Denah Ruang Rawat

Penyakit Dalam Wanita (AQSHA 3)

Hari/Tanggal : Kamis, 5 Oktober 2017

Tim Jaga : dr. Salwiyadi / dr. Andri
Dokter Muda : DM Reda/ DM Diva / DM Pocut / DM Oky / DM Fauziyah

K1B1 K1B2 K1B3 K1B4 K1B5

DPJP : dr. Azhari Gani, Sp.PD DPJP : dr. Azhari Gani Sp.PD DPJP : dr. Azhari Gani, Sp.PD DPJP : dr. Azhari Gani, DPJP :
COW : dr. Rahmi COW :dr. Rahmi COW : dr. Rahmi Sp.PD COW :
DR : dr. Saddam DR : dr. Saddam DR : dr. Saddam COW : dr. Rahmi DR :
Divisi : Divisi : Divisi : GEH DR : dr. Saddam Divisi :
Divisi :
Nama: Aisyah Nama: Yourna Nita Nama: sasmita Nama: Halimah
Umur: 65 tahun Umur: 51 tahun Umur: 25 tahun Umur: 80 tahun
CM: 0-87-50-34 CM: 1-10-58-37 CM: 1-12-20-14 CM: 0-77-23-55
Hari rawatan: 3 Hari rawatan: 1 Hari rawatan: 1 Hari rawatan: 1

Ass/ Ass/ Ass/ Ass/

1. Dyspepsia tipe like ulcer dd 1. Ca mammae metastase 1.trombositoepnia ec dd/ 1. Geriatric problem
tipe mixed tulang post kemoterapi -ITP 2. Epigastritis pain ec
2. OA genu bilateral siklus VIII -TTP dd/
3. Pneumonia geriatri 2. Anemia sedang -VWD type 2 -dyspepsia type like
4. Geriatri problem 3. Cancer pain ulcer
(inkontensia urin, stabilisasi Th/ - ulkus gaster
dan jatuh) Th/ - Bedrest di tempat tidur -Ulkus duodenum
- Bedrest - Diet MB
- Diet MII - IVFD NaCl 0,9% 20 Th/
Th/
Tranfusi PRC s/d Hb > 10 mg/dl gtt/i - Bedrest
-Bedrest
-MST tab 3x15 mg - IV metylprednisolon - NGT
- Diet MB 1700 kkal - Diet sonde 6x200 cc
- IVFD NaCl 0.9% 20 gtt/i -duragesic patch 25mg/ 3 hari 125 mg/ 12jam
- Sandimun 2x100 mg - IVFD D 10% 20 gtt/i
- IV omeprazole 40 mg/12 jam -ondansentron 3x4 mg
- Osteocal 2x1 - IV omeprazole 40
- Sucralfat syr 3 x CI - omeprazole 2x20 mg
mg/12 jam
- IV ceftriaxone 2 gr/24 jam -curcuma tab 2x1 - Oscal 2x1
- Sucralfat 3xCII
-lactulac syr 3xCI - Tranfusi Tc 10 kolf
- KSR 2x600 mg
Lab 02/10/2017 -
Hb/Ht/E/L/T: Lab 04/10/2017
Lab 04/10/2017
10,1/28/3,5/5,4/281 Hb/L/T
Urinalisa
MCV/MCH/MCHC 10,8/11,2/3
Protein : negatif
79/29/36 MCV/MCH/MCHC
Urobilinogen : positif
Diftell: 2/1/0/64/24/9 81/26/31
Glukosa +2
Na/K/Cl: 131/3,4/103 Difftel : 0/1/0/61/31/7
Epitel : 6-8 /LPB
GDS/Ur/Cr: 104/17/0,75
Albumin : 2,27
 K2B1
DPJP : dr. Azhari Gani,
Sp.PD
COW : dr. Nisa
DR : dr. Saddam
Divisi :
Nama : Fadillah
Umur : 29 tahun
CM : 1-14-15-43
Hari rawatan : 25
K2B2 K2B3 K2B4 K2B5
DPJP : dr. Azhari Gani,Sp.PD DPJP : dr. Azhari DPJP : dr. Azhari Gani, DPJP : dr. Azhari
COW : dr. Nisa Gani,Sp.PD Sp.PD Gani,Sp.PD
DR : dr. Saddam COW : dr. Nisa COW : dr. Nisa COW : : dr. Nisa
Divisi : EMD DR : dr. Saddam DR : dr. Saddam DR : dr. Saddam
Divisi : GH Divisi : Divisi :
Nama : Rasyidah Nama : Kariyem Nama : Yuslaini M Nur Nama: Maulidar Wati
Umur : 44 tahun Umur : 63 tahun Umur : 47 tahun Umur: 29 tahun
CM : 0-86-15-82 CM : 1-14-32-06 CM :1—14-48-19 CM: 1-12-77-21
Hari rawatan : 12 Hari rawatan : 1 Hari rawatan : 1 Hari rawatan: 4

