LAPORAN JAGA JASMIN

Jum’at, 2 Juni 2023 Pukul 07.00 WIB - Sabtu, 3 Juni 2023 Pukul 07.00 WIB
dr. Syarlidina Syaf, dr. Said Tryanda, dr. Nidya Febrina, dr.Rezki Permata Sari, dr. Agus Subhan, dr. Sharah Ananta.

Total Pasien Jasmin : 16 orang, Pasien Lama : 17 orang, Pasien Baru dari IGD : 1 orang, Pasien Baru dari Poli : - orang, Pasien pengawasan : 5 orang,
Pasien Pulang : 3 orang, PAPS : orang, Pasien Meninggal :- orang, Alih Rawat : - orang, Pindahan dari pinere : orang , Pindahan dari ICU Surgical : 1
orang, Pindahan dari CVCU: 0 pindahan Gardenia : - orang, Pindahan dari Kenanga lt 2 : - orang, Pindahan dari Ruangan Mawar : - orang, Pindah ke
ICU surgical : - orang. Pindah ke Teratai : -orang, Pindah dari RICU : - orang, pasien Raber baru : 0. Pindahan dari Pinere : 0 orang ,Pindah ke CVCU : -
orang, Pasien dirujuk : - orang, Pindah ke Ruangan Krisan : - orang

No Kamar Nama Pasien Diagnosis/ Masalah Pemeriksaan Penunjang Rencana DPJP

1. Jasmin Tn. Supiono/07- A: 31/5/23 Hb/Leu/Ht/Trom : R; dr. Sri Indah d

1.1.1 12-1977/45th/011 - CAP SP 125 14.5/27.48/48.4/240 - Perbaikan KU Indriani, Sp.
24028 B/E/N/L/M : - Nebu / 4 jam P(K) In
- Kanker Paru kanan 0.2/0.2/85.6/4.8/9.2 o
MRS Via IGD jenis (?) T4N0M1a NLR/ ALC : 17.83/1.33 - Cek Lab Evaluasi (DR, Ur, 2
tanggal 31/5/23 (Pleura) Stg IV A PS PT/INR/APTT : Cr, PCT) 3/6/23
14.6/1.03/25.1 - Cek GDS/pre meal
2
Hari Rawatan ke ALb/AST/ALT/GDS
4 - Nefrolitiasis bilateral 4.4/33/79/58 - Cek kultur sputum dan mo
- DM Tipe II CRP/PCT/Ur/Cr : gram  menunggu hasil
Jl. Perum Griya 31.1/0.364/122.0/1.88 - PA core biopsi hasil 8/6/23
- HT St II
Sri Palas Rumbai Hbsag/HIV : NR/NR
- AKI dd acute on - Konsul ulang radioterapi
081275888845 CKD pH/PCo2/PO2/HCO3
7.31/66/237/33 Foto Toraks
M: TCO2/BE/SO2C 31/5/23

1
 - SVKS grade 2 35/7/100
- Sindrom Obstruksi Na/K/Ca/Lactat:
134/4.0/1.10/1.90
- Nyeri kanker VAS 3
- Peningkatan enzim Sitopatologi
transaminase 17/5/23

Kesimpulan : Tidak ditemukan

Sel ganas
EKG
Sitopatologi 1/6/23
17/5/23

USG Toraks
1/6/23
Kesimpulan : Gambaran
sitopatologi sediaan ini sesuai
dengan : tidak ditemukan sel-
sel tumor ganas pada sediaan
ini

2
 Sitopatologi
19/5/23

Kesimpulan : Tidak ditemukan

sel tumor ganas

GDS : 196

pH/PCo2/PO2/HCO3
7.37/49/185/28
1/6/23 TCO2/BE/SO2C
30/3/100
Na/K/Ca/Lactat: Kesan : Cairan minimal,tarikan Berat
130/4.3/1.04/2.60
CT Scan Toraks 08/05/23
GDS : 225

2/6/23

3
4
 Ekspertise CT Scan Toraks 8/5/23

5
 Kesan:
- Cor normal
- Pulmo: abses paru kanan dd massa
paru kanan dengan pleural efusi
kanan, WSD terpasang
- Nephrolithiasis bilateral, terutama
kiri

2. Jasmin Tn. Usman/31- A: 27/5/23 Hb/Leu/Ht/Trom : R: dr. Sri d

1.1.2 Des-1965/ 57th/ - PPOK stabil grup E 12.6/8.17/38.9/365 - Nebu/8 Jam Melati
01125953 B/E/N/L/M : - Evaluasi WSD/hari Munir,
M: 0.7/3.8/67/19.3/9.2 - Pleurodesis 31/5/23 - 2/06/23 Sp.P(K) T
MRS Via IGD - Pneumotoraks paru NLR/ ALC : 3.47/1.58 ta
27/5/23 PT/INR/APTT/D-Dimer : - Foto toraks post pleurodesis H3 (H
kanan=>Paru belum
13.7/0.96/29.7/0.98 --> 3/6/23
mengembang
Hari rawatan ke 8 ALb/AST/ALT/GDS - Klem Post pleurodesis3/6/23 P
- Multiple Bulae 3.2/14/11/105 B
- Foto Toraks post klem 5/6/23
Gang Nelayan - Hipoalbumin (3,2) CRP/PCT/Ur/Cr : U
- GV/hari
Kuala Alam - Underweight 37.6/0.029/21/0.67 cm
Bengkalis - Cek kultur sputum, MO gram, 
pH/PCo2/PO2/HCO3 menunggu hasil
082288546822 7.46/41/93/29
TCO2/BE/SO2C Foto torak 21/4/23
31/5/98
Na/K/Ca/Lactat:
134/3.4/1.1/1.2

