urat : 15,7
HbsAg : negatif Ur/Cr : 177/13,51
SGOT/SGPT : 181/97 Na/K/Cl : 129/4,3/97
Albumin : 3,06
GDS : 153
Ur/Cr: 35/0,96
Na/K/Cl: 134/4,3/101
K6B1 K6B2 K6B3 K6B4 K6B5
DPJP : dr. Azhari Ghani, DPJP : dr. Azhari Ghani, DPJP : dr. Azhari Ghani, DPJP : dr. Azhari Ghani, DPJP : dr. Azhari Ghani,
Sp.PD Sp.PD Sp.PD Sp.PD Sp.PD
COW: dr. Alkausar COW: dr. Alkausar COW: dr. Alkausar COW: dr. Alkausar COW: dr. Alkausar
Dr : dr. Ishak Dr : dr. Ishak Dr : dr. Ishak Dr : dr. Ishak Dr : dr. Ishak
DM : Dea/ Isna DM : Dea/ Isna DM : Dea/ Isna DM : Dea/ Isna DM : Dea/ Isna
Nama: Irfansyah Nurdin Nama: Suriyat Samian Nama: Hamdani usman Nama: Muzakkir Nama: Ismail Ibrahim
TTL: 02/07/1987 (31 th) TTL: 01/07/1972 TTL: 24/04/1970 Syamsuddin TTL: 08-08-1941
Alamat: Aceh Besar Alamat: Aceh Barat Alamat: Langsa TTL: 02-03-1974 Alamat: Aceh Besar
Pekerjaan: pelajar Pekerjaan: petani Pekerjaan: Wiraswasta Alamat: Bireun Pekerjaan: Petani
CM: 1068645 CM: 1-18-81-30 CM: 1-19-02-11 Pekerjaan: petani CM: 1-04-82-25
Hari rawatan: 3 Hari rawatan: 5 Hari rawatan: 7 CM: 1190611 Hari rawatan: 3
Hari rawatan: 6
A/ A/ A/ A/
1. Sindroma Nefrotik 1. Hepatoma dengan cancer 1. CKD stg V dg uremic A/ 1.Pneumonia (HAP)
2. Dyspepsia Tipe Like pain syndrome perbaikan ec dd/ 1.Abdominal pain ec dd/ 2. Trombositopenia reaktif
Ulcer 1. DM -Pankreatitis dd/esensial
Th/ 2. GNC -Ulkus duodenum 3.Anemia Sedang NN ec
Th/ -bedrest 2. Anemia sedang hipokrom -Ulkus Gaster perdarahan
-bedrest -diet MII 1700kkal /hari mikrositer ec dd/ 2.HAP 4. PSMBA dd/
-diet ginjal 1700kkal /hari -IVFD aminofusin hepar 1 1.Penyakit kronis 3.PSMBA ec dd/ multiple giant ulkus antrum
-IVFD RL 500 cc/ hari fl/hari 20gtt/i 2. Def Fe -ulkus gaster 5. Aki stage 2 pre renal
- IV omeprazole 40mg/12j - IV omeprazole 40mg/12j 3. DM tipe 2 overweight -variss esofagus bleeding 6. Gout Arhtritis
(30’ ac) - lactulac syr 3xCII 4. HHD -gastritis erosif 7. geriatric problem
- IV Ondansetron 4 mg/ 8 - Domperidon 3x10mg 5. CHF FC NYHA II 4. DM tipe 2 NW 8. BPH
jam (30’ ac) - Flumucyl tab 2x200 mg 6. efusi pleura dextra 5. Hidropneumothorax ec 9. leukosituria ec dd/
- Methyl Prednisolon 3x - paracetamol 3x500mg 7.Retinopati diabetic dd/ -pneumonia, -TB -ISK
4mg (pc) 8. Pneumonia -kontaminan
-Sandimun 2x100 mg Lab 12/11/2018 9. Dispepsia type like Th/ 10. AR Mild
-Sukralfat Syr 3x CI Hb/Ht/E/L/Tr dismotility -Bedrest
11,8/34/3,9/3,7/174 -NGT, threeway Th/
lab 14/11/2018 MCV/MCH/MCHC Th/ -Diet hati sonde cair 6x200 - bedrest
kuning 88/31/35 -bedrest cc - Diet MB 1700 kkal/hari
keruh Diftell : 2/0/0/71/18/9 -O2 2-4L/menit -IVFD futrolit 20gtt/i - IVFD futrolit 20 tpm
