Lab 19/2/2022
Hb/leu/tromb: 10,5/18,50/150
Mcv/mch/mchc: 81/29/36
Diftel: 0/0/0/92/5/3
PT/APTT : 20,10/52,30
Anti HCV : neatif
HBsAg : non reaktif
Ca : 6,6
GDS : 37
Ur/cr : 83/2,60
Na/K/Cl: 135/3,60/105
Ruangan : dr. Novita COW : Dr.dr. Muhsin COW : dr. Fadhila COW : dr. Fadhila
Ruangan : dr. Nadia Ruangan : dr. Nanda Ruangan : dr. Putri
Oetami Raber : GH
Nama : Nadia Sivani Nama : Nuraini Syarwan Nama : Ismiati Binti Arifin Nama : Rinda Bustari
CM : 1301132 TL : 01/02/22 Salam CM : 1246972
TL : 04/08/2003 CM : 1170745 CM : 1-29-93-95 TL : 17/01/1997
TM : 01/02/2022 TL : 24-12-1977 TM : 21/02/2022
TM : 10/2/2022
Ass/ Ass/ Ass/ Ass/
1. Anemia berat 1. Bisitopeni ec dd 1. CKD stage V ec dd 1. CML
megaloblastik ec dd/ 1) Def. (1)penyakit kronis - DN
b12, 2) Def. Asam folat, (2)perdarahan - HN Th/
2. Elevated enzim 2. Ca mammae sinistra post 2. DM tipe II NW -Bedrest
transaminase ec dd/ 1) akut kemoterapi siklus ke 6 3. HT stage I -Diet MB 1700kkal/hari
liver failure, 2) hepatitis, 3. LBP ec spondyloarthrosis 4. Anemia sedang NN ec dd -IVFD NaCl 0,9% 20gtt/i
3. Dispepsia tipe like ulcer lumbalis penyakit kronis -IV Lansoprazole
dd tipe mixed 5. Ulcus a/r torachalis 30mg/12jam
Th/ posterior -Glivec 1x400mg
Th/ -Bedrest 6.susp mikrotrombosis -Imatero 1x400mg
Bedrest -O2 2-4L/menit via NC sistemik
Diet MB 1700kkal/hari - Diet MB 1700 Kkal/hari 7. PSMBA ec induced P/
IVFD RL 20gtt/i -IVFD Nacl 0,9% 20 gtt heparin (drugs) -Rencana PBJ setelah
Curcuma 3x1 - IV Ondasentron 4 mg/8 perbaikan
Lactulac 3 x 30cc jam Th/
Tranfusi PRC dgn bloodset -IV omeprazole 40 mg/12 -Bedrest Lab 24/02/2022
khusus sampai Hb >10 gr/dl jam -Diet ginjal 1700 kkal/hari + Hb/ht/e/t/l 8,5/25/3,1/219/9
-Curcuma 3x1 tab protein 1gr/KgBB/hari MCV/MCH 80/28
-Codetam 3x1 -Threeway E/B/NB/NS/LM
Lab (25-02-22) -Metilprednisolon 2x16mg -IV meropenem 6/8/0/61/9/16
Hb/L/tr : 3,4/13,8/327 - Tamoxifen 2x10mg 500mg/12jam (H4) LED 14
MCV/MCH/MCHC : -Drip omeprazole 80mg dlm
119/40/34 P/ NaCl 0,9% 50cc Urine rutin 22/2/2022
Difftel : 1/0/0/68/24/7 -IV Furosemide 20 mg/8 Normal
Ur/cr : 17/0,7 Lab 24/2/2022 jam
SGOT/SGPT : 61/31 Hb/L/Tr :8,4/7,4/17 -IV Ondansentron 4 mg/8 Thorax PA 22/2/2022
GDS : 93 MCV/MCH/MCHC : jam Kesan: Pneumonia
B. Total : 4,17 80/28/35 -Lactulac 3xcth I
B. Direct : 0,68 Diftel : 1/1/0/53/36/9 -Lenal ace 169 mg/12 jam Lab 21/2/2022
B. Indirect : 3,49 PT/APTT 0,9/0,83 -Asam folat 0,4 mg/12 jam Hb/ht/E/T/L
D-dimer 2980 -Clindamicin 300 mg/8 jam 6,9/19/5/234/301
Fibrinogen 1,07 -Valsartan 160 mg/24jam MCV/MCH/MCHC/RDW
-Herbesser 200 mg/24 jam 75/27/36/26,6
Lumbosacral AP/Lat -Fluconazol 200 mg/24 jam E/B//NB/NS/L/M
(21/02/22) -Flumucyl 200 mg/8 jam 5/4/0/70/13/8
Kesan: Spondyloarthrosis -amlodipin 10mg/24jam Ur/cr 16/0,5
lumbal -citicolin 500mg/12jam Albumin 3,3
Na/K/Cl/Ca 144/3,7/108/7,9
Lab 21/2/2022 P/ MDT: Susp CML fase
Hb/L/T: 9,6/6,99/5 -HD senin-kamis kronik
MCV/MCH: 79/28 -pantau tanda perdarahan
Difftel: 2/1/0/58/29/10
D-dimer : 2170,00 Lab 21/2/2022
Pt/APTT : 15,20/28,60 Hb/Ht/E/T/L
9,7/29/3,5/184/11
Lab 19/2/2022 MCV/MCH/MCHC/MPV/
Hb/L/T: 8/7,98/16 PDW/RDW
MCV/MCH: 78/28 82/28/34/13,1/20/15,4
