LAPORAN JAGA JASMIN

Jumat , 08 Desember 2023 Pukul 16.00 WIB- Sabtu, 09 Desember 2023 Pukul 07.00 WIB
dr. Pofi Risanti Yarsi,dr.Rizki Romadani,dr. Mohd. Syahbani, dr. Adhimas Brahmantyo. Dr. Yolanda Julia Pererel P, dr.Agus Subhan, dr.Daniel
Hutahaean, dr.Nurul Hazi Putri,dr.Nadia Putri Ramadhani

Total Pasien Jasmin : 23 orang, Pasien Lama : 23 orang, Pasien Baru dari IGD : orang, Pasien Baru dari Poli : orang, Pasien pengawasan : 7 orang, Pasien
Pulang : - orang, PAPS :- orang, Pasien Meninggal : - orang, Alih Rawat : - orang, Pindahan dari kenanga : - orang , Pindahan dari Melati : - orang,
Pindahan dari Bougenville : - orang, Pindahan dari Edeilweis : - orang, Pindahan dari krisan : - orang, Pindah ke RICU :- orang, Pindah ke CVCU :
orang. Pindah ke Edelweis : - orang, Pindah dari ICU infeksi : - orang, pasien Raber : - , Pindahan dari ICU Medical : - orang, Pindah ke HCU infeksi : -
orang, Pasien dirujuk : - orang, Pindah ke Ruangan Pinere : - orang, Pindah ke Bougenville : - orang, Pindah dari kenanga lt 2 : orang, Pasien titip di
kenanga lt 2 : - orang, teratai : -, pasien titip mawar : - pasien, titip krisan :- orang

No Kamar Nama Pasien Diagnosis/ Masalah Pemeriksaan Penunjang Rencana DPJP

1. Jasmin Tn. Zakiruddin / A: 30/11/23 pH/PCO2/PO2/HCO3/BE/SO2C R: dr. Dewi dr

1.1.1 78 Th/ - Abses Paru Kiri ec Non 7.46/21/52/15/16/-9/88 - KI / 6jam Wijaya,
30/09/1945 TB Na/K/Ca/Lactat - Nebu / 4 Jam Sp.P (K)
01137568 - Bronkiektasis Terinfeksi 127/3.1/1.05/4.10 - Kultur pus  menunggu In
Raber M
- Caries Dentis Hb/Leuko/HT/Tromb : hasil drg. Diki 3x
MRS Via IGD 12.1/9.25/36.6/503 - AGD jika desaturasi Febrian, (
30/11/23 M: B/E/N/L/M: 0.2/0.0/92.0/6.2/1.6 - Foto Panoramic tunda Sp. BM
Hari rawatan ke - Sepsis (perbaikan) ALC/ NLR : 0.57/14.84 L
10 - Efusi pleura bilateral PT/INR/APTT Foto Toraks 30/11/23 RS pu
- Peningkatan Enzim 18.4/1.31/30.0 Aulia (
Pekerjaan : Transaminase
Pedagang Ikan CRP/AST/ALT/GDS : Pr
BB : 44 327.9/56/55/159 30
TB : 165 Ur/cr :
71.0/1.28
PCT : 10.920

HIV/ HBsAG: NR/NR

1
01/12/23 pH/PCO2/PO2/HCO3/BE/SO2C Foto Toraks
7.49/31/54/24/25/0/90 30/11/23
Na/K/Ca/Lactat
138/2.7/1.15/1.30

pH/PCO2/PO2/HCO3/BE/SO2C
7.42/38/63/25/26/0/92
Na/K/Ca/Lactat
137/2,9/1,10/1,70

02/12/23 pH/PCO2/PO2/HCO3/BE/SO2C
7.48/36/61/27/28/3/93
Na/K/Ca/Lactat
137/3,0/1.09/1,10

3/12/23 pH/PCO2/PO2/HCO3/BE/SO2C
7.46/41/77/29/31/5/96
Na/K/Ca/Lactat
138/3.3/1.13/1.20
EKG 30/11/23
Kultur Sputum, Sputum BTA, Mo
gram, Gene Expert
4/12/23

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 Kesimpulan CT Toraks
Kultur Sputum : Identifikasi 4/12/23
ISOLATE 1 : No growth
Sputum BTA : Pewarnaan Ziehl-
Neelsen Negatif
Mo gram
Bakteri Ditemukan Bakteri basil
Gram negatif+4
Jamur Ditemukan sel ragi dan
Pseudohypa jamur +2

Gene Expert
Hasil : MTB Not Detected
Kesan:
- Abses paru sinistra
Hb/Leuko/HT/Tromb :
- Bronkiektasi
10.3/8.59/31.5/399
- Suspect proses spesifik
B/E/N/L/M:
- Pleural effusion bilateral
0.2/0.0/87.7/8.6/3.5
- Lymphadenopathy peri
ALC/ NLR :
bronkial bilateral, para
0.74/10.20
trakea bilateral ,
Tot Bil/ Bil Indr/ Bil Dir :
subcarina
0.85/0.41/0.44
- Kista multipel hepar
lobus dextra dan sinistra
CRP/AST/ALT :
- Kista multipel renal
55.3/49/46
bilateral
Ur/cr :
56/0.64
Foto Toraks 07/12/23
PCT : 0.923
Post Lung Puncture
pH/PCO2/PO2/HCO3/BE/SO2C
5/12/23 7.47/48/66/35/36/11/99
Na/K/Ca/Lactat
136/4,4/1.13/1.80

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 Urinalisa 5/12/23

Kesimpulan :
Eritrosit 0-1
Leukosit 1-2

Kultur Darah
5/12/23

Kesimpulan :
Identifikasi ISOLATE 1 : No
growth

4
 pH/PCO2/PO2/HCO3/BE/SO2C
06/12/23 7.47/48/66/35/36/11/94
Na/K/Ca/Lactat
136/4,4/1,13/1,80

pH/PCO2/PO2/HCO3/BE/SO2C
07/12/23 7.50/42/61/33/34/10/93
Na/K/Ca/Lactat
133/3,9/1,12/1,50
2. Jasmin Tn. Jhon A: 26/11/23 Hb/Leu/Ht/Trom : 11,4/9,26/33,4/ R: dr. Ananda dr
1.1.2 Saimardi/47th/18-  Kanker paru kanan Jenis 296 • GDS/pagi Febriani
12- (?) T3N2M1a (pleura) B/E/N/L/M : 0,5/1/66,1/25,3/7,1 • Bronkoskopi  12/12/23 Aulia, Sp.P
1975/01125140 PT/APTT/INR/D-dimer : • Transfusi PRC 2 kolf  (K)-Onko In
stage IV A PS 1
13,7/0,97/31/0,92 sisa 1 3x
Pekerjaan:  Bekas TB Alb/AST/ALT : 3,6/8/15 • Cek lab post transfusi Raber:
ppetani sawit  DM tipe 2 tidak GDS/Ur/Cr : 560/62/1,12 dr. G
TB : 155 cm terkontrol HIV/HbSAg : NR/NR Foto Toraks 15/05/23 Merlinda, 6/
BB : 47 kg Sp.PD 12
pH/pCO2/pO2/HCO3/TCO2/
M: BE/SO2C G
 Blood streak 7,36/38/87/21/23/-4/96 9/
MRS Via IGD Na/K/Ca :
 Anemia (8,9)
26/11/23 129/3,6/0,6
 Hiponatremia (129)
Hari rawatan ke  Sindrom dispepsia
14
Foto Toraks 10/11/23
ungai rambai,
Kampar

