AQSHA 2 (PENYAKIT DALAM PRIA)

Hari / Tanggal : Jumat / 21 Juni 2019

Dokter Jaga : dr. Mirzal/ dr. Taufik
Dokter Muda : Elena/Syiffa

K1B1 K1B2 K1B3 K1B4

DPJP : Kurnia FJ,Sp.PD DPJP : dr. Chacha, Sp.PD DPJP : dr. Chacha, SpPD DPJP : dr. Chacha, 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 Raber : PTI Raber : GH Raber : GEH
DM :
Nama: M. Ikhsan Nama: Maula Ghozhie Nama: Ady Darman Nama: M. Ali
TTL: 01/01/1999 (20thn) TTL : 21/04/1960 (59 Thn) TTL : 16/09/1964 (54 Thn) TTL: 31/12/1968 (50 thn)
Alamat: Aceh Pidie Alamat : Banda Aceh Alamat : Kota Sabang Alamat: Aceh Timur
CM: 1-21-16-66 CM :0-75-74-96 CM :1-18-94-30 CM: 1-21-11-22
Hari Rawatan: 4 Hari Rawatan : 3 Hari Rawatan : 2 Hari Rawatan: 10

A/ A/ A/ A/
1. Anemia berat hipokrom 1.Penurunan kesadaran (perbaikan) 1. CKD stage V ar CAPD dengan 1. HE gr I dengan pencetus infeksi
mikrositer ec dd/ ec uremic syndrom 2. Sirosis hepatis dengan hepatoma
- Thalasemia - Sepsis 2. Hiperkalemia Berat related hepatitis B Childpugh C
- Def. Fe -imbalance elektrolit 3. Anemia berat ec PGK 3. Varises esofagus grade 3
- Penyakit kronik -Uremic ensefalopati 4. CHF fc NYHAA II-III ec dd – 4. Gastropati Hipertensi Porta
2. Obs. Febris ec dd/ 2. Sepsis ec dd. –Pneumonia (HCAS HHD ,IHD 5. Anemia sedang ec dd
- Leukemia -ISK - Perdarahan
- Pnemunia 3. HCAP od infeksi spesifik Th/ - Peny. Kronis
- ISK 4. CKD stage V ec on HD regular - Bedrest - malignancy
- Diet ginjal 170kkal danrotein 78gr 6. SBP
Th/ Th/ - Threeway
- Bedrest - IV Levofloxacin 500mg/48 jam - Transfusi PRC 1 kolf (preload Th/
- Diet MII 1.700 kkal/hari - Amlodipin 1x10 mg furoemid 1 amp) sebelum HD - Bedrest
- IVFD Nacl 0.9% 20 tetes/menit - Omeprazole 40 mg/24 jam - Har nal Ocas 1x 0,2mg - Threeway
- IV Ceftriaxone 2 gr/24 jam (H3) - Lenal Ace 2x169mg - IV Furosemid 40mg/8j - Diet hati I 1700 kkal/hr + LOLA
- Paracetamol 3x500mg - Asam folat 2x400mg - IV Omeprazole 40mg /12j - IVFD Comafusin Hepar 1
- Domperidon 3x10mg - Ventolin 1 resp/8jam - Lenal Ace 169mg 2x1 fls/hari
- Erdostein 2x300mg - Azitromicin 1x500mg - As. Folat 400mg 2x1 - IV Cefoperazone sulbactam 1
- Transfusi PRC s/d HB > 10 gr/dl - Amlodipin 10mg 1x1 gram / 8 jam (H-5)
Lab 19-6-2019 - IV Cablukonas 1amp extra - IV Lansoprazole 30mg/12j
Lab 18-6-2019 Procalsitonin: 7,72 - IV Dextrose 40% 2 fls extra - IV Asam Tranexamat 500 mg/8j
Hb/Ht/E/L/T - SC novorapid 10 unit extra - IV Vit K 1 amp/12 jam
7,3/23/3/23,6/703 Lab 18-6-2019 - Ventolin 1 resp extra - Spironolakton 100mg/24 j
MCV/MCH/MCHC Hb/Ht/E/L/T - Kalitake 3x1 - Lactulac Syr 3 x C II
77/24/32 9,5/33/3,5/25,2/176 - Harnal ocas 1x0,2mg - Propanolol 2x10mg
Diftell : 2/1/1/67/18/11 MCV/MCH/MCHC - Fossen Enema K/P
Feritin: 200,14 94/27/29 Lab 20/6/19
besi: 217 Diftell : 0/0/0/89/2/9 HB/HT/E/L/T : 5,5/16/2/11,0/163 Lab 19-6-2019
MDT: Hipokrom mikrositer Na/K/Cl: 144/3,7/106 MCV/MCH/MCHC/RDW : Hb/Ht/E/L/T: 10,3/31/3,6/7,3/166
Kalsium :8,1 83/28/34/15,9 MCV/MCH: 86/29
Urinalisa GDS : 91 Ca: 7,8 Diftel: 1/1/0/76/14/8
