AQSHA 2 (PENYAKIT DALAM PRIA)

Hari / Tanggal : Minggu 23/06/2019

Dokter Jaga : dr. Rachmat / dr. Husna
DokterMuda : Sando/ Nazar

K1B1 K1B2 K1B3 K1B4

DPJP : dr. T. Mamfaluti,Sp.PD DPJP : dr. Chacha, Sp.PD DPJP : dr. Chacha, SpPD DPJP : dr. M.Fuad,Sp.PD
COW : dr. TM Reza Tandi COW : dr. Febri COW : dr. Febri COW : dr.Fahril
DR : dr. Okdimur DR : dr. Akmal DR : dr. Akmal DR : dr. Taufik
Raber : Raber : PTI Raber : GH Raber :
Nama: Tgk. M.Adam Arahman Nama: Maula Ghozhie Nama: Ady Darman Nama: Sudirman M Thaeb
TTL : 01/05/1938 (81 Thn) TTL : 21/04/1960 (59 Thn) TTL : 16/09/1964 (54 Thn) TTL: 20/11/1986 (32thn)
Alamat : Pidie Jaya Alamat : Banda Aceh Alamat : Kota Sabang Alamat: Aceh Utara
CM :1-21-22-19 CM :0-75-74-96 CM :1-18-94-30 CM: 1-03-26-34
Hari Rawatan : 2 Hari Rawatan : 6 Hari Rawatan : 5 Hari Rawatan: 4

A/ A/ A/ A/
1. Penurunan kesadaran ec dd/ 1.Penurunan kesadaran (perbaikan) ec 1. CKD stage V ar CAPD dengan 1. Immune Thrombositopeni
- Uremic ensepalopati - Sepsis uremic syndrom Purpura
- Sepsis -imbalance elektrolit 2. Hiperkalemia Berat
- Stroke -Uremic ensefalopati 3. Anemia berat ec PGK Th/
2. CKD stage 5 ec dd/ 2. Sepsis ec dd. –Pneumonia (HCAS 4. CHF fc NYHAA II-III ec dd – - Bedrest
- HN -ISK HHD ,IHD - IVFD NaCl 0,9% 20tpm
- PNC 3. HCAP od infeksi spesifik - Diet MB 1700kkal / hari
3. Sepsis ec dd/ 4. CKD stage V ec on HD regular Th/ - Inj Methylprednisolon
- Urosepsis - Bedrest 125mg/12jam
- Pneumonia Th/ - Diet ginjal 170kkal dan protein 78gr - Sandimon 2x100mg
- Hipoglikemia (perbaikan) - IV Levofloxacin 750mg/48 jam - Threeway
4. Pneumonia CAP dd inf.paru - Omeprazole 40 mg/24 jam - Transfusi PRC 1 kolf hingga hb 10 Lab 22-6-2019
spesifik - IVFD EAS pfrimer 1fls post HD - Har nal Ocas 1x 0,2mg Hb/Ht/E/L/T
5. Hipoglikemia perbaikan - Drip fluconazole 500g/24j - IV Furosemid 40mg/8j 16.1/4.6/6.0/14.3/17
6. HHD - Lenal Ace 2x169mg - IV Omeprazole 40mg /12j MCV/MCH/MCHC
- Asam folat 2x400mg - Lenal Ace 169mg 2x1 76/27/35
Th/ - Azitromicin 1x500mg(h5) selama - As. Folat 400mg 2x1 Diftell : 0/0/0/91/8/1
- Bedrest semifowler 5 hari - Amlodipin 10mg 1x1
- Diet ginjal 6x200cc + 0,6-0,8 - Drip hidronac 1000g - IV Cablukonas 1amp extra
gr/KgBB/hari + 3,2 gr - HD selasa jumat - IV Dextrose 40% 2 fls extra
- Threeway - SC novorapid 10 unit extra
- IV. Ceftriaxone 2gr/24 jam Lab 23-6-2019 - Ventolin 1 resp extra
- Asam Folat 400mg 2x1 Ca 9,2 - Kalitake 3x1
- Lenal Ace 2x169mg Na/K/Cl 131/4,2/106 - Harnal ocas 1x0,2mg
- Dextrose 5% 1 fls - Sukralfat 3x1cth
- IV.Citicolin 500mg/12 jam Lab 19-6-2019 -HD selasa kamis sabtu
- Tramadol 1 amp/8jam Procalsitonin: 7,72
Lab 22-06-2019 Lab 20/6/19
Hb/Ht/E/L/T Lab 18-6-2019 HB/HT/E/L/T : 6,4/18/2,3/9,6/160
8,7/25/3,8/23,6/113 Hb/Ht/E/L/T MCV/MCH/MCHC/RDW : 80/28/36
MCV/MCH/MCHC 9,5/33/3,5/25,2/176 Troponin I/CK-MB : <0,1/23
67/23/34 MCV/MCH/MCHC Na/K/Cl : 142/5/110
Diftell : 1/0/0/86/9/4 94/27/29
GDS : 58 Diftell : 0/0/0/89/2/9 Lab 20/6/19
Ur/Cr : 119/4,13 Na/K/Cl: 144/3,7/106 HB/HT/E/L/T : 5,5/16/2/11,0/163
Na/K/Cl: 140/3,7/113 Kalsium :8,1 MCV/MCH/MCHC/RDW :