Ass Ass/ Ass/ Ass/

1.CKD stage V ec PNC on HD 1. dd/ CAP 1. Penurunan kesadaran ec Ass/ 1. CML
reguler Tb paru dgn inf sek dd/ 1. anemia sedang ec dd/ 2. Bisitopenia ec CML
2. sepsis ec HAP dd/ Bronkitis - Sepsis -peny.kronik
-urosepsis 2. Hipokalemia ringan - stroke -occuld bleeding
3. HAP 3. Ulkus dekubitus grade 2 ar - Uremic ensefalopathy 2. hipokalemia sedang ec GI Th/
4. ISK pelvis 2. Sepsis ec dd/ loss -bedrest
5. hipertensi onterapi 4. Hiponatremia hipoosmolar -urosepsis 3. dyspepsia tipe like ulcer -diet MII dengan
hipovolemik -pneumonia (HAP) kebutuhan kalori 1700
6. hipokalemia ringan 4. tinea corporis
5. DM Tipe 2 NW 3. CKD stg V on HD kkal/hari
5. hipoglikemia
6. ISK dengan uremic
Th/ 6. ISK - IVFD futrolit 20 gtt/i
7. Post nefrolitotomi ai batu ensefalopaty
-Bed rest -Transfusi TC jika:
staghorn + insersi DJ stent 4. Pneumonia (HAP)
-Diet ginjal 1700 kkal + 60 Th/ Trombosit <10.000 tanpa
bilateral 5. ISK
gram protein 8. Dislipidemia - bed rest perdarahan
6. Nefrolitiasis dextra
-Amlodipine 1x10 mg 9. Parese ext inferior - diet MII 1700 kkal Trombosit <20.000
7. Anemia NN ec
-Lenal ace 2x1 -IVFD WIDA KN 2 15 gtt/i dengan perdarahan
peny.kronik
-Asam folat 2x1 Th/ - IV lansoprazole 30 mg/12 -Transfusi PRC s/d Hb 10
-Drip Paracetamol 1 gr/8 -Bed rest jam gr/dl
jam -Diet ginjal 1700 kkal/hari Th/ - domperidone 3x10 mg
- HD senin-kamis dengan 60 gr protein/hari - bed rest -cetirizine 2x10 mg Lab 04/10/2017
-tranfusi PRC s/d Hb>10 - IV Cefepim 1 gr/12 jam - O2 rebreathing mask - IV. Metoclorpamid 1 Hb/Ht/E/L/T
mg/dl - flumucyl tab 3x1 -diet sonde 6x200 kkal/hari amp/12jam 7,2/20/2,4/67,5/5
-IV moreponem 500 mg/8 - Atorvastatin 1x20mg - IV ampicillin sulbactam 1 -KSR 2x600 mg MCV/MCH/MCHC
jam - Sc Apidra 6-6-6 unit gr/ 8 jam -IV. Ca glukonas 1 amp/8 86/30/35
- Sc lantus 0-0-0-10 unit -drip PCT 1 gr/ 8 jam (k/p) jam LED : 80
Lab 02/10/2017 - KSR 2x600 mg - lenal ace 2x1 - mikonazole Diftell 0/0/0/85/12/3
Hb/Ht/E/L/T - IVFD NaCl 0,9% 20 gtt/m - as. Folat 2 x 400 mg
7,8/23/2,9/17,1/36 - Drip KCL 50 mEq dalam RL 50 cc - Vectrin 3x1 Lab 04/10/2017 Morfologi darah tepi
MCV/MCH/MCHC 15gtt/i - Hemodialisa (senin-kamis) Hb/Ht/E/L/T Eritrosit :normokrom