Leukosit:+ Ur/Cr : 48/5,27 Na/K/Cl : 143/6,4/112 Alb/CA : 2,72/12,3
Nitrit: + Analisa Gas Darah Na/K/Cl: 133/4,9/105
Bilirubin/darah: +/+ pH : 7,135 Lab 19/6/19
pCO2 : 91,40 Albumin: 3,05 Lab 16-06-2019
Lab 17-6-2019 pO2 : 87 Ca: 7,3 Hb/Ht/E/L/T: 8,6/26/3,1/7,3/152
Hb/Ht/E/L/T Bikarbonat (HCO3) : 31,1 Na/K/Cl: 140/7,1/111 MCV/MCH: 82/28
6,8/22/2,9/25,2/756 Total CO2 : 33,9 Diftel: 1/1/0/76/13/9
MCV/MCH/MCHC BE : 0,4 Lab 18/6/19
75/23/31 Saturasi O2 : 91,2 HB/HT/E/L/T : 5,3/15/1,9/9,1/141 Lab 13-06-2019
Diftell : 1/1/1/67/23/7 MCV/MCH/MCHC/RDW : AFP: >400
Na/K/Cl: 141/4,7/108 83/29/34/16,3 Urinalisis:
SGOT/SGPT : 69/35 GDS 107 Keton +
Ur/Cr : 15/0,55 UR/CR : 315/32,2 Urobilinogen +
Na/K/Cl : 142/8,2/111 Epitel 3-5 lpk

Lab 12-6-2019
Hb/Ht/E/L/T: 6/18/2,2/9,3/169
MCV/MCH: 83/28
Diftel: 0/0/1/83/10/6
PT/APTT : 17,2/42,5
Anti HCV/HbsAg : (-/++)
Alb/Glob : 2,77/3.54
SGOT/SGPT: 201/53
GDS : 144
Ur/Cr: 45/0,7
Na/K/Cl: 134/3,8/107
 K2B1 K2B2 K2B3 K2B4 K2B5
DPJP : dr. T. Mamfaluti, DPJP : dr. Azhari Gani DPJP : dr. Fauzi Yusuf, DPJP: dr.Islamuddin, Sp. DPJP : dr. islamuddin,
Sp. PD Sp.PD-KKV Sp.PD PD Sp.PD
COW : dr. TM Reza Tandi COW : dr. Rahmi COW : dr. Rahmi COW : dr. Febri COW :
DR : dr. Okdimur DR : dr. Wahyu DR : dr. Wahyu DR : dr. Akmal DR :
Raber : GEH Raber: HOM, GEH Raber : Raber:
Nama : Darmi Arifin Nama :Abdul Karim Nama :Sujono Rachman Nama: Sarmin D. Nama: Rachman Ramadhan
TTL : 19-11-1962 (56 thn) TTL : 06-10-1979 (39 thn) TTL : 06-10-1974 (44 thn) TTL: 13-7-1961 (57 thn) TTL: 27-11-2000 (18 thn)
Alamat : Aceh jaya Alamat : Aceh Tamiang Alamat : Aceh Barat Alamat: Simeulue Alamat: Sabang
CM : 1-21-12-59 CM : 1-18-46-10 CM : 1-21-19-47 CM: 1-19-97-29 CM: 1-10-57-03
Hari Rawatan : 8 Hari Rawatan : 15 Hari Rawatan : 2 Hari Rawatan: 12 Hari Rawatan: 2

A/ A/ A/ A/ A/
1. Pansitopenia ec dd/ 1. Penurunan kesadaran 1. Anemia Berat Hipokrom 1. Hodgkin Lymphoma ar 1. Efusi pleura dextra ec
- Anemia aplastik (perbaikan) ec dd/ Mikrositer ec dd/ colli dextra Karnofsky dd/
- Myelofibrosis - Imbalance elektrolit - Def FE 70% -tb paru
- MDS - Metastase proses - Penyakit Kronik 2. Hipertensi stage I -pleuro pneumonia
- - Sepsis 2. Riwayat PSMBA 3. Sepsis ec HAP 2. dyspepsia
Th/ 2. Renal Cell Carcinoma 4. Abses a/r colli
- Bed rest Post Kemoterapi Siklus I Th/
- Diet MII 1900 kkal / hari 3. Neutropenia induced -Bedrest Th/ Th/
- IVFD NaCl 0,9% 20 tpm kemoterapi -IVFD NACL 0,9% 20gtt/i - Bed rest - Threeway
- Transfusi TC jika T < 4. Hipokalemia Sedang ec -Domperidone 3x1 tab - Diet MII 1700 kkal / hari - Diet mb 1700kkal/hr
10.000 atau < 20.000 GI Loss - Transfusi PRc /d HB > - IVFD Clinimix1 fls / 48 j - IVFD NaCl 0,9%
dengan perdarahan 5. Cancer pain 10gr/dl - IV Meropenem 1 gr/ 8 20gtt
- IV Ceftriaxone 2gr/24 jam 6. High Risk Thrombosis - omeprazole 40mg/12j jam (H-2) - Omeprazole 40mg/24j
(H-5) 7. Stomatitis grade B - lagesil 3xCI - IV Omeprazole 40 mg/12 - Curcuma 3xc1
- IV Omeprazole 40 mg/12 j 8. Sindrom lisis tumo - alpazolam 1x 0,25mg jam