GDS : 91 83/28/34/15,9
Ur/Cr : 48/5,27 Ca: 7,8
Analisa Gas Darah Na/K/Cl : 143/6,4/112
pH : 7,135
pCO2 : 91,40 Lab 19/6/19
pO2 : 87 Albumin: 3,05
Bikarbonat (HCO3) : 31,1 Ca: 7,3
Total CO2 : 33,9 Na/K/Cl: 140/7,1/111
BE : 0,4
Saturasi O2 : 91,2 Lab 18/6/19
HB/HT/E/L/T : 5,3/15/1,9/9,1/141
MCV/MCH/MCHC/RDW :
83/29/34/16,3
GDS 107
UR/CR : 315/32,2
Na/K/Cl : 142/8,2/111
 K2B1
DPJP : dr. T. Mamfaluti,
Sp. PD
COW : dr. TM Reza Tandi
DR : dr. Okdimur
Raber : GEH
Nama : Darmi Arifin
TTL : 19-11-1962 (56thn)
Alamat : Aceh jaya
CM : 1-21-12-59
Hari Rawatan : 11
A/
1.Pansitopenia ec dd/
- Anemia aplastik
- Myelofibrosis
-MDS
- 2. Renal Cell Carcinoma Post
Th/
- Bed rest
- Diet MII 1900 kkal / hari
- IVFD Tutofusin 20tpm
- Transfusi TC jika T<10.000
atau <20.000 dengan
perdarahan
- IV Omeprazole 40 mg/12 j
- Paracetamol 3 x 500 mg
- Sucralfat syr 3 x C I
- Buscopan 3x10mg
Lab 20-6-2019
Hb/Ht/E/L/T:
8,3/23/2,4/1,6/42
MCV/MCH/MCHC: 93/34/37
Diftell: 1/1/0/49/48/1
Lab 17-06-2019
Retikulosit : 1,0
Lab 17-6-2019
Hb/Ht/E/L/T:
7,5/21/2,2/1,2/49
MCV/MCH/MCHC: 97/35/36
Diftell: 3/1/0/34/61/1
Retikulosit : 1,0
Lab 16-6-2019
Hb/Ht/E/L/T:
6,4/18/1,9/1,4/57
MCV/MCH/MCHC: 94/34/36
Diftell: 1/1/0/42/54/2
Lab 15-6-2019
Hb/Ht/E/L/T: 6,9/19/2/1,8/28
MCV/MCH/MCHC: 94/34/37
Diftell: 1/2/0/41/54/2
Lab 14-6-2019
Urinalisis:
Keton +
Urobilinogen +
Darah +
Eritrosit :4-5
Epitel : 4-6
-
K2B2 K2B3 K2B4 K2B5
DPJP : dr. Azhari Gani DPJP : DPJP: dr.Islamuddin, DPJP : dr. Islamuddin,
Sp.PD-KKV dr.Islamuddin,Sp.PD Sp. PD Sp.PD
COW : dr. Rahmi COW : dr. Febri COW : dr. Febri COW : dr. Febri
DR : dr. Wahyu DR : dr. Akmal DR : dr. Akmal DR : dr. Akmal
Raber: HOM, GEH, Psikiatrik Raber: GH, Raber: GH, Kardio
Nama :Abdul Karim Nama: Faiden Amin Nama: Sarmin D. Nama: Salbunis Jabad
TTL : 06-10-1979 (39 thn) TTL: 10/12/1970 (48 thn) TTL: 13-7-1961 (57 thn) TTL: 22-05-1985 (34 thn)
Alamat : Aceh Tamiang Alamat: Bireuen Alamat: Simeulue Alamat: Aceh Barat
CM : 1-18-46-10 CM: 1-21-21-15 CM: 1-19-97-29 CM: 1-20-98-97
Hari Rawatan : 18 Hari Rawatan: 3 Hari Rawatan: 15 Hari Rawatan: 4
A/ A/ A/ A/
1. Penurunan kesadaran 1. PSMBA ec dd/ 1. Massa colli dextra ec 1. CKD stg V ec hypoplasia
(perbaikan) ec dd/ - Uremic bleeding dd/ ginjal on hd reguler
- Imbalance elektrolit - Gastritis erosive - Limfoma Hodgkin 2. Anemia sedang ec PGK
- Metastase proses 2. AKI Stage III dd akut on - Ca Nasofarin 3. TB paru on oat kategori
CKD metastase paru, 1 putus obat 6 hari
Kemoterapi Siklus I 3. Anemia berat hipokrom hati, tulang 4. Penurunan kesadaran
3. Hipokalemia Sedang ec GI mikrositer ec dd/ 2. Hipertensi stage I (perbaikan)
Loss - Penyakit kronik 3. Sepsis perbaikan ec dd/
4. Cancer pain - Defisiensi besi - HAP Th/
5. High Risk Thrombosis 4. Hipokalemia sedang - Abses ar colli - Threeway
6. Stomatitis grade B 5. Hiponatremia euvolemic dextra - Diet ginjal 1700 kkal
7. Sindrom lisis tumo 4. Abses a/r colli - Inj Meropenem
8. Anemia sedang hipokrom Th/ 5. Hipoalbuminemia 1gr/8jam
mikrositer ec dd : - Bedrest sedang - Inj Metoclopramide
- Def. Fe - Threeway 10mg (K/P)