GE 21/4/23

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 Foto Toraks 8/5/23

Hasil : MTB Not Detected

31/5/23

pH/PCo2/PO2/HCO3 Foto Toraks 15/5/23

7.47/41/63/30
TCO2/BE/SO2C
31/6/93
Na/K/Ca/Lactat:
140/3.2/1.11/1.80

EKG 27/5/23

Foto toraks
27/5/23

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 Foto Toraks 29/5/23

8
 CT-Scan Toraks Kontras
31/5/23

Ekspertise Ct Scan Toraks

31/5/23

9
 Kesan : Hidropneumothoraks dext
ra (ec ruptur bullae) dengan passi
ve atelektasis lobus inferior kana
n.
Multiple bullae di paru kanan. Em
physema paraseptal dan centrilob
ular paru bilateral.
Efusi pleura kiri minimal

3. Jasmin Ny. Marianis/10- A: 26/5/23 Hb/Leu/Ht/Trom : R: dr. Sri d

1.2.1 04-1964(59th)/ - Kanker Paru Kanan 11.8/10.76/35.5/497 - GV / hari Melati
01125854 jenis (?) T3N0M1a B/E/N/L/M : - Core Biopsi/TTNA CT-Guided Munir, T
0.6/5.3/59.4/28.2/6.5  Hasil 13/06/23 Sp.P(K) W
MRS via Poli (Pleura) stage IVA PS 2 NLR/ ALC : 2.11/3.03 - Bronkoskopi --> jadwal ulang (-) h
26/5/23 - Hipertensi stage 1 PT/INR/APTT/D-Dimer : d
13.4/0.94/28.3/3.4 Foto Toraks 12 Mei 2023 1
Hari rawatan ke 9 M: Ur/Cr : 54/1.22 R
- Diagnostik Alb/ALT/AST/GDS :
Jl. Ferry/Tualang - Efusi pleura dextra 3.6/19/39/128 P
Siak - Nyeri Kanker VAS 4 Na/K/Cl : 139/3.5/103 U
- Hipokalemia (2,9) cm
088271190810 HIV/HBsAg:NR/NR B

10
 Analisa CP 27/5/23 In
L

1
(H
S

Foto 20 Mei 2023

Kesan : Transudat

Sitologi PA 23/5/23

Ct Scan 24/5/23

29/5/23
Kesan : Suatu radang kronik

11
 pH/pCO2/pO2/HCO3 :
7.44/33/75/22
TCO2/BE/SO2C
23/-2/95
Na/K/Cal/Lac :
134/2.9/1.06/1.8

Echo 29/5/23

Kesan : Fungsi jantung baik

dengan EF 76 %.

Ekspertise 24/5/23

Kesimpulan :
- Menyokong gambaran massa
paru perifer berukuran 5.22 cm

12
 x 5.33 cm x 4.25 cm yang
mengobliterasi cabang bronkus
di segmen lateral lobus medius
dan Sebagian besar segmen
lobus inferior paru kanan.
- Efusi pleura kanan minimal
disertai terpasang CTT dengan
ujung tertinggi paravertebral Th.
8 kanan
- Kardiomegali, aterosklerosis
arcus aorta, aorta descenden dan
ascenden

Foto Toraks 26/5/23

EKG 26/5/23

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 Ct Scan Toraks TTNA
30/5/23

Expertise CT Scan Toraks

31/5/23

Kesan : Kardiomegali dan aorta ka

lsifikasi.
TB paru.
Efusi pleura bilateral.

Foto Toraks 31/5/23

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 Foto Toraks Post Klem 2/6/23

4. Jasmin Ny. Dahlia/ 6-7- A: 29/5/23 Hb/Leu/Ht/Trom : R: dr. Arlina d

1.2.2 1975/ 47th/ - Tumor Mediastinum A 8.7/10.05/27.7/388 - Perbaikan K.U Gusti, Sp.P
01124785 nterior dd/ Limfoma dd/ B/E/N/L/M : - Rencana Bronkoskopi  6/6/23
0.3/0.4/71.7/15.8/11.8 - TTNA CT guided  jadwal (-)
MRS Via Poli Teratoma dd/ Timoma NLR/ALC :
29/5/23 dd/ Kanker paru kanan j 4.54/1.59 - Cek tumor marker
enis (+) T4N2M1c (cost PT/INR/APTT/D-Dimer : Cek lab post koreksi Kalium
Hari rawatan ke 6 ae,lien) stg IVB PS 1 15.5/1.1/30.7/2.84
Alb/AST/ALT/GDS/Ur/Cr : CT Scan 17/5/23
Pasir Jambu 2.4/32/16/91/21/0.68
rambah tengah M: Na/K/Chlor : 134/3.3/95
hilir, Rokan Hulu
30/05/23 pH/pCO2/pO2/HCO3 :