79/27/34 free heparin 9,4/28/3,3/13,6/509 Lekosit : leukositosis
Diftel: 0/0/0/90/4/6 Lab 03/10/2017 - IV Lansoprazole 30 mg/12 MCV.MCH/MCHC: dijumpai sel blast, sel
Ur/Cr: 72/8,00 Albumin: 2,87 jam 87/29/33 muda
Na/K/Cl: 145/3,5/99 Ur/Cr: 15/0,25 - Sucralfat syr 3x CI Diftel: 2/1/0/73/16/8 Trombosit:jumlah kurang
Na/K/Cl : 129/2,4/103 -drip vascon Ur/Cr: 19/1,17 Kesimpulan : susp. Akut
Ca : 8,2 Na/K/Cl: 134/2,7/91 leukemia? Adakah
Lab 02/10/2017 GDS : 65 organomegali?
Lab 02/10/2017 PH : 7,356 CT/BT : 8/3 Saran : BMP
Hb/Ht/E/L/T pCO2 : 37,60 HbsAg : negatif
10,0/28/3,9/8,3/222 HCO3 : 21,2 Ca : 5,8 Lab 03/10/2017
MCV/MCH/MCHC BE : -3,2 Hb/Ht/E/L/T
72/26/35 6,1/17/2/54/43
LED : 58 Lab 02/10/2017 MCV/MCH/MCHC
Diftel; 1/0/0/71/19/9 Hb/Ht/E/L/T 82/30/37
Na/K/Cl: 130/2,7/103 8,7/27/3,2/12,9/118 Diftell 0/0/1/81/10/8
MCV.MCH/MCHC:
Lab 29/09/2017 84/27/33 Lab 01/10/2017
Ur/Cr: 21/0,28 Diftel: 1/0/0/82/9/8 Hb/Ht/E/L/T
LED: 64 Ca/Ur/Cr: 9,6/104/6,74 2,5/7/0,8/87,6/3
Na/K/Cl: 138/4,3/104 MCV/MCH/MCHC
Lab 27/09/2017 82/20/36
Hb/Ht/E/L/T Lab 28/9/17 Diftell 0/0/0/71/13/16
9,9/28/3,9/8,3/246 Hb/Ht/E/L/Tr GDS 132
MCV/MCH/MCHC 9,4/27/3,4/257 Ur/Cr 20/0,57
71/25/36 MCV/MCH/MCHC Na/K/Cl
Diftell : 0/1/0/74/16/9 81/28/35 138/3,8/103
Na/K/Cl: 125/3,3/104 Diftell 1/1/0/86/5/7
PT/APTT11,5/47,1`
Lab 26/09/2017 Albumin 2,88
Na/K/Cl GDS 88
127/2,2/101 Ur/Cr 185/8,63
Na/K/Cl: 134/3,8/104
Lab 24/09/2017
Na/K/Cl/Ca Lab 27/9/17
125/2,1/96/9,0 Hb/Ht/E/L/Tr
 9,4/27/3,3/22,7/234
Diftell 2/0/0/86/6/6
MCV/MCH/MCHC
81/28/35
LED: 65
K3B1 K3B2 K3B3 K3B4 K3B5
DPJP : dr. Chaca Marisa, DPJP : dr. Chaca Marisa, Sp.PD DPJP : dr. Chaca Marisa, DPJP : dr. Chaca Marisa, DPJP : dr. Chaca Marisa,
Sp.PD COW : dr. Rahmi Sp.PD Sp.PD Sp.PD
COW : dr. Rahmi DR : dr. Rahmat COW : dr. Rahmi COW : dr. Rahmi COW : dr. Rahmi
DR : dr. Rahmat Divisi : HOM DR : dr. Rahmat DR : dr. Rahmat DR : dr. Rahmat
Divisi : Divisi : Divisi :HOM Divisi : GEH, EMD
Nama : Habsah Nama : Jamilah Ahmad Nama : Jubaidah Nama : Juwoiriah Hasan
Umur : 37 tahun Umur : 75 tahun Umur : 48thn Umur : 52 tahun
CM : 1-04-86-22 CM : 1-14-46-02 CM : 1-14-41-39 CM : 1-14-21-77
Hari rawatan : 9 Hari rawatan : 3 Hari rawatan : 7 Hari rawatan : 19