- Malignancy - Diet Ginjal 6x200 kkal Th/ - Lenal ace 2x169mg
9. Trombositeopenia ec dd : - Transfusi PRC s/d HB > 10 - Bed rest - Asam folat 2x400mcg
- Induced kemoterapi gr/dL - Diet MII 1700 kkal / - Ranitidin 2x150mg
- Inflamasi sumsum tulang - IV. Meropenem 1 gr/8jam hari - Pro TB 2FD
- dic - IV. Omeprazole 40mg/12 - IVFD Clinimix1 fls/ etambutol,
jam 48j pirazinamid
Th/ - Sucralfat syr 3xCI - IV Omeprazole 40 - Piridoxin 2x1
- Bedrest - Hemodialisa mg/12 jam - Curcuma 2x1
- NGT - Erdostein 3x1 Lab 20-6-2019
- Diet sonde 6x200cc/hari - Pradaxa 1x75mg Hb/Ht/E/L/T:
- IVFD NaCl 0,9% 20 tpm Lab 21-6-2019 - Amlodipin 1x5mg 9,1/26/3,2/11/145
- Drip Levofloxacin Hb/Ht/E/L/T: - Clinimix 1fls/48j MCV/MCH/MCHC:
500mg/24jam 6,3/18/2,4/34,4/201 - Paracetamol 300mg 83/29/35
- IV Fluconazole 200 mg/24jam MCV/MCH/MCHC:74/26/36 dan Tramadol 25mg Diftell: 2/1/0/87/5/5
- IV Bonefos / 24 jam Diftell: 0/0/0/93/4/3 dalam pulvis 2x1 Na/K/Cl/Ca :
- SC Leucogen 1 vial (K/P) PT/APTT : 15,20/37,70 - Levofloxacin 137/3,7/104/9,6
- Ondansetron 3 x 4mg Ur/Cr : 362/13,88 750mg/24jam Ur/cr : 108/2,7
- MST 2 x 15mg Na/K/Cl : 123/6,7/93
- KSR 2 x 600 mg Anti HCV negatif Lab 22-6-2019 Lab 18-6-2019
- Minosep 3x1 HbSAg negatif Hb/Ht/E/L/T: Hb/Ht/E/L/T:
- Curcuma 3x1 10,6/31/3,8/16,8/356 7,5/21/2,6/16,2/192
- Attapulgite 1 tab tiap diare MCV/MCH: 83/28 MCV/MCH/MCHC:
max 10 tab sehari Diftell: 0/0/0/84/6/10 83/29/35
- Sucralfat Syr 3 x C I Diftell: 0/0/1/86/5/8
- Lactulac syr 3xCI Lab 19-6-2019 Na/K/Ca/Mg :
- Sinbio 3x1 sach Hb/Ht/E/L/T: 140/4,5/9,1/1,9
- Lorazepam 2mg 1x1 11,5/34/4,2/15,3/387 Ur/cr : 170/4,16
- Fosen Enema extra MCV/MCH: 83/28 SGOT/SGPT/Alb :
- KCL extra Diftell: 1/0/0/77/9/13 45/20/3,48
- Transfusi PRC Hb >10g/dl Alb : 2,8
- Nystatin 4dd gtt I
Lab 18-6-2019
Lab 19-06-2019 Procalcitonin : 0,32
HB/HT/E/L/T
8.8/26/3,5/17.8/25 Lab 14-6-2019
MCV/MCH/MCHC: 73/25/35 Hb/Ht/E/L/T:
Diftell : 0/1/0/88/7/4 12,2/36/4,3/17,6/346
Na/K/Cl : 142/3,8/118 MCV/MCH: 83/28
Diftell: 1/1/0/78/8/12
Lab 15-06-2019
Hb/Ht/E/L/T: 7,4/21/3,0/12,9/22 Lab 10-6-2019
MCV/MCH/MCHC: 70/24/35 Urinalisis:
Diftell: 0/0/0/86/9/5 Keton +
INR : 1,30 Epitel : 2-3
APTT / Kontrol : 43,9/33,7
Albumin : 2,88
GDS : 164
Ur/Cr: 17/0,55
Na/K/Cl: 134/3,8/99
 K3B1 K3B2 K3B3 K3B4 K3B5
DPJP: dr.Azhari DPJP: dr. Azzaki DPJP :dr. Kurnia,Sp.PD DPJP : Kurnia DPJP : dr. Chacha, Sp.PD
Gani,Sp.PD-KKV Abubakar SPPD COW : dr. FJ,Sp.PD COW : dr. Febri
COW :dr. Rahmi COW:dr. Dedi DR : dr. Wahyu COW : dr. Rahmi DR : dr. Akmal
DR :dr. Wahyu DR: Raber : DR : dr. Wahyu Raber :
Raber : EMD Raber: DM : Raber : GEH,HOM
DM :
Nama : Muad Abdullah Nama: Tamrin Sinamora Nama: M Syahril Nama:Reza Husen Mala Nama: Idris Puteh
TTL : 1/7/1960 58th TTL: 06-06-1997 ( 22th) TTL : 31-12-1981 (37thn) TTL :6-10-1987 (31thn) TTL: 01-07-1937 (81 thn)
Alamat : Aceh Besar Alamat: Aceh Singkil Alamat : Aceh Timur Alamat :Aceh Barat Daya Alamat: Aceh Pidie
CM : 1-18-77-14 CM: 1-20-96-56 CM : 1211132 CM : 1-17-92-16 CM: 1-21-10-87
Hari Rawatan : 2 Hari Rawatan: 3 Hari rawatan : 11 Hari rawatan :8 Hari Rawatan: 12