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 082386920517 - Nyeri Kanker VAS 4 7,5/43/90/34
- Hipoalbumin (2,6) TCO2/BE/SO2C
- Hipokalemia (2,4) 35/10/98
Na/K/Cal/Lac :
132/2.4/1.03/2.3

01/6/23 Hb/Leu/Ht/Trom : Ekspertise 17/5/23

10,4/6,48/32,7/389
B/E/N/L/M :
0,2/0,0/71,5/19,8/8,5
NLR/ALC : 3,61/1,28
Alb: 2,6

Kesan :
- Limfadenopati berkonglomerasi
di sepanjang paratrakea dan
peribronkial bilateral serta
subcarinal
- Limfadenopati multiple
paraaorta abdominalis, paracava,
dan periportal  maligna. Dd
maligna
- Opasitas mikronodular dan
nodular di lobus superior paru
dekstra, nodul multiple di lien
dan lesi litik di costae 2 anterior

16
 sinistra  metastasis
- Hepatomegali

Foto toraks 22/5/23

Foto toraks 29/5/23

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 EKG 29/5/23

EKG 2/6/23

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 5. Jasmin Tn. Heri Anto A: 30/5/23 Hb/Leu/Ht/Trom : R: dr. Sri Indah d
1.3.1 Lubis/24 th/27- - CAP SP 34 10.3/13.13/30.3/555 - KI / shift Indriani, Sp.
05- B/E/N/L/M : - Cek kultur sputum, mo gram P(K) In
2000/01126197 - TB paru klinis 0.2/0.1/83.1/8.1/8.5 1
BTA sputum, GE sputum 
kasus baru status NLR/ALC : 10.26/1.06 Raber :
PT/INR/APTT: 17.5/1.26/31.2 Menunggu Hasil dr. Firdaus A
HIV (-) on OAT
MRS via IGD Alb/AST/ALT/GDS/Ur/Cr : - Cek Kultur CP=> sampel (-), Sp.PD ta
TMT 3/6/23
31/05/23 2.6/60/64/103/26.0/0.65 BTA CP, sitologi CP (H
- Susp. Demam Typ Na/K/Ca/Lac : 134/4.6/101 5/6/23
Padang Lawas hoid HIV/HBsAg : NR/NR - Kultur feces 5/6/23 O
1
081268839593 pH/PCO2/PO2/HCO3/ - Cek lab evaluasi, kultur
M: darah --> 3/6/23
082387418428 TCO2/BE/SO2C : T
- Efusi Pleura Kiri e 7,50/36/76/28/29/5/96 p
Rawatan hari ke 4 c TB dd non TB Na/K/Ca/Lac : 3
- Diagnostik 128/4.2/0.98/1.30
- Anemia (10,3)
- Hipoalbumin (2,6)
- Hiponatremia (128)
- Peningkatan enzim
transaminase
- Syndroma
Dispepsia

19
 Analisa CP Foto Toraks
31/5/23 30/5/23

31/5/23

01/6/23
Kesan : Transudat

pH/PCO2/PO2/HCO3/
Foto abdomen
TCO2/BE/SO2C :
30/5/23
7.47/37//71/27/28/3/95
Na/K/Ca/Lac :
130/3.9/1.04/2.40

CRP: 145.0
Tot Bill/Bil.Ind/Bil.Dir:
0,78/0,38/0,40
PCT: 1.680
Anti Salmonella IGM: Reaktif
Scoce 4

20
 Foto Toraks
31/5/23

USG Abdomen
31/5/23

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 Expertise USG Abdomen
31/5/23

Kesan : Efusi pleura bilateral terut

ama sinistra
6. Jasmin Tn. Ari A: 30/5/23 Hb/Leu/Ht/Trom : R: dr. Indra d
1.3.2 Purnama /37 th/ ‫־‬ CAP SP 57 9,8/19,9/27,8406 ‫־‬ KI/4 jam Yovi, Sp.P
4-4-1985 / B/E/N/L/M : 0,1/0/96,21,4/2,3 ‫־‬ Transfusi PRC 2 labu (K) In
‫־‬ TB Paru bakteriologis
01126176 NLR : 68,71 --> CM (+) --> stok (-) M
kasus baru status HIV PT/INR/APTT/D-Dimer : Raber : 3
‫־‬ Transfusi plasbumin 25 % 1 x
MRS via IGD (-) on OAT TMT 15,9/1,33/34,72,94 pemberian -> terkendala biaya dr. Yulistia, (H

22
 30/5/23 21/3/23 CRP/Alb/AST/ALT/GDS/ ‫־‬ Drip KCl 1 fls/ 12 jam 1x Sp.PD
M: Ur/Cr : pemberian --> sedang berjalan O
Hari rawatan ke 5 71,7/2,2/35/23/92/130,35 ‫־‬ Cek Lab post transfusi dan ta
‫־‬ Anemia (8,9)
PCT : 0.521 koreksi alb,elektrolit 2
Jl. Pramuka II ‫־‬ Hipoalbumin (2,2) Troponin I : 1,7 ‫־‬ Konsul Gizi Klinik (-)
Rumbai ‫־‬ Hipokalemia (2.6) HIV/HBsAg : NR/NR ‫־‬ Konsul Sp.KJ