- Buscopan 3x10mg 9. Anemia sedang hipokrom - Erdostein 3x1
- Paracetamol 3 x 500 mg mikrositer ec dd : Lab 20 -6-2019 - Pradaxa 1x75mg
- Sucralfat syr 3 x C I - Def. Fe Hb/Ht/E/L/T: - Amlodipin 1x5mg
- Sc Leucogen vial (ANC < - Malignancy 5,2/17/3/4,4/260 - Paracetamol 3 x 500 mg
1500) 10. Trombositeopenia ec dd : MCV/MCH/MCHC: - Nystatin drop gtt 2/6 jam
- Induced kemoterapi 58/18/30 - Paracetamol 300mg dan
Lab 20 -6-2019 - Inflamasi sumsum Diftell: 6/0/0/47/31/10 Tramadol 25mg dalam
Hb/Ht/E/L/T: tulang pulvis 2x1
8,3/23/2,4/1,6/42 - SLE Lab 18/6/2019
MCV/MCH/MCHC: HB/HT/Trombosit:3,24/17,4/ Lab 19-6-2019
93/34/37 Th/ 273 Belum ada hassil
Diftell: 1/1/0/49/48/1 - Bedrest K/NA/CL : 4,29/140/103
- NGT Ur/Cr : 16/1,39 Lab 18-6-2019
Lab 17-06-2019 - Diet sonde 6x200cc/hari SGOT/SGPT : 20/15 Procalcitonin : 0,32
Retikulosit : 1,0 - IVFD NaCl 0,9% 20 tpm
- Drip Levofloxacin 500 mg Lab 14-6-2019
Lab 17-6-2019 /24 jam Hb/Ht/E/L/T:
Hb/Ht/E/L/T: - IV Fluconazole 200 mg / 12,2/36/4,3/17,6/346
7,5/21/2,2/1,2/49 24 jam MCV/MCH: 83/28
MCV/MCH/MCHC: - IV Bonefos / 24 jam Diftell: 1/1/0/78/8/12
97/35/36 - SC Leucogen 1 vial (K/P)
Diftell: 3/1/0/34/61/1 - Ondansetron 3 x 4 mg Lab 10-6-2019
Retikulosit : 1,0 - MST 2 x 15mg Urinalisis:
- KSR 2 x 600 mg Keton +
Lab 16-6-2019 - Minosep 3x1 Epitel : 2-3
Hb/Ht/E/L/T: - Curcuma 3x1
6,4/18/1,9/1,4/57 - Attapulgite 1 tab tiap diare Lab 9-6-2019
MCV/MCH/MCHC: max 10 tab sehari Hb/Ht/E/L/T
94/34/36 - Sucralfat Syr 3 x C I 11,8/35/4,2/16,8/443
Diftell: 1/1/0/42/54/2 - Lactulac syr 3 x C I MCV/MCH/MCHC
- Sinbio 3x1 sach 83/28/34
Lab 15-6-2019 - Lorazepam 2mg 1x1 Diftell : 1/1/0/77/9/12
Hb/Ht/E/L/T: 6,9/19/2/1,8/28 - Haloperidol 1,5mg 2x1 Bilirubin Total : 0,46
MCV/MCH/MCHC: - Fosen Enema extra Bilirubin Direct : 0,25
94/34/37 - KCL extra SGOT/SGPT : 58/25
Diftell: 1/2/0/41/54/2 Albumin : 2,88
Lab 19-06-2019 GDS : 164
Lab 14-6-2019 HB/HT/E/L/T Ur/Cr: 17/0,55
Urinalisis: 8.8/26/3,5/17.8/25 Na/K/Cl: 134/3,8/99
Keton + MCV/MCH/MCHC:
Urobilinogen + 73/25/35
Darah + Diftell : 0/1/0/88/7/4
Eritrosit :4-5 Na/K/Cl : 142/3,8/118
Epitel : 4-6
Lab 15-06-2019
Hb/Ht/E/L/T:
7,4/21/3,0/12,9/22
MCV/MCH/MCHC:
70/24/35
Diftell: 0/0/0/86/9/5
INR : 1,30
APTT / Kontrol : 43,9/33,7
 K3B1 K3B2
DPJP: dr.Riswan, Sp. PD DPJP :dr. Hendra Zufry
COW : dr. fahril SPPD KEMD
DR : dr. taufik COW : dr. T. M. Reza
Raber : DR : dr. Okdimur
Raber: GH
Nama : Faisal Akbar Nama : Ismail Wahab
TTL : 27/01/1993 (26th) TTL : 05/01/1960 (59th)
Alamat : Aceh Besar Alamat : Aceh Timur
CM : 1-10-91-21 CM : 0-82-65-42
Hari Rawatan : 2 Hari Rawatan : 5
K3B3 K3B4 K3B5
DPJP :dr. Kurnia,Sp.PD DPJP : Kurnia FJ,Sp.PD DPJP : dr. Chacha, Sp.PD
COW : dr. COW : dr. Rahmi COW : dr. Febri
DR : dr. Wahyu DR : dr. Wahyu DR : dr. Akmal
Raber : Raber : Raber :
DM : DM :
Nama: M Syahril Nama: Reza Husen Mala Nama: Idris Puteh
TTL : 31-12-1981 (37thn) TTL : 6-10-1987 (31thn) TTL: 01-07-1937 (81 thn)
Alamat : Aceh Timur Alamat : Aceh Barat Daya Alamat: Aceh Pidie