A/ A/ A/ A/ A/
1.Ulcus Diabetic ar pedis 1. Hematozkezia ec dd 1. Penurunan 1. Ileus paralitik ec susp 1. Penurunan kesadaran ec
dekstra - Hemoroid interna kesadaran imbalance elektrolit SDA ec dd/
2. DM tipe 2 UW - Polip rekti (perbaikan) ec dd/ 2. Diare kronis ec dd/ - Urosepsis
3.Hipernatremia normoosmolar - Ca rekti - Uremic ensefalopati -colitis ulseratif - Disequilibrium Synd
hipovolemi - Sepsis -colitis infeksi 2. Sepsis ec dd/
4. Hiperkalemia ringan 2. Sindroma nefrotik 2. Sepsis ec dd/ -crohn disease - Urosepsis
5. AKI stage I prerenal 3. Aki stg II - Urosepsis 3. Pneumonia - HAP
4. ISK - Pneumonia 4. Hipokalemia ringan 3. Pneumonia (HAP) dd/
Th/ 3. DM tipe 2 NW 5. Hiponatremi Infeksi paru spesifik
- Bedrest Th/ dengan critical ill hipoosmolar 4. CKD stage V ec PNC
-O2 2-4 lpm - Bedrest 4. AKI stg II pre renal hipovolemic 5. Nefrolithiasis bilateral
- Diet DM 1700kkal/hari - Diet MII 1700kkal/hr 5. ISK ec fungi 6. Hipoalbuminemia 6. Hipertensi on therapy
- SC lantus 0-0-0-14 IU - Ivfd Nacl 0.9 20gtt/i 6. Oral candidiasis 7. Status hipokoagulasi 7. PPOK stabil
-Iv Lansoprazol 30mg/12jam - Threeway 7. Hiperkalemia 8. Geriatric Problem
- Iv ceftriaxone 2gr/24 jam - Protap colonoskopi (perbaikan) Th/ 9. Hipokalsemia(perbaikan)
-Clindamicin 2x300 mg - Drip ciprofloksasin - Bed rest Th/
200g/12 j Th/ - O22-4 lpm (nasal kanul) - Bed rest
Lab 23-06-2019 - Valsartan 1x40mg - Insulin novorapid 10 - Diet MII 1700 kkal / - O2 2-4 lpm (NK)
Na/K/Cl - Metilprednisolon 3x4 (obat unit dalam Nacl 0,9 % hari - Diet Ginjal 6x200cc / hr
118/5,4/96 pasien) 50 cc dengan kec 1 - Drip Albuminar 25% - IVFD NaCl 0,9% 30 tpm
- Furosemid 1x40mg (obat unit/jam 100cc/24j (H3) (mikro) s/s Dex 5%
Lab 22-06-2019 pasien) - Iv Meropenem 1gr/8j - IV Ceftriaxone 2 gr/24 - IVFD Eas Sfrimer 1fls/24jam
HB/L/T (H12) jam (H-8) - IV Lansoprazole 30 mg/24
9,9/24/322 Lab 20-5-2019 - Lansoprazole drip 60 - IV Omeprazole 40 jam
MCV/MCH Hb/Ht/E/L/T dalam 50 cc dengan mg/24 jam - Amlodipine 1x5 mg
77/27 12.3/36/4.7/14.0/525 kec 5cc/jam - IV metronidazole - Asam folat 2x400 mcg
Diftel MCV/MCH/MCHC - Kalitake 3x1 sach 500mg/8j (H8) - Lenal ace 2x169 mg
0/0/0/85/6/9 77/26/34 - Parasetamol 1gr/8jam - Salofalk 2x500mg - Bicnat 3x500 mg
Ur/Cr Difftel: 1/1/0/65/27/6 - Fluconazole - Attapulgit 1 tab tiap - Haloperidol 1 x 0,5 mg (sore)
101/1,44 Protein total/alb : 5.13/1,50 200mg/24jam (H4) BAB cair - Drip Fluconazole 500mg/24j
Na/K/Cl Ur/Cr: 48/1.50 - Nystatin drop 4 x 2 cc - Drip albumin 25%/24jam
114/6,2/91 Na/K/Cl: 142/4.9/113 Lab 20-06-2019 - IV Vit K 1amp/12jam - Nystatin drops 4x2cc
Ca 9,6 Hbsag: negative Hb/Ht/E/L/T - Lenal ace 2x160mg - Albendazol 2x1tab
GDS 738 CT/BT: 8/2 12,3/35/4,4/14,3/373 - Drip KCL 20meg - HD (Selasa Kamis Sabtu)
MCV/MCH/MCHC dalam D5% 40 tpm - Balance cairan
Lab 23/6/19 80/28/35 mikro cek elektrolit
Anti HCV negatif Ca/Mg: 8,4/2,4 /4jam setelah drip jalan Lab 21-6-19
Na/K/Cl : 144/3,8/103 Na/K/Cl: 135/2.9/104
Lab 23-06-2019 Kalsium: 9.1
Lab 17-06-2019 Hb/Ht/E/L/T
Hb/Ht/E/L/T 9,3/28/4,6/5,2/175 Lab 20-6-2019