081377084028

5
 SITB

Foto Toraks 26/11/23

EKG 26/11/23

CT Scan Toraks kontras

27/11/23 01/12/23
BTA evaluasi 28/11/23 : Negatif

GDP: 333 mg/dl, 2 Jam PP:204

Hba1c : 16,6
28/11/23

Sputum BTA dan Sputum Jamur

Kesan:

- Susp. Massa perihiler

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 dextra
- Limfadenopati
paratrakhea,
peribronkhial dextra,
30/11/23 subcarina
- Efusi pleura dextra
minimal
Kesan : - Proses spesifik
BTA Negatif - Susp. Mikosis paru
Jamur : Negatif

GDP : 278 mg/dl

Hasil mikrobiologi 01/12/23

Isolate: candida albicans

Sputum BTA, Gene Expert

5/12/23

06/12/23

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 Sputum BTA :
Pewarnaan Ziehl-Neelsen Negatif
Gen Expert :
Hasil Indeterminate

Hb/Leu/Ht/Trom :
8,9/6,90/27,3/261
B/E/N/L/M :
0,4/1,4/61,7/25,9/10,6
NLR/ALC:2,38/1,79
CRP:27,7
AST/ALT/GDS/Ur/Cr :
17/17/202/19/0,88
Bil.tot/bil.ind/
bil.dir:0,19/0,09/0,10

3. Jasmin Tn. Wahyu A: 06/12/23 Hb/Leu/Trom/HT: R: dr. Sri dr

1.1.3 Diningrat /39 • CAP SP 79 15,5/22,81/478/5,75 ⁻ Nebu/6 jam Indah
th/14-04- • PPOK eksaserbasi PT/APTT: 15,6/31 ⁻ Evaluasi WSD Indriani, In
1984/01137914 tanpa gagal napas AST/ALT/GDS/Ur/Cr: Sp.P(K) C
• Hidropneumotoraks 65/195/141/26,0/0,68 ⁻ GV/hari 1x
Pekerjaan: paru kanan ec Non HBsAg/HIV:NR/NR ⁻ Cek BTA,GE sputum 
Bb 45 TB dd TB CRP/PCT:140,7/1500 menunggu hasil T
Tb 155 M: ALB: 2,5 ⁻ Koreksi Nacl 3% 3 kali A
• insufisiensi hepar 1x
pemberian  sisa 1
MRS Via IGD • hiponateremi berat pH/PCO2/PO2/HCO3/BE/So2C: (H
06/12/23 (111) 7,35/47/94/26/0/97 ⁻ Cek lab post koreksi
Hari rawatan ke 4 • Hipoalbumin (2,7) Na/K/Cl/Lac: T
111/4,4/1,02/2,00 W
06
PCT/CRP : 1.500/140,7 (H
Alb : 2,7
Pr

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 25
foto toraks 06/12/23 U
cm
B
nu

foto toraks post WSD

06/12/23

EKG 06/12/23

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4. Jasmin Ny. Sukamtin/60 A 5/12/23 Hb/Leuko/HT/Tromb: R dr. Indra dr
1.2.1 th/31/Des/1962/0  Abses Paru kanan ec TB 11.1/12.01/34.4/252  KI/8 jam Yovi, Sp. P
1137911 dd non TB B/E/N/L/M  Nebu/8 jam (K) In
0.2/0.1/90.8/4.9/4 M
 TB Paru bakteriologis  Cek D-Dimer 
Bb : 54 NLR/ALC: 18.53/0.59 Raber : le
Tb: 155 kasus kambuh dd/ Mott Alb/AST/ALT/GDS/Ur/Cr: 11/12/23 dr. (H
Pekerjaan: dd/EBTB 3/14/25/129/13/0.41  kultur sputum  Juwanto,Sp
pensiunan guru  Trombus Arteri PT/INR/APTT/D-dimer menunggu hasil .PD-KKV in
Pulmonalis 13.5/0.95/27.7/ 1.31 1x
 Kultur MTB 
MRS Via IGD HIV/HBSAG:NR/NR
tanggal 5/12/23 menunggu hasil
pH/pCO2/pO2/HCO3/TCO2/  CT Angiography  in
Hari Rawatan ke M: BE/SO2C : 12/12/23 x2
5 7.43/66/146/44/46/20/99 (
 atelektasis paru kanan  Echocardiograhy
Na/K/Cl/Lactat : ha
Jl taman karya  efusi pleura bilateral 132/3.8/1.05/1.10 trombus  11/12/23
panam  hiperkarbia (66)
No hp :  hipoalbumin (3) Sitologi CP 4/12/23
081268257010 foto toraks 25/10/23
 Hiponatremi (132)
 Kardiomegali
 Hiperkoagulopati

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 SITB Foto Toraks
5/12/23

EKG 05/11/23

Alb : 3,0
6/12/23

CT scan Toraks 30/11/23

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12
5. Jasmin Alfitriyati/41 th/ A: 27/11/23 Hb/Leu/Ht/Tromb : R: Raber : dr
1.2.3 4-8- ⁻ TB paru Bakteriologis 9,1/6/28.3/438 - Cek CD4  dr.
1982/01135621 kasus baru status HIV (+) B/E/N/L/M : menunggu hasil Adrianison O
OAT TMT 29/11/23 0.8/0/70,7/19,7/8.8 - Trf Plasbumin 2x  Sp. P(K) 1x
Pekerjaan:IRT ⁻ HIV AIDS on ARV NLR/ALC: 3,59/1,18 St
BB: 39 kg PT/INR/APTT/D-dimer : Stok (-) DPJP T
5/11/23
TB: 153 - Cek AST ALT Utama : 
M: 28/11/23 Alb/bil.tot/bil.ind/bil.dir/ast/alt/ Bilirubin /3 Hari dr. Husna
MRS via poli ⁻ DIH GDS/ur/cr: 10/12/23 Sp. PD
27/11/23 ⁻ Efusi pleura kanan 2,9/0,61/0,26/0,35/24/13/111/30/1 - Reintroduce OAT
⁻ Hipoalbuminemia (2,1) .04 dr.
Hari raber ke 13 Na/K/Cl : 136/3,4/97 bila fungsi hati baik Merlinda,
⁻ Peningkatan enzim
transaminase Sp. PD
JL KEMBANG ⁻ Sindrom dyspepsia Analisa CP
SARI, Sail 27/11/23

082169513919

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 Foto toraks 27/11/23 jam 3.0
0

Foto toraks 27/11/23 jam 10.