CM : 1211132 CM : 117 CM: 1-21-10-87
Hari rawatan : 9 Hari rawatan : 5 Hari Rawatan: 10

A/ A/ A/ A/ A/
1. Limfoma Hodkin 1. Syok sepsis ec dd/ 1. Penurunan 1. Ileus paralitik ec susp 1. Penurunan kesadaran ec
Prokemoterapi siklus 5 - HAP kesadaran imbAlance elektrolit SDA ec dd/
2. Anemia berat Normokrom - Infeksi area insersi (perbaikan) ec dd/ 2. Diare kronis ec dd/ - Urosepsis
Normositer ec induced double lumen - Uremic ensefalopati - colitis ulseratif - Disequilibrium Synd
kemoterapi - Urosepsis - Imbalance elektrolit - colitis infeksi 2. SDA dengan pencetus
2. Ckd stage 5 - crohn disease infeksi (Urosepsis)
Th/ 2. HAP 3. DM tipe 2 NW 3. Pneumonia 3. Pneumonia (HAP) dd/
- Bedrest 3. CKD stg V on HD regular 4. Hipokalemia ringan Infeksi paru spesifik (TB
- Diet MB 1700kkal/hari dgn udem paru Th/ 5. Candidiasis oral Milier)
- IVFD Nal 0,9% 10tpm 4. CAD - Insulin novorapid drip 6. Hiponatremi hipoosmolar 4. Acute on CKD stage V
- Transfusi PRC s/d HB 5. Efusi pericardium 6 unit perjam hipovolemic ec dd/
>10g/dl - Iv Meropenem 1gr/8j 7. hipoalbuminemia - PGOI
Th/ - Lansoprazole drip 60 - PNC
Lab 19-06-2019 - Bedrest dalam 50 cc dengan Th/ - HN
HB/L/T - O2 NK 2-4 lpm kec 5cc/jam - Bed rest 5. Nefrolithiasis dextra
6,4/5,1/112 - Threeway - Kalitake 3x1 sach - O2 2-4 lpm (nasal kanul) 6. Hipertensi on therapy
MCV/MCH - CPG 1x75mg - Diet MII 1700 kkal / hari 7. PPOK stabil
86/29 - HD (Senin-Rabu-Jumat) - IVFD RL 20 tpm 8. Geriatric Problem
Diftel Lab 17-06-2019 - IVFD NaCl 0,9% 20 tpm (inanisi, infeksi)
1/1/0/48/25/25 Lab 19-06-2019 Hb/Ht/E/L/T - Drip Albuminar 25% 9. Hipokalsemia ringan
Ur/Cr AGD 12,8/37/4,6/46,7/300 100cc/24j 10. ISK
11/1,00 pH: 7,5 MCV/MCH/MCHC - IV Ceftriaxone 2 gr/24
pO2: 31 79/28/35 jam (H-2) Th/
pCO2: 25,8 Ca/Mg: 7,5/3,0 - IV Omeprazole 40 mg/24 - Bed rest
HCO3: 20,5 Ur/Cr : 61/2,52 jam - O2 2-4 lpm (NK)
Total CO2: 21,3 Na/K/Cl : 140/3,7/103 - Salofalk 2x500mg - Diet Ginjal 6 x 200 cc / hr
SaO2: 67,2 - Attapulgit 1 tab tiap BAB - IVFD NaCl 0,9% 20 tpm
Albumin: 3 Urinalisa cair (mikro)
Troponin I: 0,78 Leukosit:+ - Nystatin drop 4 x 2 cc - IV Meropenem 1 gr/8 jam
CKMB: 16 Keton:+ - KSR 2 x 600 mg (H-9)
Urobilinogen:+ - KCL 25 meq + D5% 40 - IV Lansoprazole 30 mg /
Lab 16-06-2019 Darah:+ tetes mikro 24 jam
Hb/HT/E/L/T : 12,0/37/4 Leukosit: 20-30 - Amlodipine 1x5 mg
Lab 19-06-2019 - Asam folat 2x400 mcg
pH/pO2 : 7,467 / 218 Hb/Ht/E/L/T - Lenal ace 2x169 mg
pCO2 / HCO3 : 28,90 / 21,2 10,9/34/5,5/7,1/291 - IV Ca Glukonas 1 amp/8j
BE : -1,1 MCV/MCH/MCHC - Bicnat 3x500 mg
Total CO2 : 21,9 62/20/32 - Haloperidol 1 x 0,5 mg
SaO2 : 99,1 Diftell : 8/1/0/66/17/8 (sore)
Ur/Cr : 31/0,34 - Drip Fluconazole
Lab 13-6-2019 Na/K/Cl : 128/2,6/95 500mg/24j
Urinalisis - Nystatin drops 4x2cc
Epitel2-3 lpk - HD (Selasa Kamis Sabtu)
Lab 17-06-2019 - Balance cairan
Lab 16-6-2019 Na/K/Cl : 130/3,0/97
Hb/Ht/E/L/T Lab 20-6-2019
12.0/37/4.2/5.7/209 Lab 16-06-2019 Hb/Ht/E/L/T
MCV/MCH/MCHC Na/K/Cl : 124/2,3/94 10,9/33/4,0/10,7/215