12,8/37/4,6/46,7/300 MCV/MCH/MCHC Hb/Ht/E/L/T
MCV/MCH/MCHC 61/20/33 10,9/33/4,0/10,7/215
79/28/35 Diftell : 0/1/0/79/13/7 MCV/MCH/MCHC
Ca/Mg: 7,5/3,0 Ca: 5,8 82/28/34
Ur/Cr : 61/2,52 Na/K/Cl : 129/1,9/100 Diftell : 22/1/0/40/24/13
Na/K/Cl : 140/3,7/103 PT/APTT: 19,70/35,70
Lab 21-06-2019 Albumin : 2,27
Urinalisa 14-6-2019 Alb: 1.31 Ca: 10,1
Leukosit:+ Na/K/Cl: 123/3.1/96 Ur/Cr : 35/3,49
Keton:+ Na/K/Cl : 139/3,1/104
Urobilinogen:+ Lab 19-06-2019
Darah:+ Hb/Ht/E/L/T Lab Mikrobiologi Klinik
Leukosit: 20-30 10,9/34/5,5/7,1/291 Jumlah koloni : > 105 CFU/ml
MCV/MCH/MCHC
62/20/32
Hasil : Terisolasi Jamur Candida
Diftell : 8/1/0/66/17/8 Lusitaniae
Ur/Cr : 31/0,34
Na/K/Cl : 128/2,6/95 Lab 13-6-2019
Prokalsitonin: 2,58
Lab 17-06-2019 Albumin: 2,61
Na/K/Cl : 130/3,0/97
Lab 16-06-2019
Na/K/Cl : 124/2,3/94
 K4B1 K4B2 K4B3 K4B4 K4B5
DPJP : Neurologi DPJP: dr.Islamuddin, Sp. DPJP : dr. T. Mamfaluti, DPJP : dr. Hendra Zufry DPJP : dr. Hendra Zufri,
COW : PD Sp. PD sp.PD Sp.PD KEMD
DR : COW : dr. Febri COW :dr. Reza COW : dr.Reza Tandi COW : dr. Reza Tandi
Raber : GEH DR : dr. Akmal DR :dr. Okdimur DR : dr. Okdimur DR : dr. Okdimur
Raber : Kardio
Nama: Harun Husen Nama: Matsah Majid Nama: Bachtiar Hasan Nama: Dedi saputra Nama: Kasiman Solin
TTL : 1-21-18-10 TTL : 1-7-1957 (61thn) TTL : 10-10-1953 (65thn) TTL :20/10/1978(40thn) TTL: 01/07/1962 (56 thn)
Alamat: Aceh Pidie Alamat: Aceh Selatan Alamat: Aceh Pidie Alamat :banda aceh Alamat:Subulusalam
CM : 1-21-18-1 CM : 1-21-12-63 CM : 0-91-65-08 CM : 1-21-20-72 CM 1212231
Hari rawatan :9 Hari rawatan : 10 Hari rawatan : 6 Hari Rawatan : 4 Hari rawatan: 2

A/ A/ A/ A/ A/
1. Penurunan keadaran ecdd 1. CKD stage V ec PNC 1. Dyspepsia type like ulcer 1. Ulcus diabetic ar 1. Hepatomegali ec dd
- Meningoensefalitis 2. ISK 2. AVR NVR pedis dextra 1.Limfoma maligna
- Stroke 3. Anemia ec PGK 3. CAD post PCI 2. Selulitis ar pedis 2.Hepatoma
- Hipernatremi 4. HT Stg I 4. HHD dextra 3. Abses hepar
2. Hipernatremi hipovolemik 5. Sepsis ec urosepsis 5. DM type 2 overweight 3. Dm tipe 2 NW 4. Kista hepar
ecGI loss (perbaikan) 5. Metastase proses
3. PSMBB ec dd Th/ 2. Hiponatremia hipoosmolar
- Hemoroid Interna Th/ - Bedrest Th/ hipovolemik
- Polip Rekti - Bedrest - Diet jantung lunak - Bedrest 3. Hipokalemia sedang
-IBD - Diet Ginjal 1700 1700kkal - Diet DM 1700kkal/hr 4. Cancer pain
-Malignancy kkal/hr+protein -IVFD Nacl 0,9% 10gtti - IVFD NaCl 0.9% 20tpm
4. hipokalemia sedang 0,6gr/kgBB/hr - IV lansoprazol 30mg/12j - Drip Ciprofloksasin Th/Bed rest
5. Hipoalbuminia - Threeway -Sukralfat syr 3xCI 400mg/12j - Diet sonde
6. Anemia sedang ec dd - Amlodipin 1x10 mg - Clopidogrel 1x75mg - Iv omeprazole 40mg/24j 6x200cc/hari
- Perdarahan - Valsartan 1x80mg - Amlodipin 1x10mg - Clindamicin 3x300mg - IVFD Tutofusin
- Penyakit kronis - Lenal ace 2x169 mg - Concord 1x 2,5mg - Domperidone 3x10mg 20tpm
- Asam folat 2x400mcg -Atorvastatin 1x20mg - Paracetamol 1gr/8jam - KSR 2X600mcg
Th/ - IV. Meropenem 1gr/8jam -ISDN 5mg (SL) k/p - Levemir 0-0-0-12 Unit - Tramadol tab
- Bedrest (H7) - Naletal 1x100mg 2x50mg