glukosa+ PT/APTT -diet ginjal 1700kkal+40mg -IVFD aminofusin hepar 1 - IVFD Clinimix 1 fls/hari
urobilinogen + 10,7/38,0 protein/hari fl/hari 20gtt/menit - IV Ceftriaxone 2gr/24jam
leu: 2-3 LPB AFP: 40,33 -drip furosemide 1ml/24j -domperidon 3x10mg (H9)
erit: 1-2 LPB Anti HCV: negative -IV ceftriaxone 2gr/24 j (H8) -curcuma 3x2 tab - IV Omeprazole 40 mg/8
epitel: 3-5LPK Bil tot/ bil direct/bil indirect: -lenal ace tab 2x169mg -sukralfat syr 3xCII jam
0,79/0,38/0,41 -as folat 2x400mg -Sistenol 3x1 tab - IV ondansetron 4mg/8ajam
Lab 12/11/2018 Urinalisa -C. Lyters 3xgtt ODS -Drip paracetamol 500mg - Sucralfate syr 3xCII
Hb/Ht/E/L/Tr Kuning -Spinorolacton 25mg 2x1 tab (k/p) bila T>38 C - PCT 3x500mg
11,8/34/3,9/3,7/174 Jernih -tanapres 1x5mg -Ampicilin sulbactam 1gr/8j - Colchisin tab 2x0,5 mg /
MCV/MCH/MCHC Urobilinogen + -drip furosemid 2 amp/8jam -Sc apidra 10-10-10 - IV dipenhidramin 1 amp/
88/31/35 Leu: 2-3 LPB -artovastatin 1x2mg -Sc lantus 0-0-0-14 24 jam
Diftell : 2/0/0/71/18/9 Erit: 1-2 LPB -clopidogrel 1x75mg -Lansoprazole 30mg/12j -Domperidon tab 3x10 mg
PT/APTT Epitel: 3-5 -Azythromicin 1x 500 mg -Graphalac syr 3xCII -Lactulac syr
10,7/38,0 -Domperidone 3x10mg -Amoxicilin 2x1000 mg
Lab 10/11/2018 -Sucralfat syr 3xCI Lab 12/11/2018 -Azythromisin 1x 500 mg
Lab 10/11/2018 Hb/Ht/E/L/T: Hb/Ht/E/L/Tr -Sucralfat syr 3xCII
Hb/Ht/E/L/T: 11,5/33/3,8/4,1/154 Lab 12/11/2018 6,7/20/2,3/16,1/249
11,5/33/3,8/4,1/154 MCV/MCH/MCHC Urinalisa : MCV/MCH/MCHC Lab 13/11/2018
MCV/MCH/MCHC 88/31/35 Protein (+2) 87/29/34 warna hijau, bau khas,
88/31/35 Diftel 3/0/0/64/23/10 Glukosa (+1) Diftell : 0/0/1/83/8/8 eritrosit negative, leukosit:
Diftel 3/0/0/64/23/10 HbsAg : pos Analisis cairan pleura: ALP : 117 negative, konsistensi: lunak
HbsAg : pos SGOT/SGPT : 133/80 Warna: kuning Amilase : 47 Lab 12/11/2018
SGOT/SGPT : 133/80 Alb/GDS: 3,32/82 Kejernihan : keruh Lipase : 137 PT/APTT
Alb/GDS: 3,32/82 Ur/Cr : 25/1,16 Bekuan : negative 10,2/36,0
Ur/Cr : 25/1,16 Na/K/Cl : 139/4,0/100 Mikros : Lab 10/11/2018 Anti HCV Negatif
Na/K/Cl : 139/4,0/100 PMN: 0 Hb/Ht/E/L/T: Albumin 3,07
MN: 0 6,4/18/2,2/17,9/248 Ureum/ Kreatinin
Leu: 130 MCV/MCH/MCHC: 68/2,18
Total prot: 1,2 82/29/35 Na/K/Cl
Glu: 173 Diftell:0/0/0/88/5/7 132/5,2/95
Anti HCV/HbsAg: neg/neg
Lab 07/11/2018 SGOT/SGPT : 22/26 Lab 09/11/2018
Hb/Ht/E/L/T: Alb : 3,15 Ur/Cr : 75/2,26
8,1/23/3,1/8,6/287 GDS : 381 Lab 08/11/2018
MCV/MCH/MCHC: Ur/Cr : 34/0,77 Hb/Ht/E/L/T:
73/26/36 Na/K/Cl : 130/4,2/92 7,4/21/2,7/18,8/519
Diftell:2/0/1/79/8/10 MCV/MCH/MCHC:
Ferritin/Besi : 451.32/24 79/27/35
Asam urat : 9.6 Diftell:1/0/0/86/5/8
As. Urat : 7,0
LED : 140