00

Kesan : Eksudat e.c?

Foto Toraks
BTA CP
5/12/23
28/11/23

USG Abd 7/12/23

Pewarnaan Ziehl-Neelsen Negatif:
Negatif

30/11/23
Hb/Leu/Ht/Tromb :
11,5/6,31/33,5/360
B/E/N/L/M :
0.3/1,1/78,7/13,2/6,7
NLR/ALC: 3,59/1,18

Hasil BTA Sputum 30/11/23

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 BTA Sputum: Negatif
GE : MTB Detected Low Kesan :
- Multiple limfadenopati
perihepatic hilar dan
06/12/23
paraaorta.
Hb/Leu/Ht/Tromb :
- Sludge gallbladder.
10,6/5,74/31,3/416
B/E/N/L/M : - Efusi pleura dextra
0.5/0,5/79,8/11/8,2
NLR/ALC: 7,25/0,63
Alb/AST/ALT/Ur/Cr:
2,1/371/134/19/0,57

6. Jasmin Ny. Liana Br A: 01/12/23 Hb/Leu/Ht/Tromb : R: dr. dr

1.2.4 Purba/43Th/18/07 ⁻ Terduga Tumor Paru 10,4/12,12/34,3/426 ⁻ KI/ 8 jam Zarfiardy,
/1 Kanan dd Metastasis B/E/N/L/M : ⁻ Nebu/ 8 Jam Sp.P(K),
0.5/11,3/68,2/13/7,0 FISR, Pr
Tumor di Paru ⁻ GV /hari
Pekerjaan: IRT NLR/ALC: 5,25/1,58 FAPSR
BB: 65 kg ⁻ Post kraniotomy tumor PT/INR/APTT: 17,8/1,27/34,7 ⁻ Cek lab evaluasi 
TB: 160 cm removal a/i SOL supra Alb/AST/ALT/GDS/Ur/Cr: 9/12/23 Raber : dr.
tentorial 3,0/11/11/77/11/0,55 ⁻ CT scan toraks+ kontras Daril, Sp.S
MRS via IGD ⁻ Hemi Facial Spasme dd  12/12/23
02/12/23 pH/pCO2/pO2/HCO3/TCO2/ dr. Rinelia,

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 Focal Seizure BE/SO2C : ⁻ Hasil IHK  16/12/23 Sp. JP
Hari rawatan ke 8 7,47/50/67/36/38/13/94 ⁻ Sitologi Cairan Pericard
Na/K/Cl/Lactat : dr.
 13/12/23
Dusun Sinaboi , M: 136/2,8/1,02/1,70 Juwanto,
seberida ⁻ Luluh paru kanan Sp.PD -
Foto Toraks
⁻ Efusi Pericard Massif pH/pCO2/pO2/HCO3/TCO2/ KKV
31/07/23
085265206555 BE/SO2C :
⁻ Hipoalbumin (3) 7,50/49/140/38/40/15/99
⁻ Hiperkarbia (49) Na/K/Cl/Lactat :
⁻ Hipokalemia (2,7) 136/2,7/1,09/1,10
⁻ Nyeri kanker vas 5
foto toraks 01/12/23

USG Toraks
4/12/23

Kesan
Tidak tampak efusi pleura
dextra.
Konsolidasi inhomogen di
paru dextra.

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 Foto Toraks 07/12/23
Post Pericardiosintesis

7. Jasmin Tn. A: 3/12/23 Hb/Leuko /HT/Trom : R: Raber dr

1.3.1 Muhtarom/43th/1 • Acute CML 9,1/14,03/28,5/11 • KI / 8 jam dr. Indi
5-11- • TB Paru Bakteriologis B/E/N/L/M : 0,1/0,1/93,2/4,9/1,7 • GDS / pagi Esha,Sp.P O
1980/01137760 NLR/ ALC : 19,02/0,69 • Cek BTA, GE sputum  (K) 1x
Kasus Baru Status HIV PT/INR/APTT : 14,5/1,02/26,1 menunggu hasil
Pekerjaan : (-) Alb/AST/ALT : 2,5/99/72 • Cek GDT  11/12/23 DPJP (m
operator warter CRP : 119,7 • Transfusi PRC 2 labu  dr. Marlina, 9/
treatment pks M: GDS/Ur/CR : 127/26/0,83 sisa 1 Sp. PD-
BB : 50 kg • Diagnostik Na/K/Cl : 134/3,8/105 • Transfusi TC 20 kantong KHOM
TB : 165 cm • Efusi Pleura kanan HIV/HbsAg : NR/NR  Sisa 15 kantong
dr. Nova,
MRS via IGD • Bisitopenia, (anemia pH/pCO2/pO2/HCO3/TCO2/ Foto toraks 3/12/23 Sp. PD (K)
3/12/23 (8,1), trombositopenia BE/SO2 : Onk
(6.000) 7,45/40/42/28/29/4/80
Hari rawatan ke 7 • Hipoalbuminemia (2,5) Na/K/Cl/Lact :
• Peningkatan enzim 127/3,1/1,06/2
Alamat : dusun transaminase
buluh rambai • Hipoksemia,
kecamatan • Asites PCT USG Abdomen
seberida • Hiperbilirubinemia 4/12/23 0,912 4/12/23

082285625269
Sputum BTA, MO Gram
5/12/23

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 Kesimpulan
Sputum BTA
Pewarnaan Ziehl-Neelsen Negatif Kesan :
Mo gram Hepato-splenomegali
Bakteri Batang Gram negatif 10- Asites
12/lp Coccus Gram negatif 3-5/lp Pleural effusion dextra
Jamur Positif

Hb/Leu/Ht/Tromb :
7/12/23
8,1/12,7/25/6
B/E/N/L/M :
0,1/0/94/3,9/2
NLR/ALC : 24,10/0,5
Na/K/Cl: 134/4,6/107
Anti HCV : NR