Ass/ Ass/ Ass/ Ass/

1. Efusi pleura dex ec dd 1. Splenomegali ec dd/ 1. PSMBA ec dd/
1.Asites ec dd:
- Metastase proses - CML - gastritis erosif
-sirosis hepatis
- Pleuropneumonia - Malaria - stress ulcer
- Pleuritis TB -megh syndrome -TB limpa 2. HAP ec dd TB paru
2. NHL Post kemoterapi - TB peritoneal 2. Anemia berat ec peny 3. DM tipe 2 NW
siklus VI - hipoalbumin kronis 4. Hipoalbuminemia
3. Massa intraabdomen ec dd/ 2.Hipoalbuminemia 3. High risk trombosis 5. Geriatric problem
- Metastase proses 6. Ileus paralitik
4. CAP dd -TB paru 3. Geriatric problem
Th/ 7. Hipokalemia
-bronkitis 4.hiponatremia hipoosmolar
-Bed rest 8. High Risk Trombosis
5. Higk risk trombosis hipervolemia ec -Diet MB 1700kkal
hipoalbuminemia -IVFD Futrolit 20gtt/i Th/
Th/
-IV Omeprazol 40 mg/12 -Bed rest
-Bed rest
Th/ jam - Diet DM dengan
- O2 2-4 l/i
-Bed rest - lacbon 3x1 kebutuhan kalori 1700
-Diet MB dengan kebutuhan
- Cytodrox 2x500mg kkal/hari via sonde
kalori 1700kkal/hari -Diet hati II 1700 kkal/hari
- Attapulgit 3x1 tab bertahap mulai 6 x 50
- IVFD futrolit 20 gtt/i -three way
- Aspilet 1 x 80 mg cc/hari
-IV Ambacin 1 gr/8 jam -IVFD aminofusin hepar 1 - pct 4x500 mg - IVFD NaCl 0,9% 20gtt/i
- Curcuma 3x1 fls/hari - transfusi PRC sd Hb > 10 - diet sonde 6x200c/hari
-Flumcyl 3x1
-IV furosemide 1 amp/ 8 jam mg/dl - SC Apidra 3-3-3-3-3-3
- Pradaxa 1x75 mg
-Drip Albumin 25% 100cc -SC lantus 0-0-0-8 iu
- Drip metrodinazol 750 mg/6 jam
/hari Lab 3/10/2017 -SC lovenox 0,4cc/12 jam
LDH : 1281 -IV lansoprazole 30 mg/
Lab 04/10/2017 - spironolacton 1 x 100 mg
Asam urat : 7,4 12 jam
Hb/Ht/E/L/T
Na/K/Cl : 133/4,2/103 - Drip albumin 25% 100
8,4/27/3,6/10,3/525
cc/hr
MCV/MCH/MCHC Lab 02/10/2017 Lab 2/10/2017 - IV Cefepime 1gr/8j
76/23/31 Hb/Ht/E/L/T Hb/Ht/E/L/T - Azytromicin 1x500 mg
LED : 105 11,1/31/3,6/10,7/484 7,2/20/2,3/403,9/369
Na/K/Cl : 126/4,0/101 MCV/MCH/MCHC Urinalisa 3/10/2017
87/31/36 Lab 30/09/2017 Leukosit (+)
Lab 29/09/2017 Diftel 0/0/0/84/11/5 Kreatinin : 0,69 Protein (+2
Prot total: 4,85 HbsAg negatif MCV/MCH/MCHC Glukosa (+1)
Albumin/Globulin: 2,98/1,86 Bil.total/dir/indir 87/31/36 Darah (+)
0,44/0,28/0,16 Diftel : 7/8/0/75/4/6 Leukosit 30-40
Lab 28/09/2017 SGOT/SGPT: 44/23 Albumin : 3,18 Eritrosit 20-25
Hb/Ht/E/L/T Albumin 2,44 Na/K/Cl : 134/3,4/103 Epitel 8-10
10,1/30/4,0/33,6/108 GDS/Ur/Cr : 86/62/1,42
MCV/MCH/MCHC Na/K/Cl : 125/4,9/102 Lab 30/09/2017 29/9/2017
75/26/34 Hb/Ht/E/L/T Hb/Ht/E/L/T
Diftel 0/0/0/91/5/4
6,4/18/1,9/357,/366 11,9/35/4,3/10,1/348
GDS/Ur/Cr : 447/118/6,44 MCV/MCH/MCHC MCV/MCH/MCHC :
Na/K/Cl : 126/4,0/97
93/33/36 82/28/34
Diftel 7/6/0/78/3/6 Diftell: 2/0/0/69/15/14
Urinalisa
Bilirubin total : 0,41 Na/K/Cl: 134/2,4/101
Leukosit (+) Bil.direct/indirect : Albumin: 2,20
Protein (+1)
0,26/0,15
Darah (+) SGOT/SGPT Lab 27/09/2017
Leukosit 8-10
31/10 Urinalisa
Eritrosit 6-8 Ur/Cr Leukosit (+)
Epitel 3-5
32/0,69 Protein (+1)
Glukosa (+2)
Lab 29/09/2017 Nitrit (+)
Hb/L/T : 6,7/372/502 Leukosit 20-30
CT/BT: 8/2 Eritrosit 10-20
HbsAg : Negatif Epitel 10-15
Ur/Cr: 22/0,85
Lab 25/9/2017
Hb/Ht/E/L/T
 4,2/13/1,6/17,1/296
MCV/MCH/MCHC
81/26/33
Diftell : 1/0/0/76/15/8
Alb/glob: 1,82/2,69
GDS/Ur/Cr/Ca
151/53/0,61/7,2
Na/K/Cl : 131/3,9/107