- o2 2-4 liter - Transfusi PRC on HD - nitrokaf R 2x2,5mg Lab 20/06/2019 - Laxadin syr 3xCI
- NGT, kateter Hemodialisa (Senin-Rabu- HB/HT/E/L/T :
- Diet sonde 6300 cc/hari Jumat) Lab 18/06/2019 12,4/36/4,2/20,6/400 Lab 22/06/19
- Drip KCL 25meq 20tpm HB/HT/E/L/T : MCV/MCH/MCHC : 86/30/35 Hb/Ht/L/T
- IV meropenem 1gr/12 j Lab 18-06-2019 12,8/37/4,4/6,6/172 Diftel : 0/1/0/88/5/6 13/37/6,4/428
- IV omeprazole 40mg/12j Hb/Ht/E/L/T mCV/MCH/MCHC : GDS : 206 Mcv/mch 87/31
- drip albumin 25% 100cc/hari 8,4/25/3,2/11,4/229 84/29/35 UR/CR 25/0,62 Hepatitis negatif
-KSR 2x600mg MCV/MCH/MCHC Diftel : 2/1/1/67/17/12 Na/K/Cl : 135/4,3/98 Alb 3,49
- IV citicoline 500mg/12j 77/26/34 Troponin/CK-MB <0,10/18 Ur/Cr 26/0,46
- IV mecobalamin 500mg/12j Diftell : 18/1/0/56/13/12 GDS : 369 21/06/19 Na/K/Cl: 129/2,9/102
Ur/Cr : 193/15,05 UR/CR 41/2,01 PT/Kontrol : 13,50/13,5
Lab 20-06-2019 Na/K/Cl : 144/4,3/111 Na/K/Cl : 138/4,6/103 Aptt/kontrol: 39,50/31,8
Hb/Ht/E/L/T Procalcitonin 0,49
8,3/23/2,6/15/317 Lab 17-06-2019
MCV/MCH/MCHC
88/32/36 pH/lekosit/protein/glukosa/k
Diftell : 1/0/0/84/7/8 eton/nitrit/bilirubin/darah:
Na/K/Cl/Ca : 155/2,4/121/7,7 6,5/positif/+1/+1/negatif/ne
gatif/negatif/negatif/positif
Lab 18/6/2019
PT/kontrol: 14,50/14,2 Lab 17-06-2019
APTT/kontrol : 25,70/30,8 Procalcitonin : 13,05
HbsAg negatif
Alb : 2.25 Lab 13-6-2019
GDS 182 Hb/Ht/E/L/Tr :
UR/CR 40/1,09 8,4/24/3,2/21,6 /257
MCV/MCH/MCHC:
74/27/36
Diftell: 6/1/0/79/8/6
HbsAg/AntiHCV:-/-
Ca: 7,7
GDS: 210
Ur/Cr: 396/29,36
Na/K/Cl: 138/4,7/101
 K5B1 K5B2 K5B3 K5B4 K5B5
DPJP : dr. Chacha, Sp.PD DPJP : dr. Islamuddin, DPJP :dr. T Mamfaluti DPJP : dr. Kurnia, sp.PD DPJP: dr.Islamuddin, Sp.
COW : dr. Febri Sp.PD SPPD COW : dr. Rahmi PD
DR : dr. Akmal COW : dr.Febri COW : dr. T. M. Reza DR : dr. wahyu COW : dr. Febri
DR : dr.Akmal DR : dr. Okdimur DR : dr. Akmal
Raber : GEH Raber: THT
Nama: Rahmat Hidayat Nama : Sulaiman Ibrahim Nama: M Hafiz Anwar Nama: Husaini Nurdin Nama: M. Nur Puteh
TTL : 17/01/2001 (18 thn) TTL : 12/04/1949 (70 thn) TTL : 4-3-1996 (23thn) TTL : 30/05/1963(56thn) TTL : 31/12/1930
Alamat : Aceh Tenggara Alamat : Bireuen Alamat : Aceh Jaya Alamat :Aceh Pidie Alamat : Pidie Jaya
CM : 1-20-90-74 CM : 1-16-61-63 CM : 1213105 CM : 1-21-05-52 CM : 0-91-55-77
Hari Rawatan : 23 Hari Rawatan :6 Hari rawatan : 5 Hari Rawatan : 6 Hari Rawatan : 8

A/ A/ A/ A/ A/
Chronic Hip Pain ec dd/ 1. Penurunan kesadaran ec 1. Febris ec dd/ 1. dd/ 1. SDA dgn pencetus infeksi
1. Sacroiliac Joint dd/ - Tonsilofaringitis akut - Trombositosis esensial 2. TB paru on terapi kategori
 Disruption -sepsis - Sinusitis - Trombositosis relatif I
2. Dislocation of the Hip -imbalance elektrolit - Hepatitis viral 2. Varises vena safena 3. Immobilisasi
3. Athritis septic -uremic ensefalopati - Tifoid fever magna sinistra et vena 4. Instabilitas dan jatuh
4. Athritis TB - - Kolesistitis tibialis anterior 5. HT stage I on therapy
5. Rheumatoid athritis 2. Sepsis ec dd/ 2. Nyeri kuadran kanan atas 3. Hematuria ec dd/ 6. Xerosis cutis + LSK
6. Ankilosis spondilitis -hcap ec dd/ - Isk