86/28/33 MCV/MCH/MCHC
Difftel : 1/2/0/56/29/12 Lab 15-6-2019 82/28/34
SGOT/SGPT: 24/7 Hb/Ht/E/L/T Diftell : 22/1/0/40/24/13
Albumin: 3.21 11/34/5,6/6,2/334 PT/APTT: 19,70/35,70
GDS: 132 MCV/MCH/MCHC Albumin : 2,27
Ur/Cr: 53/2.63 61/20/33 Ca: 10,1
Na/K/Cl: 140/4.3/110 Difftel: 0/1/0/74/15/10 Ur/Cr : 35/3,49
Anti HCV: (-) Alb : 1,13 Na/K/Cl : 139/3,1/104
HBsAg: (-) Ur/Cr: 27/0,45
Na/K/Cl: 121/2,3/90 Lab Mikrobiologi Klinik
Jumlah koloni : > 105
CFU/ml
Hasil : Terisolasi Jamur
Candida Lusitaniae

Lab 13-6-2019
Prokalsitonin: 2,58
Albumin: 2,61
 K4B1
DPJP : dr. Hendra Z, Sp.PD
COW : dr. TM. Reza Tandi
DR : dr. okdimur
Nama: Harun Husen
TTL : 1-21-18-10
Alamat: Aceh Pidie
CM : 1-21-18-1
Hari rawatan : 7
K4B2 K4B3
DPJP: dr.Islamuddin, Sp. DPJP : dr. T. Mamfaluti,
PD Sp. PD
COW : dr. Febri COW : dr. Reza
DR : dr. Akmal DR : dr. Okdimur
Raber : Kardio
Nama: Matsah Majid Nama: Bachtiar Hasan
TTL : 1-7-1957 (61 thn) TTL : 10-10-1953 (65 thn)
Alamat: Aceh Selatan Alamat: Aceh Pidie
CM : 1-21-12-63 CM : 0-91-65-08
Hari rawatan : 7 Hari rawatan : 3
K4B4 K4B5
DPJP : dr. Azhari Gani, DPJP : dr. Azhari Gani,
sp.PD sp.PD
COW : dr.Rahmi COW : dr.Rahmi
DR : dr. Wahyu DR : dr. Wahyu
Nama: Dedi saputra Nama: Muhammad Idris
TTL :20/10/1978(40thn) TTL : 01/07/1945(73thn)
Alamat : banda aceh Alamat : Aceh Pidie
CM : 1-21-20-72 CM : 1-21-14-36
Hari Rawatan : 2 Hari Rawatan : 7

A/ A/ A/ A/ A/
1. Penurunan keadaran ecdd 1. CKD stage V ec dd/ 1. Dyspepsia type like ulcer 1. Sepsis ec abses ar 1. Gangren diabetik a/r
- imbalance elektrolit - HN 2. AVR NVR pedis dextra pedis sin
- sepsis - PNC 3. CAD post PCI 2. Ulcus diabetic ar 2. DM Tipe 2 Underweight
- stroke - PGOI 4. HHD pedis dextra 3. PAD fontaine III a/r
2. Sepsis ec dd Urosepsis dengan uremik sindrom 5. DM type 2 overweight 3. Selulitis ar pedis pedis dextra
3. PSMBB ec dd (perbaikan) dextra 4. Hipoalbuminemia
- Hemoroid Interna 2. ISK Th/ 4. Dm tipe 2 NW
- Polip Rekti 3. Anemia ec PGK - Bedrest Th/
-CA rekti 4. HT Stg II - Diet jantung lunak - Bed rest
-CA colon 5. Sepsis ec dd 1. CAP 2. 1700kkal Th/ - O2 2-4 lpm (K/P)
4. hipokalemia sedang ISK -IVFD Nacl 0,9% 10gtti - Bedrest - NGT, kateter
5. Hipoalbuminia - IV lansoprazol 30mg/12j - Diet DM 1700kkal/hr - Diet DM 1700 kkal/hari +
6. hipernatremia -Sukralfat syr 3xCI - IVFD NaCl 0.9% extra putih telur
Th/ - Clopidogrel 1x75mg 20tpm - IVFD NaCl 0,9% 20 tpm
Th/ - Bedrest - Amlodipin 1x10mg - Iv omeprazole - IV Meropenem 1gr/8jam
- Bedrest - Diet Ginjal 1700 kkal/hr - Concord 1x 2,5mg 40mg/24j (H-5)
- o2 2-4 liter + protein 0,6 gr/kgBB/hr -Atorvastatin 1x20mg - Clindamicin - IV Metronidazole
- NGT, kateter - Threeway -ISDN 5mg (SL) k/p 3x300mg 500mg/8j (H-5)
- Diet sonde 6300 cc/hari - IV Cefuroxim 1gr/12jam - Naletal 1x100mg - Domperidone - IV Omeprazole 40 mg/12
- IV meropenem 1gr/12 j (H5) - nitrokaf R 2x2,5mg 3x10mg jam
- IV omeprazole 40mg/12j - Amlodipin 1x10 mg - Paracetamol - SC Lantus 0-0-0-8 unit