085272893226 pH/PCO2/PO2/HCO3/
TCO2/BE/SO2C :
7,64/33/228/36/37/15/100
Na/K/Ca/Lac :
100/2,0/0,74/1,2
31/5/23
pH/PCO2/PO2/HCO3/
TCO2/BE/SO2C : Foto Toraks 30/5/23
7.58/42/79/39/41/18/97
Na/K/Ca/Lac :
120/2.5/0.94/2.50

2/6/23
Hb/Leu/Ht/Trom :
8,9/12,14/27,5/257
B/E/N/L/M :
0,2/0,0/92,1/3,1/4,6
NLR/ALC : 29,71/0,38
Alb/AST/ALT/GDS/Ur/Cr :
2,2/23/20/77/24/0,5
Na/K/Cl :
132/2,6/98

23
 EKG
31/5/23

7. Jasmin Tn. Wan Ridwan/ A: 1/6/23 CRP/Alb/GDS : R: dr. Indra d

1.3.5 81 th/ 12-06-1941 ‫־‬ CAP SP 111 03:17 47,2/3,7/347 ‫־‬ Nebu / 8 jam Yovi, Sp.P
/ 01126285 ‫־‬ Cek kultur sputum, mo gram --> (K) In
‫־‬ Obstruksi saluran napas
pH/PCO2/PO2/HCO3/ sampel (-) M
MRS via IGD ec corpus alienum post TCO2/BE/SO2C : 3
‫־‬ Cek HBA1C --> 5/6/23
1/6/23 bronkoskopi 7,29/48/45/23/25/-4/75 ‫־‬ Kultur urine --> 5/6/23
‫־‬ Bekas TB Na/K/Ca/Lac : ‫־‬ Bilasan bronkus --> menunggu
Pindah rawatan 143/3,8/1,12/4,10 hasil
‫־‬ DM tipe 2
ke Jasmin 2/6/23 ‫־‬ Kultur darah --> menunggu
hasil
Hari rawatan ke 3 M: 08:48 Hb/Leu/Ht/Trom : konsul gizi klinik
‫־‬ Atelektasis paru kanan 13,7/17,25/45,3/311
Air Putih, (perbaikan) B/E/N/L/M : Foto Toraks 30/5/23 RSUD
Bengkalis 0,1/0,1/91,2/2,2/6,4 Bengkalis
‫־‬ Sindrom geriatri NLR : 41,45
PT/INR/APTT/D-Dimer :
15,6/1,11/22,2/2,6
CRP/AST/ALT/GDS/Ur/Cr :
74,2/30/12/350/36/0,97
HBsAg/HIV : R/NR

pH/PCO2/PO2/HCO3/
TCO2/BE/SO2C :
7,26/50/48/22/24/-5/76

24
 Na/K/Ca/Lac :
145/3,5/1,11/6 Foto Toraks 1/6/23 pre BC
13:38
Tot. Bil/ Bil. Indirek/ Bil.
Direk :
0,49/0,32/0,17

Urinalisa
Makroskopis
Warna : Kuning Tua
Kejernihan : Keruh
Kimia Urin
Protein : Positif 2
Glukosa : Positif 3
Bilirubin : Negatif
Urobilinogen : 0,2
pH : 6,0
BJ : 1,025
Darah : Positif 3
Keton : Negatif
Nitrit : Negatif
Leukosit estrase : Negatif

Bronkoskopi 1/6/23

Post BC 1/6 23

Kesan : Terdapat corpal di

25
 BUKA

17.00 pH/PCO2/PO2/HCO3/
TCO2/BE/SO2C :
7,434/41,8/145/28/29/4/99
Na/K/Ca/Lac :
145/3,6/1,23

20.00 pH/PCO2/PO2/HCO3/ CT Scan Toraks 1/6/23

TCO2/BE/SO2C :
7,92/42,1/159/27,3/29/3/99/14
3/3,5/1,16
Na/K/Ca/Lac :
143/3,5/1,16
2/6/23 pH/PCO2/PO2/HCO3/
TCO2/BE/SO2C :
7,397/40,3/112/24,8/26/0/98 EKG 1/6/23
Na/K/Ca/Lac :
142/3,6/1.2

8. Jasmin Tn. Bona A: 29/5/23 Hb/Leu/Ht/Trom : R: dr. d

1.3.6 Nababan/ 13-4- - TB Paru Bakteriologis 14.2/6.58/44.4/185 - Evaluasi WSD/ Hari, Adrianison,
1972/ 51th/ Kasus Baru Status HIV B/E/N/L/M : GV/Hari Sp.P(K) O
01126116 (-) on OAT TMT 0.5/1.5/76.2/13.7/8.1 - RM/ Hari 1
NLR/ ALC : 5.56/0.9 8
MRS via IGD 08/05/23 PT/INR/APTT / D-Dimer: - Kultur Cairan Pleura dan
tanggal 29-5- 13.1/0.92/28.1/3.2 sitologi cairan pleura --> T