Urinalisa 7/12/23

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 8/12/23

Bill.Tot/Bil.Ind/Bil.dir/AST/
ALT :
0.49/0.27/0.22/15/10

8. Jasmin Tn. A: 07/12/23 Hb/Leu/Ht/Trom : R: dr. dr

1.3.3 Ayon/68th/18-5-  Loculeted empiema paru 9,8/7,32/30/348  Cek Analisa CP, BTA Ananda F
1955/01138039 kiri ec TB dd Tumor paru B/E/N/L/M : CP  menunggu hasil Aulia, O
0,1/2,2/67,6/16,3/13,8 Sp.P(K) 1x
kiri  Kultur sputum,MO
MRS Via IGD NLR/ALC : 4,15/1,19 T
07/12/23  TB Paru klinis kasus baru PT/INR/APTT : gram  menunggu
status HIV (-) TMT 19,9/1,43/30,5/4,36 hasil In
BB: 48kg 7/10/2023 CRP/Alb/AST/ALT :  Koreksi plasbumin 2x 3x
TB: 168cm 126,3/2,3/54/49  sisa 1
Pekerjaan : Petani M: GDS/Ur/Cr : 110/17/0,61
PCT : 0,232  BC Jadwal (-)
 Nyeri vas 3
HIV/HBsAg : NR/NR  Koreksi Nacl 3% 2x 
 Hipoalbumin (2,3)
Hari Rawatan Ke pH/pCO2/pO2/HCO3/TCO2/ sisa 1
3  Peningkatan enzim BE/SO2C :
transaminase 7,45/58/60/40/42/16/92
 Anemia (9,8) Na/K/Cl/Lactat :
126/2,8/1/1,6
 Hipokalemia (3)

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 Hiponatremia (127) Echokardiografi Foto Toraks
8/12/23 6/11/23

Foto Toraks
25/11/23

Kesan :
Efusi pericard minimal dengan
fungsi LV baik, EF 65 %
8/12/23 Foto Toraks
pH/pCO2/pO2/HCO3/TCO2/
BE/SO2C : 2/12/23
7.50/41/106/32/33/9/99
Na/K/Cl/Lactat :
127/3.0/1.03

Foto Toraks
7/12/23

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 Foto Toraks
7/12/23

Foto Toraks
Post punksi 7/12/23

CT Toraks 24/11/23

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22
 EKG
7/12/23

USG Toraks 8/12/23

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 Kesan :
Tampak efusi pleura
sinistra,loculeted

9. Jasmin Tn. Rusli A: 07/12/23 Hb/Leu/Ht/Trom : R: dr. Ananda dr

S./76th/22-3-  TB Paru 12,5/7,45/36,6/331  Cek fungsi hati/3hari  F Aulia,
1.3.4 1947/01138033 B/E/N/L/M : 0,3/0,4/85,1/4/10,2 11/12/23 Sp.P(K)-
bakteriologis kasus
NLR/ALC : 21,28/0,3 Onk O
baru status HIV (-)  Reintroduksi OAT jika
MRS Via IGD PT/INR/APTT :
07/12/23 TM2 28/11/2023 18,5/1,32/35,3/2,9 perbaikan fungsi hati
CRP/Alb/AST/ALT :  Konsul gizi  jawaban Raber :
BB: 29Kg M: 55,6/2,9/588/347 (-) Dr.Asrizal,
TB: 154cm  DIH GDS/Ur/Cr : 95/60/0,76 Sp.PD
 USG Abdomen
Pekerjaan : Petani  Hipoalbumin (2,9) Bil.Tot/Bil.Ind/Bil.Dir :
6,1/1,33/4,77 11/12/23
 Hiponatremia (129)
Hari Rawatan ke HIV/Hbsag : NR/NR
3  Hipokalemia (3,1)
pH/pCO2/pO2/HCO3/TCO2/ Foto Toraks
081318785637 BE/SO2C : 28/8/23
7,42/49/80/32/33/7/96 RSIA Athaya
Na/K/Cl/Lactat :
129/3,1/1,1/1,5

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 Foto Toraks
05/09/23
RS Mandau

Foto Toraks
16/11/23
RSUD Mandau

Foto Toraks
28/11/23
RS Pratomo

25
 Foto Toraks
7/12/23

EKG

10. Jasmin Tn. Bangun A: 4/12/23 Hb/Leu/Ht/Trom : R: dr. dr

1.3.4 Panjaitan/58th/16  PPOK eksaserbasi tanpa 14,1/7,79/41,3/221 ⁻ Nebu/ 8jam Adrianison,
/2/1965/0113784 gagal napas B/E/N/L/M : 0,3/0,1/76,4/17,7/5,5 ⁻ GDS /pagi Sp.P(K) In
4 NLR /ALC : 4,32/1,38 C
 Bekas TB ⁻ Evaluasi WSD/hari
PT/INR/APTT : 14,1/0,99/31,3 1x
Alb/AST/ALT : 3,8/22/29 ⁻ Cek lab evaluasi
BB : 65kg GDS/Ur/Cr : 224/21/0,84 9/12/23 T
TB : 165cm M: Troponin I : <1,5 A
⁻ GV/Hari
Pekerjaan : Petani  Hiperglikemia reaktif 1x
⁻ Kultur sputum, mo
 Pneumotoraks dextra pH/pCO2/pO2/HCO3/TCO2/ (H
MRS Via IGD BE/SO2C : gram menunggu hasil ST
 Emfisema Subkutis grade
4/12/23 7,43/51/91/34/36/10/97
3
Na/K/Cl/Lactat : T
Hari Rawatan ke  Hiperkarbia (51) 131/3,8/1,08/1,9 W
6  Hiponatremia (131) 4/
(H

26
 Foto Toraks Pr
04/12/23 U
Sputum BTA cm
5/12/23 B
Fo
bu

Foto Toraks
Kesimpulan 04/12/23
Pewarnaan Ziehl-Neelsen Negatif
GE: MTB Not detected

06/12/23 HbA1C: 5,8

Foto Toraks
Post WSD
05/12/23

Foto toraks post reposisi

27
 EKG
4/12/23

11. MDR 1 Tn. Dani kardo A: 2/12/23 Hb/Leuko/Trom/HT : R: dr

silaban/34TH/21/ ⁻ TB Pre XDR 12,6/12,4/331/34,7 • Pengobatan Regimen dr. Sri
11/1989/0113773 ⁻ Gangguan Mental AST/ALT/Cr Individual Melati
4 9/11/0,76/119 • Cek elektrolit post Munir ,
Organik Sp.P ( K)
koreksi  9/12/23
Pekerjaan : pH/PCO2/PO2/HCO3/ BE/SO2C
Karyawan PT 7,57/23/129/21/-1/99 Foto toraks RS mutia sari
M:
TB : 65 kg SITB 20/7/23
- Halusinasi
BB : 173 cm
- Gangguan penglihatan
MRS via IGD OS
3/12/23 - Hiponatremia (120)
Hari rawatan ke 7 Raber :
- Low Intake
Alamat : jln.PT dr. Rina
Adai div pinggir Amtarina,
bengkalis Sp.KJ
085281924358 Foto toraks RS Mandau
7/9/23

28
 3/11/23 Alb/TotBil/BilInd/BilDir/GDS/
Ur/Cr:
3,5/9,47/0,25/0,22/94/13/0,81

06/11/23 Na/K/Cl: 120/4,3/94

Foto toraks RS Mandau

4/11/23

CT Scan
RS Mandau

12. MDR 2 Nn. Nadine A 5/12/23 Hb/Leu/Ht/Tromb : R Raber: dr

Aurelia ⁻ TB MDR 12.4/6.48/296/36.8/296  Cek LPA dr. Indra
Sianturi/15th/ B/E/N/L/M : Yovi, Sp. P
04/Jul/2008/ M 0.5/0.9/77/13.4/8.2 Foto Toraks RS. Santa Maria (K)