K4B1 K4B2 K4B3 K4B4 K4B5

DPJP : dr. Chaca Marisa, DPJP : dr. Chaca Marisa, DPJP : dr. Chaca Marisa, DPJP : dr. Chaca Marisa, DPJP : dr. Chaca Marisa,
Sp.PD Sp.PD Sp.PD Sp.PD Sp.PD
COW : dr. Rahmi COW : dr. Rahmi COW : dr. Rahmi COW : dr. Rahmi COW : dr. Rahmi
DR : dr. Rahmat DR : dr. Rahmat DR : dr. Rahmat DR : dr. Rahmat DR : dr. Rahmat
Divisi : Divisi : Divisi : GH, pulmo Divisi : Divisi : GEH
Nama : Nanda Meutia Nama : Jauhari Nama: Rubiah Nama : Patisah Nama : Tasriati
Umur : 35 tahun Umur : 61 tahun Umur: 57 Tahun Umur : 55 tahun Umur : 55 tahun
CM : 0-95-41-42 CM : 0-98-94-27 CM: 1-11-886-15 CM : 1-14-42-23 CM : 1-14-37-43
Hari rawat : 4 Hari rawat :7 Hari rawatan: 3 Hari rawatan : 5 Hari rawatan : 10

Ass/: Ass/ Ass/ Ass/ Ass/

1. Anemia NN ec dd/ 1. Penurunan kesadaran 1.Penurunan kessadaran ec 1. Selulitis pedis D 1. PSMBA ec dd/
-penyakit kronik ec dd/ dd dd DVT pedis D - Ulkus gaster
-malignancy - uremicensefalitis -Sepsis 2. Hipertensi stage I 2. LBP ec dd/
2. Dyspepsia type like ulcer - Imbalance elektrolit -stroke recurrrent (perbaikan) - Spondilitis
3. Ca mammae dengan - stroke -imbalance elektrolit lumbalis
metastasis tulang ec dd/ -sepsis 2. CAP dd/ T Th/ - HNP
-ischium 2. CKD stage V on HD -B paru dengan infeksi - Bedrest
regular ec DN dgn - Diet MB rendah garam Th/
-femur sekunder
uremic syndrome dengan kebutuhan kalori 1.Bedrest
4. Konstipasi -bronkoektasis
3. LBP ec dd 1700 kkal /hari 2.Diet MII1700kkal/hari
3.Anemia berat NN ec dd:
- spondilitis lumbalis - IVFD RL 20gtt/i 3.IVFD NaCl 0,9% 20 gtt/i
Th/ -HNP -penyakit kronis - IV Ceftriaxone 1 gr/12 4.IV lansoprazole 30
-Three way 4. Neuropati diabetikum -perdarahan jam mg/12jam
-Diet MB dengan kebutuhan 5. DM tipe II overweight 4. AKI stage II post renal - Clindamicin 2x300 mg 5. Sucralfat syr 3xCI
kalori 1700 kkal/hari 5.Hipokalemi - Amlodipin 1x5mg 6.Drip Paracetamol 1 gr/ 8
-IVFD NaCl 0,9% 20 gtt/i Th/ - Pct 3x500 mg jam
-IV omeprazole 40 mg /24 -Bedrest Th/ 7.Amoxicilin 2x1000
jam - NGT, kateter -bed rest Lab 29/09/2017 8.Azitromicin 1x500mg
-IV Ondancetron 4 mg/12 -Diet ginjal 1700 kkal -NGT, kateter D-dimer : 338,94
jam + 50 gr protein -O2 2-4 L/i Lab 02/10/2017
-MST 2x10 mg (k/p) -Treeway -Three way Lab 29/09/2017 Hb/Ht/E/L/Tr
- Transfusi PRC 1 kolf/hari -IV Cefepim 500mg/12jam -Transfusi PRC Urinalisa 7,5/22/2,5/5,6/255
-Lactulac syr 3 x CII -IV omeprazol 40mg/12 jam Hb target >10 gr/dl Protein (-) MCV/MCH/MCHC
-Amplodipin 1x5mg -IV omeprazole 40 mg/24 Leukosit (-) 89/30/34
-Lenal Ace 2x1 jam Darah (-) Diftell: 0/1/0/63/28/8
Lab 02/10/2017 -Asam Folat 2x1 -Fluimucyl syr 3xCI Epitel 4-6
Hb/Ht/E/L/Tr -pct 3x500 mg -Amlodipine 1x10mg
8,8/27/3,4/5,5/112 -Gabapentin 1x300 -IV meropenem 1 gr/8 jam Lab 01/10/2017
MCV/MCH/MCHC -antasida syr 3xCI -IV Citicolin 500mg/12 jam Hb/Ht/E/L/Tr
82/26/32 -HD reguler senin-rabu- -KSR 2x600mg 7,6/22/2,5/6,8/281
Diftell 2/1/0/51/39/7 jumat MCV/MCH/MCHC
Lab 03/10/2017 90/31/34
Lab 03/10/2017 Urinalisa Diftell: 0/0/0/70/24/6
Lekosit : positif Protein (+2)
Protein : +2 Glukosa : (-) Lab 29/09/2017
Glukosa : +1 Leukosit (+) Analisa Tinja
Darah : + Darah (+) Telur cacing negatif
Epitel8-10/LPB
Leukosit : 30-40 /LPB Lab 26/09/2017
Eritrosit : 25-30 / LPB Lab 02/10/2017 Hb/Ht/E/L/T
Epitel : 6-8 /LPB Hb/Ht/E/L/Tr 9,9/29/3,2/16,2/122
3,6/4/0,4/20,3/383 MCV/MCH/MCHC
Lab 01/10/2017 MCV/MCH/MCHC 89/31/34
Hb/Ht/E/L/Tr 106/100/95 Diftell : 0/0/0/73/22/5
8,2/24/3,2/38,6/62 Diftell 0/0/1/78/14/7 CT/BT : 7/2
MCV/MCH/MCHC CT/BT; 9/3 GDS : 115
75/26/34 Ur/Cr: 86/1,99 Ur/Cr : 125/1,08
Diftell 1/1/0/85/7/6 Na/K/Cl: 134/3,3/106 Na/K/Cl : 140/3,4/118
Ur/Cr: 131/6,29
Na/K/Cl: 129/4,0/96