- drip albumin 25% 100cc/hari - Valsartan 1x80 mg Lab 18/06/2019 3x500mg - Clopidogrel 1 x 75 mg
-KSR 2x600mg - Lenal ace 2x169 mg HB/HT/E/L/T :
- Asam folat 2x400 mcg 12,8/37/4,4/6,6/172 Lab 20/06/2019 Lab 18-6-2019
Lab 18/6/2019 - IV. Meropenem 1gr/8jam mCV/MCH/MCHC : HB/HT/E/L/T : Hb/HT/E/L/T:
PT/APTT : 14,50/25,70 - Transfusi PRC on HD 84/29/35 12,4/36/4,2/20,6/400 10.831/3.7/12.2/269
Alb : 2.25 - Hemodialisa (Senin- Diftel : 2/1/1/67/17/12 MCV/MCH/MCHC : 86/30/35 MCV/MCH/MCHC
GDS 182 Rabu-Jumat) Troponin/CK-MB <0,10/18 Diftel : 0/1/0/88/5/6 84/29/35
UR/CR 40/1,09 GDS : 369 GDS : 206 Diftel
Lab 18-06-2019 UR/CR 41/2,01 UR/CR 25/0,62 2/0/0/81/11/6
Hb/Ht/E/L/T Na/K/Cl : 138/4,6/103 Na/K/Cl : 135/4,3/98 Anti HCV/HbsAg :
8,4/25/3,2/11,4/229 positif/negatif
MCV/MCH/MCHC GDS/Hb-A1c : 238/11,00
77/26/34
Diftell : 18/1/0/56/13/12 Lab 14-6-2019
Ur/Cr : 193/15,05 Hb/Ht/E/L/Tr :
Na/K/Cl : 144/4,3/111 12,8/38/4,6/15,5/388
MCV/MCH/MCHC:
Lab 17-06-2019 83/28/33
Diftell: 1/0/0/87/8/4
pH/lekosit/protein/glukosa/k PTT/APTT: 1,16/1,33
eton/nitrit/bilirubin/darah: Alb: 2,73
6,5/positif/+1/+1/negatif/ne GDS: 200
gatif/negatif/negatif/positif Ur/Cr: 50/0,68
Na/K/Cl: 137/4,8/110
Lab 17-06-2019
Procalcitonin : 13,05

Lab 13-6-2019
Hb/Ht/E/L/Tr :
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, DPJP : dr. islamuddin, DPJP :dr. T Mamfaluti DPJP : dr. Kurnia, sp.PD DPJP: dr.Islamuddin, Sp.
Sp.PD Sp.PD SPPD COW : dr. Rahmi PD
COW : dr. Febri COW : dr. Febri COW : dr. T. M. Reza DR : dr. wahyu COW : dr. Febri
DR : dr. Akmal DR : dr. Akmal DR : dr. Okdimur DR : dr. Akmal
DM : Raber:
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 : 21 Hari Rawatan : 3 Hari rawatan : 2 Hari Rawatan : 3 Hari Rawatan : 6

A/ A/ A/ A/ A/
Chronic Hip Pain ec dd/ 1. Penurunan kesadaran ec 1. Febris ec dd/ 1. dd/ 1. SDA dgn pencetus
1. Sacroiliac Joint dd/ - Tonsilofaringitis akut - Trombositosis esensial infeksi
Disruption -sepsis - Sinsitis - Trombositosis relatif 2. Pneumonia geriatric dd/
2. Dislocation of the Hip -imbalance elektrolit - Hepatitis A 2. Varises vena safena TB Paru
3. Athritis septic -uremic ensefalopati - Tifoid fever magna dextra et vena 3. Immobilisasi
4. Athritis TB 2. Sepsis ec dd/ 2. Nyeri kuadran kanan atas tibialis posterior dextra 4. Instabilitas dan jatuh
5. Rheumatoid athritis -hcap ec dd/ sinistra 5. HT stage I on therapy
6. Ankilosis spondilitis -Isk - Colesistitis 3. Hematuria ec dd/ 6. TB paru on terapi (kat.1)
7. Osteosarcoma 3. CKD stage V - Colelitiasis - Isk 7. dermatitis
Leukositosis + 4. PSMBA ec dd/ - Bsk
Trombositosis esensial -gastritis erosif - Malignancy Th/
Ulkus decubitus grade 2 -ulcua duodenum Th/ - Bed rest
-ulcus gaster - Bedrest Th/ - Diet sonde 1500cc/hr
Th/ - Diet MII 1700 kkal/hr - Bedrest - O2 2-4 lpm
- Bed rest Th/ - IVFD tutofusin 20tpm - Diet MB 1700 kkal/hr - IVFD NaCl 0,9% 20 tpm
- Diet MB 1700 kkal / hari - Iv ceftriaxone 2gr/24j - omeprazole 2x20mg - IV Cefuroxim 1g/12j (H7)
- Threeway - Bedrest - Drip paracetamol 1gr/24j - domperidone 3x10mg - IV Lansoprazole