Difftel: 2/1/0/51/36/10 E/B/NB/NS/L/M
3/0/0/85/11/1
Lab 17/2/2022 PT/APTT 0,78/0,77
Hb/l/tr: 5,2/7,33/4 INR 0,83
MCV/MCH/MCHC: D-dimer >4000
79/29/36 AGDA 21/2/2022
Diftel:0/2/0/50/38/10 pH : 7,0
Ur/cr: 32/0,90 berat jenis : 1,020
Na/K/CL/ca: Darah : postif
145/4,60108/10,4 Eritrosit : 5-10
Lab 19/02/2022
Mapping Aqsha 3
Minggu 27 Februari 2022
PT/APTT 0,86/11,1
D-dimer 1020
Fibrinogen/kontrol 588/266
Lab 18/02/2022:
Hb/L/T : 9,1/9,05/242
MCV/MCH: 82/29
Ur/cr: 104/9,69
Na/K/CL: 141/4,2/106
Lab 14/02/22
Hb/L/T : 9,1/9,0/242
MCV/MCH/MCHC :
82/29/35
Ur/cr: 104/9,69
Na/K/CL/Ca:
141/4,2/106/7,7
Lab 14/02/22
Hb/L/T : 9,6/8,74/275
MCV/MCH/MCHC :
81/28/34
RDW : 15,2
Diftel : 3/0/0/71/12/14
Ur/cr: 49/5,3
Na/K/CL/Ca:
143/3,6/105/7,6
d-dimmer: 3860,00
albumin: 2,6
Lab 14/02/22
Urinalisis
Warna: kuning
Kejernihan: keruh
Berat jenis: 1,013
Ph: 5,0
Leukosit: +
Protein: +2
Glukosa: -
Keton:+
Nitrit: -
Leukosit:25-60
Eritrosit:50-60
Epitel: 0-1
Darah +
Bilirubin –
Urobilirubin –
Lab 11/2/2022
Hb/L/T :
8,4/15,40/407
MCV/MCH/MCHC
82/28/34
Diftel : 0/0/0/95/4/1
PT/APTT : 1,1/1,1
Ur/Cr : 87/7,80
Na/K/Cl : 141/4,80/114
Foto Thoraks AP
10/02/2022
Efusi pleura dextra
Lab 10/2/2022
Hb/L/T :
6,4/19,24/494
MCV/MCH/MCHC
86/29/34
Diftel : 0/0/0/92/6/2
PT/APTT : 1,1/1,1
HIV : Non reaktif
Mapping Aqsha 3
Minggu 27 Februari 2022
Anti HCV/HbSAg :
Negatif/Non reaktif
GDS : 215
Albumin : 3,00
Ur/Cr : 125/11,30
Na/K/Cl/Ca :
145/6,50/120/8,9
Analisa Gas Darah –
Ph :7,268
Pco2 : 20,70
Po2 : 107
HCO3 : 9,5
Total CO2 : 10,2
BE : -15,1
Saturasi O2 : 93,2
Lab 21/02/2022
Hb/L/T: 4.9/382.03/7
MCV/MCH/MCHC:
84/26/31
Diftel: 0/0/0/1/69/30
Na/K/Cl/Ca:
142/2.50/108/7.7
Ur/Cr: 25/0.5
Ass/ Ass/
1.DD: -Ileus Paralitik 1. Hepatomegali ec dd 1)
-Ileus Obstruktif hepatoma, 2) metastase
2. Pneumonia (HAP) proses
2. Efusi pleura sinistra
Th/ dd massa paru sinistra
Bedrest 3. Pneumonia (HAP)
Pasang NGT=> puasa 6 jam, 4. Hipokalemia ringan
evaluasi hematemesis 5. Hipoalbumin berat
Ivfd Nacl 0,9% 20gtt/i
Iv ceftriaxon 2gr/24jam Th/
Iv lansoprazole 30mg/12 jam Bedrest
Drip novalgin 1 amp/8 jam Diet Hati ll 1700kkal/hari
Po synbio 2x1 IVFD aminofysin hepar
Po sucralfat syr 3xcII 1fls/hari
Iv. Lansoprazole
Lab 26/2/2022 30mg/25 j
Hb/leu/tromb: 8.7/4.44/492 Iv. Cefoferazone
Mcv/mch/mchc: 72/23/33 sulbaktam 1gr/8j
Diftell: 6/0/0/67/22/5 Drip albumin 25%
PT/APTT: 1.1/1.7 100cc/hari
Anti HCV/HBsAg: negatif/ Curcuma 3x1
non reaktif Lactulac 3 x 30cc
Bil tot/D/I: 0.57/0.17/0.40 Paracetamol 3x500mg
Sgot/sgpt: 22/8 KSR 1x600mg
Albumin: 2.90
Gds: 87
Ur/Cr: 31/0.90 Lab (25-02-22)
Na/K/Cl/Ca: 146/3.80/108/8.0 Hb/L/tr : 12,4/16,9/302
MCV/MCH/MCHC :
76/26/34
Difftel : 2/0/0/81/9/8
Albumin : 2,00
Ca : 11,2
Ur/cr : 25/0,4
Na/k/cl : 131/3,3/98
SGOT/SGPT : 30/13
GDS : 126
B. Total : 0,97
B. Direct : 0,44
B. Indirect : 0,53
DPJP : dr. M. Riswan, Sp.PD-KHOM DPJP: dr. Alfi syahrin, Sp.PD DPJP: dr. Desi S, Sp.PD-
COW : dr. M.Riza COW: dr. Muhsin KGH
Ruangan : dr. Intan Ruangan: dr. Novita COW: dr. Irhash
Ruangan:dr.Fitrah
Retikulosit:20,3
MDT : Eritrosit : hipokrom mikrositer,
agglutination erytrocyet +,
poikilositosis.