Lab 30/09/2017
Na/K/Cl: 125/3,9/102

Lab 29/09/2017
Urinalisa
Protein +2
Glukosa +2

Sedimen urin
Leukosit : 20-30 / LPB
Eritrosit : 10-20 / LBP
Epitel : 15-20 /LBP

K5B1 K5B2 K5B3 K5B4 K5B5

DPJP : dr. Abdullah, DPJP : dr. Abdullah, DPJP : dr. Abdullah, DPJP : dr. Abdullah, DPJP : dr. Abdullah,
Sp.PD.,KGH Sp.PD.,KGH Sp.PD.,KGH Sp.PD.,KGH Sp.PD.,KGH
COW : dr. Nisa COW : dr. Nisa COW : dr. Nisa COW : dr. Nisa COW : dr. Nisa
DR : dr. Irhas DR : dr. Irhas DR : dr. Irhas DR : dr. Irhas DR : dr. Irhas
Divisi : Divisi : Nefro Divisi : Divisi : Divisi :
Nama: Nurma Nama: Ainon Marziah Nama: Zahara Nama: Tumiyem Nama: Bundi Martini
Umur: 62 tahun Umur: 62 tahun Umur: 50 tahun Umur: 74 Tahun Umur: 54 Tahun
CM: 1144787 CM: 1142564 CM: 1-11-13-70 CM: 1-14-42-75 CM: 1-02-53-60
Hari rawatan : 2 Hari rawatan : 18 Hari rawatan: 3 Hari rawatan: 5 Hari rawatan: 3