29
 01137751 - Peningkatan enzim NLR/ALC 1/12/23
transaminase 5.75/0.87
MRS Via IGD Tot. Bil/ Bil. Indr/Bil. Dire DPJP
Tanggal 5/12/23 0.24/0.11/0.13 Utama:
Alb/AST/ALT :
Hari Rawatan ke 3.6/58/57 dr Riza
5 GDS/Ur/Cr Iriani
109/15/0.62 Nasution,
Pekerjan pelajar Na/K/Ca: SpA
Tb : 155 138/4.1/107
bb : 45 CRP/PCT:

Jl Sumbersari HIV/HbSAg: NR/NR

pekanbaru
081276380000

13. Jasmin Tn. Satria A: 4/12/23 Hb/Leu/Trom/Ht : R: dr. dr

1.4.1 Simanjuntak/30th/ ⁻ TB Paru Klinis Kasus 11.9/17.14/241/37.9 ⁻ GE Sputummenunggu Adrianison,
2-8- Baru Status HIV (+) On B/E/N/L/M : 0.2/0.1/85/7.5/7.2 Hasil Sp.P(K)
1993/01137771 PT/INR/APTT/D-Dimer : O
OAT TMT 6/12/23 ⁻ Cek CD 4  menunggu
14.3/1.01/32.0/0.35 Raber : 1x
⁻ Suspek PCP PCT/CRP : 5.850/262 hasil dr. Andika, T
BB: 37 kg ⁻ HIV Alb/AST/ALT/GDS/Ur/Cr : ⁻ Rencana mulai ARV  Sp.PD 6/
TB: 165 cm ⁻ Kandidiasis Oral 2.9/38/25/95/19/0.71 18/12/23
Pekerjaan : HBSAg/HIV = NR/Reaktif dr. T
pekerja Pabrik Foto Toraks Merlinda, C

30
 M: pH/pCO2/pO2/HCO3/TCO2/ 4/12/23 Sp.PD ol
MRS Via IGD ⁻ Hiponatremia (133) BE/SO2C : 96
4/12/23 ⁻ Hipoalbumin (2.9) 7.47/33/41/24/0/80 dr. tengku
Na/K/Cl/Lactat : misdalia,
Hari Rawatan ke ⁻ Manutrisi 120/2.8/1.0/1.4 Sp.KFR
6
pH/pCO2/pO2/HCO3/TCO2/
BE/SO2C :
7.48/33/131/25/1/99
Na/K/Cl/Lactat :
121/3/1/0.99/1.1
EKG 4/12/23
5/12/23 pH/pCO2/pO2/HCO3/TCO2/
BE/SO2C :
7.42/31/91/20/21/-4/97
Na/K/Cl/Lactat :
134/3,4/1,11/0,6

06/11/23 Bil.tot/bil.ind/bil.dir:
0,94/0,40/0,54
AST/ALT: 59/33

Na/K/Cl: 133/4,1/106

BTA sputum, kultur sputum

5/12/23

31
 Kesan :
BTA sputum : negative
Kultur sputum : Batang gram
negative 3-5/lp
Coccus gram negative 2-3/lp
Jamur : negative

14. Jasmin Tn. M. Sulaiman A: 4/12/23 Hb/Leu/Ht/Trom : R: dr. dr

1.4.3 Kasim/68th/31-  TB Paru Bakteriologis 15,1/16,81/47/433  Evaluasi WSD/ Hari Adrianison,
12- Kasus Baru Status HIV B/E/N/L/M : 0,4/0,4/74,1/15,3/9,8  GV/ Hari Sp.P(K) T
1954/01137812 NLR : 4,84 W
(-) Fase lanjutan TMT  Cek sitologi biopsi
PT/INR/APTT : 14,2/1/28,5 ta
BB: 33kg 21/08/2023 Alb/AST/ALT : 3,6/48/29 abram  menunggu Raber: 4/
TB:  Kanker paru kiri jenis ( ?) GDS/Ur/Cr : 110/26/0,81 hasil 16/12/23 Dr. tengku (H
Pekerjaan: T4N0M1B (pleura, PCT : 0,192  Cek sitologi CP + cell misdalia,
Satpam pericard, Vertebra C7, Th HIV/Hbsag : NR/NR Sp.KFR Pr
block  menunggu
30
2, Th 9) hasil 16/12/23
MRS Via IGD pH/pCO2/pO2/HCO3/TCO2/ dr. U
4/12/23 BE/SO2C :  Bronkoskopi  12/12/23 Nurhasanah 6c
M:
7,5/37/91/29/30/6/98 AGD 10/12/23, ,Sp.GK B
Hari Rawatan ke  Efusi Pleura Kiri Na/K/Cl/Lactat : fo
Swab,IL6  11/12/23
6  Nyeri Kanker VAS 5-6 135/3,2/1,06/2,5
O

32
 Foto Toraks 1x
T
Sputum BTA, Kultur Cairan 21
Tubuh
5/12/23

Foto Toraks
Post Abram

Kesimpulan
Sputum BTA
Pewarnaan Ziehl-Neelsen Negatif

Kultur Cairan Tubuh

Bakteri 0/lp
CT Toraks
Jamur Negatif

Echokardigrafi 8/12/23

33
 EKG
4/12/23

Kesan :
normal
Foto Toraks Post WSD
5/12/23

Foto toraks post reposisi

06/12/23

34
15. Jasmin Tn.Syaflaizar/ A 5/12/23 HB/Leuko/HT/Tromb: R Dr. Indra dr
1.4.4 01/Sep/ ⁻ TB Paru bakteriologis 12.1/6,16/35,1/355 ⁻ KI/8 jam Yovi, Sp.P
1955/68th/ Kasus Baru ST HIV (-) B/E/N/L/M:0,2/0,0/80,3/8,0/11,5 ⁻ Nebu /6 Jam (K) 4F
01137727 NLR/ALC: 10,04/0,49 ta
on OAT TMT 06/12/23 ⁻ CT scan toraks + Kontras
CRP/Alb/AST/ALT/GDS/Ur/Cr: 06
MRS Via IGD ⁻ PPOK Stabil Grup E dd 81/2,8/35/32/89/15/0,60  Jadwal ulang
Tanggal 5/12/23 Tumor paru kiri Jenis (?) PT/INR/APTT:16,2/1,15/31,5 ⁻ Cek sitologi CP 
HBSAG/HIV:NR/NR menunggu hasil 11/12/23
Hari Rawatan ke
5 M pH/PCO2/PO2/HCO3/BE/SO2C: Foto Toraks
 Efusi Pleura bilateral 7,52/43/78/35/36/12/97 3/12/23
TB :175cm  Hiponatremia (122) Na/K/Ca/Lactat:
Bb : 40 127/2,5/1.01/1,20
Pekerjaan tidak  Hipokalemia (2,5)
bekerja Analisa CP
3/12/23
Jl. Utama Sri
meranti
Foto Toraks
082287825015
5/12/23