7. Osteosarcoma -Isk - Colesistitis - Bsk Th/
2.Anemia sedang ec dd 3. CKD stage V ec HN on - Colelitiasis - Ca Buli - Bed rest
1. Penyakit kronik HD Reguler - Diet sonde 1500cc/hr
2. Perdarahan 4. PSMBA ec dd/ Th/ Th/ - O2 2-4 lpm
3.Ulkus decubitus grade 2 ar -gastritis erosif - Bedrest - Bedrest - IVFD NaCl 0,9% 20tpm
malleolus lat pedis s -ulcua duodenum - Diet MII 1700 kkal/hr - IVFD NaCl 0,9% 20tpm - IV Cefuroxim 1g/12j (H7)
-ulcus gaster - IVFD tutofusin 20tpm - Diet MB 1700 kkal/hr - IV Lansoprazole
Th/ 5. Trombositopenia ec - Iv ceftriaxone 2gr/24j - omeprazole 2x20mg 30mg/24jam
- Bed rest induced repair - Drip paracetamol 1gr/24j - domperidone 3x10mg - Erdostein 3x1tab
- Diet MB 1700 kkal / hari - Iv omeprazole 40mg/12j - aspilet 1x80mg - Aspilet 1x80mg
- Threeway Th/ - Iv ondancetron 4mg/8j - Nystatin 2xgtt II
- IV Meropenem 1g/8jam - Curcuma 3x1 ] - Valsartan 1x160mg
(H-11) - Bedrest - IV Buscopan 1amp/12jam Lab 23-6-2019 - Pro TB 4 FDC 1x3 (h7)
- IV Ranitidin 1amp/12j - Diet ginjal 6x200 Hb/Ht/L/T - Curcuma Syr 2x1
- IV Heparin 5000mg/8jam - Threeway Lab 21-6-19 15,2/48/6,3/34,8/1704 - piridoksin 2x1
- Drip Paracetamol 1g/8j - Iv meropenem 1gr/24j (H6) Urinalisa MCV/MCH/MCHC : 77/24/31
- Drip Tramadol 1amp/8j - Lenal ace 2x169 Leukosit: negative
- Lactulac syr 3 x C I - Asam folat 2x400mg Protein: (+1) Lab 20-6-2019 Lab 15-6-2019
- Duragesic patch 25 mcg / - Iv citicolin 500mg/12j Glukosa: (+3) Hb/Ht/L/T Hb/Ht/E/L/T
3 hari - Iv mecobalamin 500mg/12j Keton: (+) 14/43/29200/1.220.000 12,2/36/4,7/9,2/271
- Burnazine cream + Rawat - Lansoprazole 30mg/12j MCV/MCH/MCHC : 80/25/31 MCV/MCH : 77/26
luka decubitus - HD free heparin Lab 21-6-19 Diftell : 4/0/0/72/16/8
- Transfusi PRC Hb>10g/dl Malaria: (-) URINALISA Bili direk : 0,36
- Duragesic patch 25 Lab 23-6-2019 Infeksi lain: (-) Leukosit/darah: +/+ SGOT/SGPT: 19/5
mg/3hari Hb/Ht/E/L/T Eritrosit: 250-270 K/Cl: 4,4/110
10,2/28/3,6/9,6/83 Lab 20-06-2019
Lab 19-6-2019 MCV/MCH: 79/28 Hb/Ht/E/L/T Lab 21-6-2019 Lab 14-6-2019
Hb/Ht/E/L/T RDW 15,3 11,1/33/6,2/7,4/249 PT/APTT: 16,70/50,80 Procalsitonin: 0,08
7,7/23/2,6/16,1/523 Diftel: 1/0/0/79/14/6 MCV/MCH/MCHC Bili tot/direk/indirek :
MCV/MCH : 88/30 54/18/33 1,17/0,51/0,66
Diftell : 0/5/0/76/13/6 Lab 21-6-2019 Diftell : 2/1/0/61/22/14 SGOT/SGPT : 17/10
ALP: 144 PT/kontrol/INR : HbsAg: -
LDH: 247 17,4/13,5/1,37 Bil total: 1,86 Lab 12-6-2019
APTT/kontrol : 40,1/31,8 Bil direct: 0,93 Hb/Ht/E/L/T
Urinalisa: Bil indirect: 0,93 12,3/36/4,7/9/268
normal Lab 19-6-2019 SGOT/SGPT: 49/54 MCV/MCH : 78/26
Hb/Ht/E/L/T GDS: 128 Diftell : 2/1/0/72/16/9
Lab 14-6-2019 8,7/27/3,2/14,9/253 Alb : 3,37
Hb/Ht/E/L/T MCV/MCH: 84/27 Ur/Cr: 61/0,89
8,5/27/3/21,4/480 Diftel: 7/1/0/76/12/4 Na/K/Cl: 145/4,1/113
MCV/MCH : 89/28 GDS : 118
Diftell : 2/0/0/84/7/7 Ur/Cr : 12/0,84
PT/APTT : 0,88/1,15 Na/K/Cl : 146/3,6/110
D-dimer : 2170,59 Procalcitonin : 121,99

Lab 10-6-2019
Hb/Ht/E/L/T
9,3/29/3,3/41,8/646
MCV/MCH : 87/28
Diftell : 0/0/0/86/6/8
PT/APTT : 13,3/29,8
D-dimer : 1644,11
HbsAg : (-)
Bil. Direk/indirek : 0,22/0,17