Ass/ Ass/ Ass/ Ass/ Ass/

1. PSMBA ec dd/ 1. CKD stg V ec PNC on HD 1. psoriatik arthritis 1. Pneumonia geriatri 1.Febris ec susp. ISK dd
-gastritis erosif reguler 2. GEA 2. DM tipe II nNW malaria
- ulkus gaster 2. HAP 3. hiponatremia 3. Konstipasi 2.DM tipe 2overweight
2. Anemia sedang NN ec dd 3. HHD hipoosmolar euvolemia 4. hiponatremia 3.Dyspepsia type like ulcer
4.Ureterolitiasis sinistra post
perdarahan akut 4. Hipoalbuminemia ec renal 4. hipoalbuminemia berat
op
3. OA genu bilateral loss 5. Akut on CKD dd/AKI Th/
4. hipokalemia stage III -Bedrest Th/
-diet MB -bedrest
Th/ Th/ Th/ -IVFD NaCl 0,9% 20 gtt/i -diet DM 1700 kkal/hr
- Bedrest -Bedrest -bed rest -IV ceftriaxone 2 gr/12 jam -IVFD NaCl 0,9% 20 gtt/i
- Diet MB 1700 kkal -Diet sonde ginjal 1700 kkal + -myfortic -PCT 3x500mg -Drip Levofloxacin 500mg/
-IVFD NaCl 0,9% 20 gtt/i 60 gr protein - sulfasalazine3x500 mg -Flumucyl 3xC1 24 jam
- IV Lansoprazole 30 mg/12 -threeway -lenal ace 2x1 -Laxadyn syr 3x30 cc -Parasetamol 3x500 mg
j -lenal ace 2x1 -sucralfat 3xCI -lantus 0-0-0-15 -kaltropen supp
-IV transamin 500 mg/ 8 -asam folat 2x1 -Attapulgite tab 1 kali -Novorapid 10-10-10 -Omeprazole 2x20 mg
jam -amlodipin 1x10 mg setiap mencret -Azytromicin drip 500mg/24 -Domperidone 3x10 mg
-IV cefotaxim 1 gr/12 jam - valsartan 1 x 80 mg - ostiol 0,5 mg 2x1 jam - SC apidra 8-8-8 ui
- tranfusi PRC sampai -IV Furosemid 20 mg/8j - lansoprazole 2x30 mg - SC lantus 0-0-0-12 ui
Hb>10 mg/dl -HD regular freeheparin -valsartan 80 mg 1x1 Lab 03/10/2017 - IV ondansentron 4 mg
(ekstra)
- Sucralftat syr 3 x CI 3xseminggu (senin-rabu- -balance cairan seimbang Kolestrol total : 169
jumat) LDL/HDL : 97/29
Lab 03/10/2017
-IV ceftriaxone 2gr/24jam Lab 02/10/2017 Trigeliserida : 180
Malaria : negatif
Lab 03/09/2017 - IV ondansetron 4 mg/8 j Hb/Ht/E/L/T
Hb/Ht/E/L/T -laxadyn syr 3xCI 9,0/26/3,1/13,9/332 Lab 03/10/2017 Lab 02/10/2017
4,1/12/1,5/12,4/203 MCV/MCH/MCHC Lekosit : positif Hb/Ht/E/L/T
MCV/MCH/MCHC Lab 4 /10/2017 84/29/34 Protein +1 11,9/34/4,8/22,5/235
84/28/33 Hb/Ht/E/L/T Diftel: 1/0/0/87/8/4 Glukosa negatif MCV/MCh/MCHC
Diftell6/0/0/67/19/8 10,2/31/3,6/12,3/303 Albumin: 1,42 Urobilinogen negatif 71/25/35
GDS/Ur/Cr MCV/MCH/MCHC Ur/Cr: 64/3,85 Diftel: 0/1/0/86/6/7
124/44/0,67 86/28/33 Na/K/Cl 128/4,3/112 Lekosit : 20-25 /LPB GDS: 396
Na/K/Cl: 128/3,3/102 LED : 70 Eritrosit : 2-3 / LPB Ur/Cr: 17/0,71
HBsAg negatif Na/K/Cl Epitel 6-8/LPB Na/K/Cl: 132/3,5/103
130/4,0/99
Ur/Cr : 76/4,24 Lab 29/09/2017
Albumin : 2,69 Hb/Ht/E/L/T
9,4/29/3,4/7,4/176
Lab 26/09/2017 MCV/MCH/MCHC
Hb/Ht/E/L/T 85/28/33
8,9/26/3,2/10,9/347 Diftell 2/1/0/61/26/10
MCV/MCH/MCHC GDS 205
82/28/34 Ur/Cr 33/0,98
Diftel: 0/1/1/83/7/8 Na/K/Cl: 140/4,8/104
Alb 2.58 Ca 10,4
Ur/Cr/Na/K/Cl
189/4,01/130/5,4/99

Lab 21/09/2017
Hb/Ht/E/L/T
7.7/22/2.8/14.3/196
MCV/MCH/MCHC
79/27/35
Diftel: 0/2/1/0/82/9/8
Alb 2.71 Ca 10
Ur/Cr/Na/K/Cl
114/3.22/138/3.3/104