26
 2023 M: Alb/AST/ALT/Ur/Cr : Menunggu Hasil tgl 7/6/23 W
- Hidropneumothoraks 3.5/31/36/28/0.63 - ADA Test menunggu hasil 2
Hari Rawatan ke sinistra Asam Urat/GDS/PCT : - Foto Toraks evaluasi 4/6/23
6 - Hiperuricemia 13.6/85/ 0.055
Bil. Total/Direk/Indirek : - CT Scan toraks P
Jl. Sei Duku - Syndroma Dispepsia 1.41/0.96/0.45 Kontras06/6/23 cc
HIV/ HbSag : NR/NR U
082334675674 Foto Toraks 29/5/23 (1
pH/pCO2/pO2/HCO3 B
7.37/40/151/23 F
TCO2/BE/SO2C: b
24/-2/99
Na/K/Cl/Lac :
139/3.4/1.1/2.6

Analisa CP 30/5/23

Foto Toraks Post WSD 30/5/23

27
 Kesan : Eksudat
EKG 29/5/23
SITB
4/5/23

Foto Toraks 30/05/23

28
 9. Jasmin Tn.Master A 25/5/23 Hb/Leu/Ht/Trom : R dr. Indra d
MDR 1 Sihotang/52th/30- ‫־‬ TB MDR 14.2/11.46/5.17/271 ‫־‬ Nebu / 6 jam Yovi, Sp. P
6-1970/01125819 ‫־‬ PPOK eksaserbasi B/E/N/L/M : ‫־‬ Kultur sputum --> menunggu In
0.4/3.6/70.7/16.1/9.2 C
tanpa gagal napas hasil
MRS Via NLR : 4.39 1
IGD PT/INR/APTT/D-Dimer ‫־‬ Cek lab evaluasi --> 4/6/23
M
30/5/23 :14.5/1.02/34.4 ‫־‬ Pursue lips breathing T
‫־‬ Hiperkarbia (56) Alb/AST/ALT/GDS/Ur/ A
‫־‬ Chest fisioterapi
Hari Rawatan ke 5 Cr :4.1/17/15/90/ 15.0/0.68 1
(H
Jl. Tanjung datuk Ph/Pco2/p02/HCO3/TCO2/
pekanbaru BE/SO2C
7.37/55/110/32/34/7/98
082123439852 Na/K/Ca/Lac
131/3.9/1.03/0.80
Hbsag/Hiv : NR/NR

SITB
08/08/22

Foto Toraks
SITB 25/5/23

29
 3/4/23

26/5/23 Hba1C : 6,5

Hb/Leu/Ht/Trom :
30/5/23 14.7/9,5/47,4/248
B/E/N/L/M :
0,4/1,2/79,5/11,3/7,6
NLR/ALC : 7,04/1,07
Alb/AST/ALT/GDS/Ur/Cr :
4,3/20/15/107/17/0,61

Ph/Pco2/p02/HCO3/TCO2/
BE/SO2C
7,35/76/164/42/44/16/99 Foto Toraks
Na/K/Ca/Lac 30/5/23
135/4,2/1,08/0,8

31/5/23 pH/pCO2/pO2/HCO3/
TCO2/BE/SO2C:
7.47/56/104/41/43/17/98
Na/K/Cl/Lac :
134/4.0/1.06/2.40

30
 10. Jasmin Tn.Arlijon A 01/6/23 Hb/Leu/Ht/Trom : R: dr.Arlina d
1.4.3 Sirumapea/30-04- - Bronkiektasis 12,1/12,74/38/326 - KIE Hemoptisis Gusti, Sp.P
1982/01117621 terinfeksi B/E/N/L/M : - Cek BTA, kultur sputum, mo In
- Bekas TB 0,4/1,2/79,9/11,5/7,0 gram, kultur sputum jamur -- C
MRS via IGD NLR/ALC: 6,95/1,47 1
01/6/23 - Posibble Mikosis PT/INR/APTT: 15,9/1,13/29,5 > sampel (-)
paru - Transfusi plasbumin 25 % 2x T
Hari rawatan ke 3 pH/pCO2/pO2/HCO3/ pemberian --> sisa 1 A
TCO2/BE/SO2C: - Cek albumin post koreksi 1
Jl.Pelabuhan M: 7,45/40/85/28/29/4/97 (H
- Hemoptisis masif - Cek darah rutin serial bila
Tualang Siak Na/K/Cl/Lac :
- Multiple bullae 135/3,4/1,11/1,10 hemoptisis masih In
081276665307 bilateral berlangsung F
- Hipoalbumin (1,6) 2/6/23 Hb/Leu/Ht/Trom : - Rencana BC-BDMO --> 1
11,2/13,20/34,5/304 tidak acc BTKV (H
B/E/N/L/M : Foto Toraks 6/1/23 m
0,3/2,7/71,4/15,3/10,3
NLR/ALC: 4,67/2,03 P
PT/INR/APTT: H
16,8/1,2/30,3/0,27 8
CRP/Alb/AST/ALT/GDS/
Ur/Cr :
54,7/1,6/6/6/163/0,35/13/0,
57 Foto Toraks 22/1/23

31
 pH/pCO2/pO2/HCO3/
TCO2/BE/SO2C:
7,42/41/79/27/28/2/96
Na/K/Cl/Lac :
135/3,8/1,12/0,8

HIV/HBsAg : NR/NR

GE 10/5/23

CT Scan Toraks 26/1/23

Kesan : MTB Not Detected

Ekspertise CT Scan Toraks

26/1/23

Kesan :