SGOT/SGPT : 25/89
Ca/Mg : 9,4/2
GDS : 91
Ur/Cr: 42/0,58
Na/K/Cl: 136/4,6/100

K6B1 K6B2 K6B3 K6B4 K6B5

DPJP: dr. M.Fuad,Sp.PD DPJP: DPJP: dr. Azhari Gani SPPD DPJP : dr. Chacha,Sp.PD DPJP : dr. Hendra Z,
COW: dr. COW: COW: dr. Rahmi COW : dr. Febri Sp.PD
Dr: dr. Dr: Dr: dr. Wahyu DR : dr. Akmal COW : dr. TM. Reza
Raber : BTKV Raber : Raber : Tandi
DR : dr. Okdimur
Raber : HOM
Nama: Fadli Jailani Nama: M. Yati Nama: Hasballah Amin Nama: Ibrahim Syamsyuddin
TTL: 31/10/1984 (34 Thn) TTL: 01-07-1951 TTL : 19/07/1938 (80 Thn) TTL: 13-08-1976 (42thn)
Alamat: Bireun Alamat: Aceh Selatan Alamat : Bireun Alamat: Aceh Utara
CM: 1-21-20-88 CM: 1-21-22-28 CM :1-21-22-44 CM : 1-21-10-22
Hari Rawatan: 4 Hari Rawatan: 3 Hari Rawatan : 2 Hari Rawatan: 14

A/ A/ A/
A/ 1. Hematoskezia ec dd 1. Pneumonia dd/ 1. Anemia aplastik
1. Sepsis ec dd: - Colitis Infeksi - Bronkitis
 - Hepatitis fulminan - Colitis ulseratif - Infeksi goiter Th/
- Thypoid fever - Colon Disease 2. PPOK - Bedrest
- Pneumonia - Ca recti 3. CHF FC NYHA I-II ec - IVFD NaCl 0,9% 20 tpm
2. Anemia berat 2. Dispepsia tipe mixed dd dd/ - O2 2-4 lpm(nasal kanul)
hipokrom mikrositer ec tipe dysmotility - HD - Methylprednisolon TAB
dd/ - HHD 3X16 mg
- Perdarahan akut Th/ 4. DM Type 2 NW - Sandimon 2x50mg
- Penyakit kronis - Bed Rest 5. Geriatri problem (inanisi, - Transfusi PRC Hb>10g/dl
3. AKI stage II pre renal - Diet MB 1700kkal/hr infeksi, imobilitas) Premed dexamethasone
dd akut on CKD - IVFD NACL 0.9 30gtt
4. Hiponatremia - IV metronidazole 500g/8j Th/ Lab PK BMP 19/6/2019
hiposmolar - IV omeprazole 40mg/12j - Bedrest semifowler Gambaran BM Hipoplastik
Hipovolemik - IV asam traneksmat 150mg/8j - Diet MII 1.700 kkal/hari
5. Hipokalemia ringan - Attapulgit 1/mencret - Threeway Lab 23-06-2019
6. Acute compartemen -Nystatin drop/6jam - IV. Ceftriaxone 2gr/24 jam Hb/Ht/E/L/T:
syndrome dd/ - IV. Omeprazole 6,4/19/2,3/1,7/18
- Celulitis 40mg/24jam MCV/MCH: 84/28
- DVT - Ventoline 1 resp/8jam Diftell: 0/1/0/46/35/18
- Rhabdomyolysis - Flexotide 1 Resp/12 jam
- Pheriperal Vaskular - Clopidogrel 75mg 1x1 tab Lab 13-06-2019
Injurie - Furosemide 40mg 1x1 Hb/Ht/E/L/T:
Th/ - Fluimucyl 3x100mg 4,5/14/1,5/2,7/17
- Bedrest MCV/MCH: 92/31
- IVFD Nacl 0,9%  20 Lab 22-06-2019 Diftell: 1/0/0/29/41/29
gtt/mnt Hb/Ht/E/L/T
- Diet lunak 1.700 kkal/hari 8,6/26/3,0/8,5/296 Lab 12-06-2019
- IV. Meropenem 500mg/8 MCV/MCH/MCHC Hb/Ht/E/L/T:
jam 88/29/33 5,3/16/1,8/2,3/14
- IV Omeprazole 40 mg/12 Diftell : 32/1/0/41/18/8 MCV/MCH: 87/29
jam GDS : 131 Diftell: 4/0/0/30/43/23
- Sucralfat syr 3xCI Ur/Cr : 51/2,22 HbsAg: negatif
- Bicnat tab 3x1 Na/K/Cl: 133/3,5/106 Anti HCV: negatif
- Paracetamol 500mg 3x1
- Kalitake sachcet 3x1
- Transfusi PRC s/d HB >
10 mg/dl

Lab (21/06/19)
Hb/Ht/E/L/T:
3,2/9/1,2/30,4/113
MCV/MCH: 71/26/37
Diftell: 0/0/0/85/8/7
MDT Hipokrom mikrositer
Lekositosis
trombositopenia
Lab (21/06/19)
Hb/Ht/E/L/T:
3,4/9/1,3/31,2/129
MCV/MCH: 71/26/37
Diftell: 0/0/0/85/8/7
Albumin : 2,83
Na/K/Cl : 128/5,8/105
CT/BT : 9/3
Lab 20/6/19
SGOT/SGPT: 1754/774
Ur/Cr: 81/2,53