EKG
5/12/23
Kesan : Eksudat

pH/PCO2/PO2/HCO3/BE/SO2C:
06/12/23 7,31/75/231/38/40/12/100
Na/K/Ca/Lactat:
123/3,0/0,95/1,40

35
7/12/23 Na/K/Cl : Foto Toraks 6/12/23
133/3,8/99

BTA Sputum 8/12/23

Kesan :
Negative
GE 8/12/23

Kesan :
Intermediate

8/12/323 pH/PCO2/PO2/HCO3/BE/SO2C:
7.51/38/66/30/32/7/95
Na/K/Ca/Lactat:
122/2.6/0.99/1.10

36
16. Jasmin Tn. Zulyanis A: 3/12/23 Hb/Leuko/Trom/HT : R: dr. Indi dr
1.6.1 Sutan - Tumor mediastinum 12,9/15,15/39,7/340 - KIE hemoptisis Esha, Sp.P
Muncak/65th/31- media jenis limfoma dd B/E/N/L/M : 0,2/1,9/78,5/13,1/6,3 - Nebu/8 jam ( K)
12- NLR/ ALC : 5,99/1,98 - Cek evaluasi, D- Pr
1957/00856191 timoma dd teratoma dd PT/INR/APTT : 15,6/1,11/33 Raber : 20
tumor paru kanan Alb/AST/ALT : 3,5/15/15 dimer,Profil lipid dr. Daril,
- Stroke vertebrobasiler CRP : 12 GDP.GD2PP  9/12/23 Sp.S
Pekerjaan : GDS/Ur/CR : 94/24/1,06 - MRI leher  21/12/23
pedagang M: HIV/HbsAg : NR/NR - Ct scan kepala danleher
BB : 48 kg  11/12/23
TB : 156 cm - Jenis belum diketahui pH/pCO2/pO2/HCO3/TCO2/
- Hemoptisis ringan BE/SO2 : - Sitologi Sputum 
MRS Via Poli - Retensi sputum 7,46/40/87/28/30/5/97 11/12/23
3/12/23 - Nyeri vas 3 Na/K/Cl/Lact : - Bronkoskopi  12/12/23
- Disfoni dan disfagia 139/3,2/1,12/1,2 AGD  9/12/23
Hari Rawatan ke Swab,PCT,CRP,IL6 
7 - Sind dyspepsia 8/12/23 LDH :
392 11/12/23
Alamat : - NGT menolak  IC (+)
jln.Duyung Pekan Imunologi :
baru TPSA : 0.59
AFP : 1.87
Cea : 3.7 Foto toraks 23/11/23
bHCG : reagen kosong

Kultur sputum 7/12/23

Foto toraks 3/12/23

37
 Kesan :
Isolate 1 : Normal Flora

Echokardiografi 8/12/23

CT Scan leher 23/11/23

Kesan : normal

Kesan :
Tidak tampak tumor laring
Tidak tampak
lymphadenopathy colli
Tidak tampak destruksi
tulang

CT Scan Toraks
5/12/23

38
17. Jasmin Tn. Irwansyah/51 A: 1/12/23 Hb/Leu/Ht/Tromb : R: dr. dr
1.6.4 thn / 22-12-1971 /  KPKSK Paru kanan 10,5/18,12/33,4/389  Rencana kemoterapi lini Zarfiardy,
01136035 Ekstensive disaese PS 2 B/E/N/L/M : 0,2/1,5/82,9/7,9/7,5 1 siklus 1 regimen AF, Sp.P
NLR/ ALC : 10,49/1,43 carboplatin ,etoposide (K), FISR,
MRS via IGD M: PT/INR/APTT/D-Dimer :  11/12/23 FAPSR
1/12/23  SVKS Grade 2 14,3/1,01/28,5/1,06  Tampung CCT pukul
 Nyeri Kanker VAS 5 Alb/AST/ALT : 2,9/18/23 06.00 9/12/23 – 06.00
Hari rawatan ke-9  Hipoalbumin (2,9) GDS/Ur/ Cr : 91/56/0,74 10/12/23
 Efusi Pleura Kanan Cek tgl 10/12/23
DESA  Sindrom Dispepsia pH/pCO2/pO2/HCO3/TCO2/
TELAYAP, BE/SO2C : Foto toraks 7/11/23
senapelan 7,45/37/97/26/27/2/98 :
Na/K/Ca/Lac :
081276136638 131/3,7/1,34/1,10

4/12/23 CRP/PCT :
28/0.148 Foto toraks 14/11/23

39
 Foto toraks 1/12/23
Sitologi sputum 09/11/23

Foto toraks post punksi 1/12/

23

Analisa CP
1/12/23
CT Scan toraks kontras 2/11/
23

Kesan : eksudat

Sitologi FNAB

40
 Kesan ;
Kesan : sel sel atipik curiga - Massa solid
metastasis small cell carcinoma lobulated di
mediastinum
8/12/23 CCT : 96.17 medium sampai
Ur/Cr : 64/0.53 posterior yang
menempel dengan
vena cava superior,
main bronkus, trakea
dan arteri pulmonalis
kanan
- Massa solid di
cavum pleura sampai
dinding
posterolateral
hemithoraks kanan
curiga metastasis
- Pneumonia dan
nodul di lobus
inferior paru kanan
curiga pulmonal

41
 metastasis
- Efusi pleura kanan

CT Scan toraks 06/12/23

Kesan :
-Massa paru sentral di
perihiler kanan, yang
menginfiltrasi bronkus
kanan,
vena cava superior, vena
pulmonalis kanan dan meluas
ke mediastinum, ec
sugestif lung malignancy.
-Limfadenopati paratrakea

42
 kanan, perihiler kiri,
supraclavicula dan
infraclavicula kanan.
-Efusi pleura kanan.
-Efusi pericard.
-Lesi destruktif pada vertebra
Th 1.
---> sesuai T4N3M1b (stage
IVA).
18. Jasmin Tn. A 24/11/23 Hb/leuko/trom/Ht : R: dr. dr
1.7.2 Adriantoni/50th/1 ⁻ HAP 11,7/15,19/597/36,2 Zarfiardy
9/Jun/1973/01137 ⁻ Kanker paru kanan Jenis B/E/N/L/M : 0,1/0,0/92,1/5,2/2,6 ⁻ Transfusi PRC 2 kolf à AF, In
274 PT/INR/APTT : 15/1,06/27,6/3,91  sisa 1 Sp.P(K), L
(?) T4N2M1b (pleura,
Alb/AST/ALT : 4,2/24/27 FISR, n
Pekerjaan : supir pericard, hepar) Stg IV A GDS/Ur/Cr : 137/28/0,86 ⁻ Cek lab post transfusi FAPSR (H
BB : 70 Kg PS 2 PT/INR/APTT/ ⁻ Bronkoskopi 
TB : 165 Cm Ddimer:156/1.06/27,6/3,91 12/12/23
HBSAG/HIV:NR/NR AGD  10/12/23
MRS Via IGD M: Swab,CRP,PCT 
tanggal 24/11/23 ⁻ Anemia (9.5) pH/pCo2/pO2/HC03/TC02/BE/
S02C 11/12/23
⁻ Efusi pleura
Hari rawatan ke :7,47/37/137/27/28/3/99
16 ⁻ Efusi Pericard Na/K/Cal/lactat : Foto Toraks RS mandau
⁻ Hiperkoagulopati (3,9) 133/3,6/0,66/1,30 23/11/23
Jl gaya baru kab.
Kampar