32
 - Proses spesifik lama
- Multiple bullae kedua paru

11. Jasmin Tn. Juan Raju/21 A: 29/5/23 Hb/Leu/Ht/Trom : R: dr. Indra d

1.4.4 th/24-4-2002/ - CAP SP 71 9,1/2,39/27,1/125 - KI / Cek BTA , GE sputum, Yovi,Sp.P
01126128 - TB paru klinis kasus baru B/E/N/L/M : kultur sputum, kultur sputum (K) In
status HIV (+) TMT 0,8/2,9/72,4/13,4/10,5 jamur dan Mo gram--> C
NLR/ALC:5,40/0,29 Raber: 1
MRS via IGD 01/06/23 PT/INR/APTT / D-Dimer: menunggu hasil dr. Ligat
29/5/23 - Possible mikosis paru 17,4/1,25/33,8/>20 - Cek CD4 --> 5/6/23 Pribadi T
- AIDS CRP/ALB/AST/ALT/Ur/Cr : - USG Abdomen --> 5/6/23 Sembiring A
Pindahan dari - PCP 73,2/3,3/90/48/103/13/0,72 Sp.PD 1
Pinere 1/6/23 - Hepatitis B kronik PCT: 1.0 Foto Toraks 29/5/23 (H
HIV/HBsAg:Reaktif/Reaktif dr. Rina
Hari rawatan ke 3 - Gangguan Mental Amtarina,
Organik pH/pCO2/pO2/HCO3/ SpKJ
Jl.Agus salim TCO2/BE/SO2C:
rumbio jaya M: 7,51/31/85/25/26/2/97
Kampar - Leukopenia (2,67) Na/K/Cl/Lac :
- Trombositopeni (95) 125/2,5/0,97/1,40
082179058881 - Candidiasis oral
31/5/23 Tot.Bil/Bil Ind/Bil EKG 30/5/23
- Sindrom dispepsia
Dir:0,52/0,20/0,32
- Hipoalbuminemia (3.2)
- Peningkatan enzim AST/ALT/LDH: 191/71/2527
transaminase
- Sindroma dispepsia
01/6/23 Hb/Leu/Ht/Trom :
11,0/2,67/33.1/95
B/E/N/L/M :
EKG 01/6/23
0,7/4,1/81,0/8,6/5,6
NLR/ALC:9,42/0,21

33
 PT/INR/APTT / D-Dimer:
ALB/AST/ALT/LDH
3,2/216/102/2590
GDS/Ur/Cr: 102/21.0/0,70

pH/pCO2/pO2/HCO3/
TCO2/BE/SO2C
7,45/28,8/101/20.0/21/-4/98
Na/K/Ca/Lac
136/3,8/1,21/31/10,5

2/6/23 Na/K/Cl :
137/4,1/108

12. Jasmin Tn. Jansyahman A: 31/5/23 Hb/Leu/Ht/Trom : R: dr. dr

1.7.3 Saragih/21-03- - KSS paru kanan 10.4/10.44/31.1/324 - KI/8 jam Adrianison,
1960(63th)/01042 T4N2M1c (pleura, B/E/N/L/M : - Koreksi Natrium 3% 1x Sp. P(K)
868 hepar, costae, 0.3/1.1/85.2/7.3/6.1 pemberian --> sedang berjalan
NLR/ALC /Ret:
MRS Via IGD vertebra, clavicula, 11.67/0.76/1.93 - Cek IHK5/6/23 (konfirmasi
31/05/23 scapula, humerus) PT/INR/APTT/D-Dimer : divisi onkologi)
stage IVB PS 2 14.2/1.00/28.0/3.80 - Radioterapi  Menunggu
Hari rawatan ke 4 - Adenocarsinoma CRP/Alb/AST/ALT/GDS : jadwal dari radioterapi
prostat 80.9/3.0/31/24/94 - CT scan kepala kontras -->
Ds. Kandis Ur/Cr : 28.0/0.86
Godang/ kandis Na/K/Chlor /PCT : jadwal (-)
M:
siak - SVKS grade 2; 125/3.6/93/0.360

085355904716 - efusi pleura dextra Sitopatologi Foto Toraks

- nyeri kanker VAS 7 22/5/23
31/5/23
- Hiponatremia (129)

34
 - Hipoalbuminemia
(3,1)
- syndrome dyspepsia

Kesimpulan : gambaran
sitologi sediaan ini sesuai
dengan :
Sitologi TTNA paru kanan
positif mengandung sel epitel
maligna,non small cell lung
EKG 31/5/23
carcinoma jenis
adenocarcinoma

Histopatologi
30/5/23

Kesimpulan : Gambaran
histopatologi sediaan ini
sesuai dengan :
Jaringan biopsy paru
kanan :positif sel tumor
ganas,jenis Non Small Cel