Lab 20/09/2017
Urinalisa protein +1

K6B1 K6B2 K6B3 K6B4 K6B5

DPJP : dr. Abdullah, DPJP : dr. Abdullah, DPJP : dr. Abdullah, DPJP : dr. Abdullah, DPJP : dr. Abdullah,
Sp.PD.,KGH Sp.PD.,KGH Sp.PD.,KGH Sp.PD.,KGH Sp.PD.,KGH
COW : dr. Nisa COW : dr. Nisa COW : dr. Nisa COW : dr. Nisa COW : dr. Nisa
DR : dr. Irhas DR : dr. Irhas DR : dr. Irhas DR : dr. Irhas DR : dr. Irhas
Divisi : GH Divisi : Divisi : Divisi : Divisi : GH
Nama: Evirisna Nama: Murhamah Nama: Bahriana Nama: Ainal Mardhiah
Umur: 50 tahun Umur: 38 tahun Umur: 45 tahun Umur: 57 tahun
CM: 1-14-30-54 CM: 1-01-57-98 CM: 0-98-60-90 CM: 0-87-52-41
Hari rawatan : 15 Hari rawatan : 1 Hari rawatan : 3 Hari rawatan : 1

Ass/ Ass/ Ass/ Ass/

1. CKD stage V ec PNC on 1. Anemia hipokrom 1. SLE derajat sedang 1. Anemia sedang
HD reguler mikrositer ec defisiensi besi 2. LBP ec dd/ 2. Ca caput
2. anemia ringan NN ec - due to SLE pankreas
PGK - spondilitiasis
3.DCM Th/ -HNP Th/
4.Efusi perikard minimal - bedrest 3. cushing syndroma - bedrest
5.HHD - IVFD NaCl 0,9% 10 gtt/i - diet MB
6. dislipidemia - Asam folat 2x1 Th/ - tranfusi PRc s/d 10 gr/dl
7. hipeurisemia -tranfusi PRC s/d Hb > 10 - bedrest
8. Hipokalemia ringan mg/dl - threeway
- Metilprednisolon 3x 16
Th/ Lab 03/10/2017 mg
-bedrest Urinalisa - PCT 3x500 mg
-Diet 1800kkal dengan 60 pH :6,0 - Lansoprazole 2x30 mg
gr protein/hr protein : negatif - ostiol 2x1
-Threeway glukosa : negatif -lenal ace 2x1
-as folat 2x1 urobilinogen : negatif - myfortic 2x360 mg
-lenal ace 2x1 - Nystatin drop 4x2 cc
-amlodipin 1x5 mg epitel 20-25 /LPB
-atorvastatin 1x20 mg leukosit : 3-5 /LPB Lab 3/10/2017
-aspilet 1x80mg eritrosit : 1-2 / LPB Hb/Ht/E/T/L :
-cpg 1x75 mg 13/40/4,5/13,7/241
-lansoprazol 2x30 mg Lab 02/10/2017 MCV/MCH/MCHC:
- allopurinol 1 x 300 mg Bilirubin total : 0,33 88/29/33
- HD regular free heparin Direct/indirect : 0,16/0,17 Diftel 0/0/0/82/15/3
(senin-kamis) SGOT/SGPT : 18/15 Alb : 3,76
-Iv. Ondancentron GDS/Ur/Cr
4mg/8jam Analisa tinja 139/28/0,69
Telur cacing : negatif Na/K/Cl
Lab 02/10/2017 Parasit : negatif 139/3/96
Ur/Cr: 132/10,12
Lab 02/10/2017
Lab 29/09/2017 Hb/Ht/E/T/L :
Hb/Ht/E/L/T 6,9/24/3,8/613/5,3
8,4/24/3,0/13,4/322 MCV/MCH/MCHC:
MCV/MCH/MCHC 63/18/29
81/28/35 LED : 20
Diftel: 2/1/1/72/16/8 Diftel : 2/0/0/47/41/10
Albumin: 3,37 Ferritin : 30,60
Ca/Ur/Cr/Na/K/Cl Besi : 37
9,1/84/6,11/136/3,5/105
Morfologi darah tepi
Urinalisis 25/09/2017 Anemia hipokrom mikrositer
Protein : (+2) +trombositosis
Glukosa : (+2)
Leukosit 8-10 lpb Lab 27/09/2017
Eritrosit 4-6 lpb Hb/Ht/E/T/L :
Epitel 3-5 lpb 7,5/25/4,1/631/6,0
MCV/MCH/MCHC:
Lab 22/09/2017 62/18/30
Albumin : 3,14 Diftel 2/0/0/52/39/7
Kolesterol tot : 309 GDS ; 131
HDL/LDL/Trig : 33/220/181 Ur/Cr : 24/0,48
As. Urat : 10,2 Na/K/Cl : 138/3,9/110