085272813449

Sitologi CP Foto Toraks

43
 20/11/23 25/11/23

EKG
24/11/23
Analisis CP 26/11/23

Foto Toraks Post WSD

25/11/23

Foto toraks 27/11/23

\
Eksudat

Hb/leuko/trom/Ht :
10,6/10,12/33/380
26/11/23 B/E/N/L/M : 0,1/1,0/74,6/14/10,3 USG Abdomen
NLR/ALC: 5,33/1,55 30/11/23

30/11/23

44
 Hb/leuko/trom/Ht :
11.2/11.93/333/33.7
B/E/N/L/M :
0.2/0.6/82.2/8.1/8.9
NLR/ALC : 10.15/0.97
CRP/PCT : 74.9/1.240

kultur CP 2/12/23

Kesan: isolate No growth

5/12/23 Kesan :
Tak tampak metastase pada
Hb/leuko/trom/Ht : hepar.
9.5/9.43/29.6/389 Tak tampak limfadenopaty
B/E/N/L/M : paraaorta
0.3/1.5/79.3/10.8/8.1 Foto Toraks
NLR/ALC 30/11/23
7.34/1.02
PT/INR/APTT :

Alb/AST/ALT :
3.2/69/86
Tot Bil/ Bil Indr/Bil dir
0.69/0.33/0.36
Ur/Cr : CT Scan Toraks 01/12/23
15/0.76

45
 Na/K/Chol
137/3.9/105

Kultur sputum & Mo gram

sputum 05/12/23

Kesan:

Massa paru dextra

Limfadenopati paratrakhea
dextra, peribronkhial
bilateral, subcarina

Efusi pleura dengan nodul

pleura dextra

Efusi pericardial
Isolate: acinotebacter baumanii
Nodul pada hepar

T4, N3, M1a

Foto Toraks
04/12/23

Isolate: Candida glabrata

Echo 06/12/23

46
19. Jasmin Tn. Suardi/ A: 2/12/23 Hb/Leu/Ht/Tromb : R: dr. Sri dr
1.7.3 68TH/ 3/5/1955/ - CAP SP 138 10,7/11,85/32,1/331 - KI/8 jam Melati
01137714 - Kanker paru kanan B/E/N/L/M : 0,1/0,0/86,5/6,1/7,3 - Bronkoskopi  tunda Munir Sp.P In
T4N2M1a (Pleura) stage NLR/ALC : 14,18/0,72 - Radioterapi  jadwal (-) (K) C
Pekerjaan: buruh PT/INR/APTT/ 1x
harian IVA PS 2 dd/ dd tumor Ddimer:15,8/1,12/28,8/2,12 Raber 
BB: 48kg mediastinum CRP: 90,4 dr Hery Sp.
Foto Toraks 2/12/23
TB: 155cm - CAD alb/AST/ALT/LDH/GDS/Ur/Cr : JP A
- Atrial Takikardia ec OMI 3,6/23/42/124/62/0,77 ta
MRS via IGD HIV/HBSAG:NR/NR m
02/12/23 M: st
pH/pCO2/pO2/HCO3/BE/SO2C
Hari rawatan ke 8 - SVKS Grade 2 7,50/29/62/23/24/-1 T
- Hiponatremia (132) Na/K/Cl/Lac : ci
Jl. Hanglekir 128/4,0/1,06/1,90 n
- Nyeri kanker vas 3
06/12/23 pH/pCO2/pO2/HCO3/BE/SO2C
7,51/31/47/25/26/2/87

47
 Na/K/Cl/Lac :
132/3,8/1,04/3,80
Kultur sputum 6/12/23

EKG 2/12/23

CT Scan Toraks 06/12/23

Isolate : E.coli ESBL (+)

07/12/23 Hb/Leu/Ht/Tromb :
10,1/15,66/31,2/299
B/E/N/L/M : 0,1/0,0/91,4/2,4/6,1
NLR/ALC : 38,08/0,38

Sitologi sputum 8/12/23

48
 EKG 06/12/23

Kesan :
Negative sel tumor ganas

20. Jasmin Tn. A: 6/11/23 Hb/Leu/Ht/Tromb : R: dr. dr

1.7.4 Irwanto/45Th/14- − Tumor mediastinum 10.1/17,37/32,2/296 − KI/ 8 jam Adrianison,
Apr-1978/ Anterior dd/ Limfoma B/E/N/L/M : 0.1/0/96,1/2.0/1.8 − Evaluasi WSD/Hari Sp.P(K)
01125285 dd/timoma dd/ teratoma NLR/ALC : 48,05/0,35 − GV / Hari te
PT/INR/APTT:15,3/1.09/29.7 Raber : W
Pekerjaan : Buruh − Hidrokel bilateral CRP/ PCT: 4,5/0,154 − Spooling WSD /hari dr. Sari ta
TB : 170 Cm alb/AST/ALT/LDH/GDS/Ur/Cr : − Cek histologi biopsi colli harahap, 6/
BB : 40 Kg 2,8/17/46/235/95/36/0.53  menunggu hasil Sp.PD - (H
M: HIV/HBSAG:NR/NR KKV
− Jenis belum diketahui 11/12/23
MRS Via IGD − Pleurodesis  9/12/23 Pr
6/11/23 − Hidropneumotoraks pH/pCO2/pO2/HCO3/BE/SO2C dr.Muham 33
− Trombus vena cava 7,48/46/161/34/36/11/100 mad Adan U
Hari Rawatan ke superior + atrium Na/K/Cl/Lac : Sp.U cm
34 − Xylotoraks 133/3,4/1.12/1.80 B
dr. Dewi, Fo
Talang bangai TTNA Foto Toraks 25/10/23 Sp.GK B

49
sibanga duri − Nyeri kanker Vas 6 15/08/23 RS Mandau
− Hipoalbumin (2.5) T
081378349871 − Limfadenopati Colli D
1x
dextra m