35
 Lung Carcinoma (NSCLC),
sesuai untuk Squamous Cell
carcinoma Poorly
Differentiated
31/5/23
pH/pCO2/pO2/HCO3/
TCO2/BE/SO2C
7.54/30/58/26/27/3/93
Na/K/Ca/Lac
121/3.4/0.99/2.00
2/6/23
Alb : 3,1
Na/K/Cl :
129/4/96
13. Jasmin Tn.Lismari, /23- A: 01/6/23 Hb/Leu/Ht/Trom : R: dr. Arlina dr
1.7.2 4-1965/01126283 - PPOK Eksaserbasi 13,1/11,52/40,9/292 - Nebu /8 jam Gusti,Sp.P
tanpa Gagal Napas B/E/N/L/M : - CT scan toraks dengan in
MRS via IGD 0,1/0,0/83,6/9,5/6,8 Raber : M
01/6/23 - Kanker Paru Kanan NLR/ALC : 8,80/1,10 kontras jadwal(-) Dr. Heri, 3x
jenis (?) T4NxM1b PT/INR/APTT/D-Dimer : - Bronkoskopijadwal(-), Sp.JP
Hari rawatan ke 3 (Pleura,Colli) stage IVA 14,3/1.01/28,8/3,95 konsul SpPD
CRP/Alb/AST/ALT/GDS/ Dr.Heri,
Jl.Kutilang ujung PS2 dd/ Tumor Ur/Cr : (-),SpJP(-),SpAn(-) Sp.PD
Balam, Rokan Mediastinum dd/ 49,1/3,6/80/55/91/49/0,95 - FNAB colli
Hilir Metastasis Tumor di HbsAg/HIV/antiHCV: - Kultur
NR/NR/NR
082388535219
Paru. SputumMenunggu hasil
- Aki dd/ Dehidrasi pH/PCO2/PO2/HCO3/
TCO2/BE/SO2C :
7,48/30/84/22/23/-1/97
M: Na/K/Ca/Lac :
- Sepsis 135/4,6/1,14/1,80
01/6/23 Foto Toraks RS Rokan Hilir
14.00 pH/PCO2/PO2/HCO3/

36
 - Prodiagnostik TCO2/BE/SO2C : 30/5/23
- Nyeri Kanker Vas 4 7,17/49/114/18/19/-11/97
- Peningkatan Enzim Na/K/Ca/Lac :
132/4,8/1,07/5,80
Transminase
- Hiperkoagulopati 20.00 wib
(3,95) pH/PCO2/PO2/HCO3/
TCO2/BE/SO2C :
7,37/41/40/24/25/-2/73
Na/K/Ca/Lac :
135/4,4/1,08/3,20

Tot.Bil/Bil Ind/Bil Dir: CT Scan Toraks RS Ibnu Sina

0,70/0,34/0,36 21/3/23
2/6/23
pH/PCO2/PO2/HCO3/
TCO2/BE/SO2C :
7,44/35/154/24/25/0/99
Na/K/Ca/Lac :
135/4,1/1,07/1,9

37
 Foto toraks 01/6/23

38
 EKG 01/6/23

14. Jasmin Tn. Mohd. Amin A: 2/6/23 Hb/Leu/Ht/Trom : R:

1.7.6 Bin Zainal/08-10- ─ Kanker paru kanan 11,9/10,66/35,1/160 ─ Perbaikan KU dr. Arlina dr
1963/59th/011250 jenis (?) T4N3M1B B/E/N/L/M : ─ IHK --> hasil 8/6/23 Gusti, Sp.P
92 (pleura, pericard, colli) 0,2/0,1/94,1/2,9/2,7
NLR/ALC : 32,45/0,31 Foto Toraks RSUD Bangkinang
MRS via IGD Stage IV A PS 2 PT/INR/APTT/D-Dimer : 29/3/23
2/6/23 ─ PPOK stabil grup E. 14,8/1,04/26,3/1,59
CRP/Alb/Ast/Alt/LDH/
Hari Rawatan ke M: GDS/Ur/Cr:
2 ─ Low intake 76,5/3,2/34/21/54/43/0,7
─ Nyeri Kanker VAS 5
Sungai Museing ─ SVKS Grade 2 pH/pCo2/pO2/HCO3/TCO2/
─ Hiponatremia (129) BE/SO2C
085363238137 7,5/35/81/28/29/5/97
─ Hipokalemia (3,0) Na/K/Cl/Lac
─ Hipoalbumin (3,2) 129/3/93/0,94/1,3

Echo 17/5/23

39
 Foto Toraks 15/5/23

Kesan : Normal function heart

Sitopatologi 17/5/23

Ct Scan Toraks Kontras

16/5/23

Kesimpulan :
Metastasis carcinoma pada
KGB Colli dextra, small round
cell tumor, jenis suggestive
suatu Small Cell Lung

40
 Carcinoma dd/ Poorly Expertise Ct Scan Toraks Kontras
differentiated Carcinoma 16/5/23

Histopatologi 22/5/23

Kesan :
─ Massa sentral paru dextra dan
sindrom vena cava superior.
─ Efusi pericard dan efusi pleura
Kesimpulan : Small round cell dextra.
tumor, jenis suggestive suatu ─ Limfadenopati multiple di
Small Cell Lung Carcinoma paratrakea dextra, supraclavicula
dd/ Poorly differentiated dan colli bilateral yang
Carcinoma
tervisualisasi. -Fibrosis
TTNA 24/5/23 parakardial sinistra.
─ Tidak tampak metastasis hepar
dan tulang.