- IV Meropenem 1g/8jam - Diet ginjal 6x200 - Iv omeprazole 40mg/12j - aspilet 1x80mg 30mg/24jam
(H-9) - Threeway - Iv ondancetron 4mg/8j - Erdostein 3x1tab
- IV Ranitidin 1amp/12j - Iv meropenem 1gr/24j - Curcuma 3x1 - Aspilet 1x80mg
- IV Heparin 5000mg/8jam - Lenal ace 2x169 - Nystatin 2 x gtt II
- Drip Paracetamol 1g/8j - Asam folat 2x400mg Lab 20-6-2019 - Valsartan 1x160mg
- Drip Tramadol 1amp/8j - Iv citicolin 500mg/12j Lab 20-06-2019 Hb/Ht/L/T - Pro TB 4 FDC 1x3 (h4)
- Lactulac syr 3 x C I - Iv mecobalamin 500mg/12j Hb/Ht/E/L/T 14/43/29200/1.220.000 - Curcuma Syr 2x1
- Duragesic patch 25 mcg / - Lansoprazole 30mg/12j 11,1/33/6,2/7,4/249 MCV/MCH/MCHC : 80/25/31 - piridoksin 2x1
3 hari MCV/MCH/MCHC
- Burnazine cream + 54/18/33 URINALISA
Rawat luka decubitus Lab 19-6-2019 Diftell : 2/1/0/61/22/14 Leukosit/darah: +/+ Lab 15-6-2019
Hb/Ht/E/L/T HbsAg: - Eritrosit: 250-270 Hb/Ht/E/L/T
Lab 194-6-2019 8,7/27/3,2/14,9/253 Bil total: 1,86 12,2/36/4,7/9,2/271
Hb/Ht/E/L/T MCV/MCH: 84/27 Bil direct: 0,93 MCV/MCH : 77/26
7,7/23/2,6/16,1/523 Diftel: 7/1/0/76/12/4 Bil indirect: 0,93 Diftell : 4/0/0/72/16/8
MCV/MCH : 88/30 GDS : 118 SGOT/SGPT: 49/54 Bili direk : 0,36
Diftell : 0/5/0/76/13/6 Ur/Cr : 12/0,84 GDS: 128 SGOT/SGPT: 19/5
ALP: 144 Na/K/Cl : 146/3,6/110 K/Cl: 4,4/110
LDH: 247
Lab 14-6-2019
Urinalisa: Procalsitonin: 0,08
normal Bili tot/direk/indirek :
1,17/0,51/0,66
Lab 14-6-2019 SGOT/SGPT : 17/10
Hb/Ht/E/L/T
8,5/27/3/21,4/480 Lab 12-6-2019
MCV/MCH : 89/28 Hb/Ht/E/L/T
Diftell : 2/0/0/84/7/7 12,3/36/4,7/9/268
PT/APTT : 0,88/1,15 MCV/MCH : 78/26
D-dimer : 2170,59 Diftell : 2/1/0/72/16/9
Alb : 3,37
Lab 10-6-2019 Ur/Cr: 61/0,89
Hb/Ht/E/L/T Na/K/Cl: 145/4,1/113
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. Riswan, DPJP : dr. Mamfaluti, DPJP : dr. Azzaki, Sp.PD DPJP : dr. Azhari Gani, DPJP : dr. Hendra Z,
Sp.PD Sp.PD COW : dr. Dedy Sp.PD Sp.PD
COW : dr. faril COW : dr. TM. Reza Tandi DR : dr. Muna COW : dr. Rahmi COW : dr. TM. Reza
DR : dr. Taufik DR : dr. Okdimur DM : DR : dr. Wahyu Tandi
DM : Raber : Psikiatri DR : dr. Okdimur
Raber : HOM
Nama: M Isa P Nama: Muhammad Nazar Nama: Hamdan A Rahman Nama: Munasir Adnan Nama: Ibrahim
TTL: 28-05-1953 (66 thn) TTL: 21-04-1967 (52 thn) TTL: 26-05-1962 (57 thn) TTL: 01-12-1977 (41th) Syamsyuddin
Alamat: Banda Aceh Alamat: Pidie Jaya Alamat: Banda Aceh Alamat: Banda Aceh TTL: 13-08-1976 (42 thn)
CM : 1-21-13-22 CM : 1-21-16-96 CM : 1-20-04-81 CM : 1-00-62-05 Alamat: Aceh Utara
Hari Rawatan: 3 Hari Rawatan: 4 Hari Rawatan: 12 Hari Rawatan: 11 CM : 1-21-10-22
Hari Rawatan : 10
A/ A/ A/ A/
1. Anemia sedang 1. CHF FC NYHA II-III ec 1.Sirosis hepatis stadium 1. Dispepsia tipe like ulcer A/
normokrom normositer dd/ decompensata dd/ tipe mixed 1. dd/
ec dd/ - IHD 2. Asites permagna 2. Gangguan cemas dan - Anemia aplastik
- Perdarahan - HHD 3. DM Tipe 2 Obese Gr 2 depresi - Leukemia akut
- Penyakit kronik - DCM 4. AKI Stg I dd/ Hepatorenal 3. Suspect Cushing - Lymphoma maligna