41
 Foto Toraks 2/6/23

Kesan :Small round cell EKG 2/6/23

carcinoma, jenis suggestive
suatu Small Cell Lung
Carcinoma dd/ Poorly
Differentiated Carcinoma

15. Jasmin Tn. Salmi, /10-8- A: 28/5/23 Hb/Leu/Ht/Trom : R: dr. Ananda dr

1.8.1 1967/ 55th/ - KPKSK paru kiri 8.5/12.21/23.4/52 - KI/Shift Febriani
01107155 extensive disease PS 3 B/E/N/L/ - Rencana Pemberian Bondronat Aulia Sp. P
M :0..0/0.0/96.6/1.2/2.2  Setelah Perbaikan KU T
MRS Via IGD recist I partial respon NLR/ ALC: 80.50/0.15 Raber M
tanggal 28/5/23 - PPOK stabil grup E PT/INR/APTT: 16.6/1.19/28.1 - MRI --> 13/6/23 dr. Mulyadi, le
- Ulkus dekubitus grade 2 CRP/Alb/AST/ALT/GDS/ - Kultur Sputum menunggu Sp.BP-RE (H
Hari Rawatan ke Ur/Cr : hasil
7 M: 128/2.3/1.53/0.61/0.94/28/27/ - Transfusi plasbumin 25 % 2x dr. Desby, In
- Nyeri kanker vas 8 102/47/0.64 pemberian --> sisa 1 Sp.S C
Jl. Yossudarso - Anemia (8.6) HIV/HBsAg : NR/NR 1x
Rumbai - Drip KCl 1x pemberian -->
- Trombositopenia sudah selesai=> cek lab post
Pekanbaru pH/pCo2/pO2/HCO3/TCO2/ K
BE/SO2C M

42
 081276560759 (22.000) 7.58/26/124/24/25/2/99 koreksi 3/6/23 N
- Hipoalbumin (2.1) Na/K/Chl/Lac
- Paraplegia inferior 113/2.7/0.92/2.10
- Hiponatremia (132) Foto toraks
2/6/23 Hb/Leu/Ht/Trom : 22/3/23
- Hipokalemia (2.0) 8,9/2/24,6/22
B/E/N/L/M : 0/0,5/86/5/8,5
NLR/ ALC: 17,2/0,1
Alb/AST/ALT/GDS/Ur/Cr :
2,1/12/13/98/34/0,63
Na/K/Cl :
132/2,0/104 Foto Toraks
27/3/23

Foto Toraks
8/5/23

Foto Toraks
15/5/23

43
 Ct Scan Toraks
21/2/23

Expertise CT Scan
21/2/23

44
 Kesan : Dibandingkan ct-scan toraks
8-11-22 saat ini
- massa paru sinistra, ukuran
berkurang
- Limfadenopati peribronkial sinistra
dan subcarina berkurang
- Efusi pleura sinistra minimal
Lesi listrik batas tegas di kedua lobus
hepar

Foto Toraks
28/5/23

45
 16. Jasmin Tn. Hasan Basri/ A: 29/5/23 Hb/Leu/Ht/Trom : R: dr. Sri melati dr
1.8.2 19-6-1964/ 58th/ - CAP SP 98 12/9.24/38.2/475 - TTNA dan Core biopsi --> Munir,
01125162 - Kanker Paru Kanan B/E/N/L/M : menunggu hasil 13/6/23 Sp.P(K) B
Jenis (?) T4N2M1a 0.5/8.7/62.2/17.6/11 - Sitologi CP  menunggu hasil H
MRS via Poli NLR/ALC : 3.53/1.63 Raber : 40
29/5/23 (pleura) Stage IVA PS 1 PT/INR/APTT/D-Dimer : 13/6/23 dr. Sari, 
13.4/0.94/29.4/2.84 - Cek lab evaluasi 3/6/23 Sp.PD KKV
Hari rawatan ke 6 Alb/ AST/ALT/GDS : - Foto toraks evaluasi --> 3/6/23 dr
M: 3.3/58/43/91 20
- Diagnostik - Punksi pleura jika sesak
Sungai Kubu Ur/Cr : bertambah da
Dusun Beringin, - SVKS grade 1 21/0.98 0,
Rokan Hilir - Trombus vena kava Na/K/Cl : Foto Toraks 29/5/23 
superior + atrium dextra 133/3.1/1.03 cc
082260627562 + brakiocephalika HbSag/HIV : NR/NR se
- Efusi Pleura Kanan pH/pCo2/pO2/HCO3/TCO2/ In
- Nyeri kanker VAS 3 BE/SO2C le
- Peningkatan enzim 7.52/39/109/32/33/9/99 1x
transaminase Na/K/Chl/Lac (H
- Bloodstreak 130/3/1.03/0.9

Analisa CP 30/05/23

46
 Foto toraks Post Pungsi
29/5/23

31/5/23
Kesan : Eksudat Hemoragik

01/6/23 PT/INR/APTT :
14.0/0.99/32.6

PT/INR/APTT :
16,3/1,17/33,6

47
 Ct Scan Toraks 24/5/23

Ekspertise CT Scan Toraks 24/5/23

Kesan :
- Massa paru dextra, sugestif maligna
- Trombus vena cava superior,
brachicephalica bilateral dan atrium
dextra dengan sindroma vena cava
superior
- Multiple nodul di lapangan paru
dextra dengan GGO
- Limfadenopati multiple di
paratrakea dan peribronkial serta
subcarina
- Efusi pleura dextra dan pericard
- Tidak tampak metastasis hepar

48
 EKG 29/5/23

EKG
31/5/23

49