2. PSMBA ec dd/ 2. DM Tipe 2 NW Syndrome (perbaikan) Syndrome - PNH
- Gastritis erosif 3. HHD 5. Hipoalbuminemia berat 4. Konjungtivitis ODS - Myelofibrosis
- Ulcus gaster 4. Gastropati diabetik - MDS
- Ulkus duodenum 5. Cephalgia Th/ Th/
3. HIL D - Bed rest - Bed rest Th/
Th/ - Three way - Diet MB 1700 kkal/hari - Bed rest
- Tirah baring - Diet hati lunak 1700 kkal/hr - IVFD NaCl 0,9% 20 tpm - IVFD NaCl 0,9% 20 tpm
Th/ - O2 2-4 L/mnt - Drip Aminofusin Hepar 1 - Drip Ondancetron 8mg/8j - O2 2-4 lpm (nasal kanul)
- Bed rest - Diet jantung lunak 1.700 fls/hari - IV Lansoprazole 30mg/12j - IV Levofloxacin 1 x 500
- Three way kkal/hari - Drip Albuminar 25% 100 cc - IV Metoclopramide 1 amp/8 mg (H-7)
- Diet MB 1700 kkal/hr - Threeway / hari jam - Paracetamol tab 500mg
- Transfusi PRC s/d HB > - IV. Metoclopramide - Drip Furosemid 5mg/jam - Sucralfat syr 3xCI 3x1
10 gr/dl 10mg/8jam  0,5cc/jam - Duragesik Patch 12,5g/3h
- Codein 15mg 3x1 - IV. Lansoprazole 30mg/12 - IV Lansoprazole 30mg/12j - Clobazam 5mg+setraline Lab 13-06-2019
- Cetirizine 1gr 1x1 jam - IV Furosemid 20mg/12j 12,5mg pulv/12j Hb/Ht/E/L/T:
- Ciprofloksasin 20mg/8j - IV Furosemid 20 mg/8jam - Spironolacton 2x100mg - Cendo lyteers ods 4x1gtt 4,5/14/1,5/2,7/17
- SC Levermir 0-0-0-8 unit - Propanolol 2x10mg - Iv albuminar 25% MCV/MCH: 92/31
Lab 19-06-2019 - SC Novorapid 6-6-6 unit - Lactulac syr 3 x C II Diftell: 1/0/0/29/41/29
Hb/Ht/E/L/T: - Paracetamol 3x500mg - Vectrin 2x300mg Lab 18/06/2019
7,0/21/2,3/7,2/437 - Clopidogrel 1x75mg - Sistenol 3x500mg Na/K/Cl : 127/3.5/101 Lab 12-06-2019
MCV/MCH: 92/31 - Aspilet 1x80mg - Domperidon 3x10mg Ca : 6,6 Hb/Ht/E/L/T:
Diftel: 4/0/0/69/18/9 - ISDN 3x5 mg - Drip NE dalam 50cc titrasi 5,3/16/1,8/2,3/14
Ur/Cr : 42/1,51 - Atorvastatin 1x20mg 0,05/jam Lab 12-06-2019 MCV/MCH: 87/29
Na/K/Cl: 142/4,9/114 - Ramipril 1x2,5mg Anti HCV/HbsAg : (- / -) Diftell: 4/0/0/30/43/23
- Lactulosa syr 3xCI Lab 19-06-2019 HbsAg: negatif
Urinalisa Hb/Ht/E/L/T: Lab 10-06-2019 Anti HCV: negatif
Protein: +1 Lab 19-06-2019 10,3/28/2,8/10/152 Hb/Ht/E/L/T:
Nitrit: + Kol total: 162 MCV/MCH: 99/37 13,4/37/4,7/14,6/659
Bakteri: + Kol HDL: 70 Diftel: 1/0/0/78/12/9 MCV/MCH: 78/29
Kol LDL: 112 Albumin : 2,46 Diftell: 11/0/1/45/35/8
Lab 16-06-2019 Trigliserida: 159 Ur/Cr : 73/1,37 GDS: 110
Hb/Ht/E/L/T: HbA1C: 12,5 Na/K/Cl: 133/4,1/102 Na/K/Cl: 128/4,1/99
7,5/22/24/14,7/550
MCV/MCH: 91/31 Urinalisa Lab 16-06-2019
Diftel: 2/0/0/76/14/8 Leukosit: + Hb/Ht/E/L/T:
GDS : 104 Protein: +1 9,4/26/2,7/7,3/129
Ur/Cr : 62/1,98 Keton: + MCV/MCH: 97/35
Na/K/Cl: 141/4,0/109 Darah: + Diftel: 1/0/0/71/15/13
Bakteri: + Albumin : 2,26
Ur/Cr : 60/1,20
Lab 18-06-2019 Na/K/Cl: 135/4,8/104
Hb/Ht/E/L/T:
18,4/53/6,6/15,4/207 Lab 13/06/19
MCV/MCH: 80/28/35 Alb: 2,27
Diftel: 1/0/0/81/11/7 Koletrol
GDS : 170 Total/HDL/LDL/trigliserida:
Ur/Cr : 42/1,11 112/9/119/75
Na/K/Cl: 131/3,0/91 Ca/ur/cr: 8,1/77/1,82
Na/k/cl: 133/4,5/103
Urinalisis
Leukosit +
Darah +
Leukosit10-15 lpb
Hyalin cast +