T
L
n
1x
Analisa CP Foto Toraks RS Mandau (H
7/11/23 30/10/23

Foto Toraks 06/11/23

Foto Toraks 07/11/23

Kesan : Eksudat e.c? dd/chylus.

pH/pCO2/pO2/HCO3/BE/SO2C
7,48/38/101/28/30/5/98
Na/K/C/Lac :

50
 133/3,7/1.1/0.7
CT Scan Toraks 03/8/23
13/11/23 Hb/Leu/Ht/Tromb :
9.9/16.48/30.6/283
B/E/N/L/M : 0,1/0,2/88,7/4,7/6,3
NLR/ALC : 18,87/0,78
Alb : 2.6

pH/PCO2/PO2/HCO3/BE/SO2C
7.48/38/101/28/30/5/98
Na/K/Ca/Lactat :
133/3,7/1,10/0,70

Hasil kultur CP 03/11/23

Kesan : Massa Mediastinum
Anterior susp. Lymphoma
Efusi Pleura Bilateral
Trombus V. Cava Superior

EKG
6/11/23

Isolate: klabsiella pneumoniae ss

pneumoniae

USG Colli 14/11/23

18/11/23 Hb/Leu/Ht/Tromb :
11/10.42/34.6/400
B/E/N/L/M : 0.1/0.0/88.8/6.3/4.8
NLR/ALC : 14.10/0.66

D-Dimer : 3,73

51
 Alb :2,6
Na/K/Cl : 139/3,9/111

20/11/23 D-dimer/Alb/Na/K/Cl :
3.73/2.6/139/3.9/111

27/11/23 Hb/Leu/Ht/Tromb :
11,7/25.02/37.9/398
B/E/N/L/M : 0.0/0.1/90.9/3.1/5.9
NLR/ALC : 29.32/0.77
PT/INR/
APTT:14.7/1.03/27.9/3.11
alb/glo/protein tot/bil tot/bil
ind/bil dir AST/ALTUr/Cr :
2.9/3.0/5.90/0.18/0.07/0.11/12/27/
32.0/0.61

7/12/23 Hb/Leu/Ht/Tromb :
11,4/14,57/34,8/192
B/E/N/L/M : 0,2/0,4/92,6/3,4/3,4
NLR/ALC : 27,24/0,5 Kesan: nodul multiple pada
PT/INR/APTT : 20,7/1,48/34,4 colli bilateral supraclavicula
D-Dimer : 1,15 bilateral ec susp metastasis
Alb/AST/ALT :
2,5/15/38 Foto toraks 14/11/23
Ur/Cr : 19/0,47
Bil.Tot/Bil.Ind/Bil.Dir :
0,78/0,37/0,41
Na/K/Cl :
133/3,8/104

Foto toraks evaluasi 18/11/23

52
 CT Scan Toraks
22/11/23

Kesan :
Dibandingkan CT scan
toraks tanggal 3-8-2023, saat
ini :
-Massa mediastinum anterior
bilateral, ukuran bertambah.
-Efusi pleura bilateral
bertambah.
-Trombus vena cava superior
dan atrium dextra dengan

53
 sindroma vena cava superior.
-Nodul soliter di perihiler
sinistra.
-Limfadenopati multiple di
supraclavicula bilateral.
-Tidak tampak metastasis
hepar dan tulang.

Foto toraks 29/11/23

USG Testis, Skortum

5/12/23

Kesan :
Hydrocele bilateral.

Foto toraks 06/12/23

21. Jasmin Tn. A: 14/11/23 Hb/Leu/Ht/Trom : R: dr. Sri dr

1.7.6 Damin/54th/29- - Timoma B1 dd limfoid 15.7/5.48/46.8/243 - Evaluasi WSD/hari Indah

54
10-1969/ hipoplasia B/E/N/L/M : 1.3/3.3/71.9/12/11.5 - GV/ hari Indriani, T
01120991 - Pyoopneumotoraks kanan NLR/ALC : 5.99/0.66 - RM/ hari Sp.P (K) W
ec non TB PT/INR/APTT/D-Dimer : - Kemoterapi regimen
Pekerjaan: petani - Polip gallblader 15.5/1.1/32.1/1.06 ADOC  11/12/23 pr
BB: 54 kg - Susp. Hemoroid Interna Ur/Cr : 21/0.84 - Tampung CCT mulai cc
TB : 160 cm - Candidiasis oral Alb/AST/ALT/GDS: 06.00 9/12/13 sampai un
- Mikosis paru probable 3.9/92/161/94 06.00 10/12/23 cm
MRS Via poli Na/K/Ca/Lac : 146/4.1/107 - Kultur CP  menunggu B
14/11/23 M: HIV/HbsAg : NR/NR hasil fo
- Jenis belum diketahui
Hari rawatan ke - Pyopneumotoraks paru Hasil sitologi CP 14/03/23 Foto toraks 07/03/23
26 - Nyeri kanker VAS 6 It
- Sindroma dyspepsia 2x
JL. ABDUL - Hipoalbumin (2.5) (
RAUF PASIR
EMAS, kuantan M
singingi 1g
Foto toraks 10/11/23
081372597612
Gambaran sitologi sediaan ini
sesuai dengan : Reaktif
Mesothelial

Hasil histologi 14/03/23

CT Scan toraks kontras
09/03/23

Kesan: Jaringan ikat Negatif sel

55
 tumor ganas

Analisa CP

Kesan: massa vetebrae th 4-

11 dextra dd massa pleura
dextra
Efusi pleura dextra

CT Scan toraks kontras

10/11/23

Kesan :
Eksudat

pH/PCO2/PO2/HCO3/BE/SO2C
7.41/48/46/30/32/6/82
Na/K/Ca/Lactat :
130/4,3/1,06/1,60

Hasil sitologi 21/11/23

23/11/23 Kesan:
Tumor mediastinum

56
 posterior regio paravetbrae th
3-12
Paru dextra kollaps
Pleural effusion dextra
massive
Herniasi paru dextra

Sitologi Cairan Pleura dextra : EKG 14/11/23

Negatif sel tumor ganas, Pleuritis

Hasil histologi Core biopsi

22/11/23

Foto toraks post punksi

14/11/23

Kesan: Jaringan ikat Negatif sel USG abdomen 16/11/23

tumor ganas

CRP/Alb/AST/ALT/Ur/Cr/PCT
239,3/2,5/14/38/58/1,13/22,310

Hb/Leu/Ht/Trom :
23/11/23
13.9/10.51/42.4/212
B/E/N/L/M : 0.9/0.0/94.7/1.2/3.2
NLR/ALC : 78.92/0.13
24/11/23
CRP/Alb/AST/ALT:

57
 1771.1/2.7/14/37

Kultur Sputum 28/11/23

Kesan : No Growth

Hb/Leu/Ht/Trom :
12/16,79/35,4/679
B/E/N/L/M : 0,6/1,3/87/3,8/7,3
NLR/ALC : 22,89/0,63
01/12/23 Ur/Cr : 19/0,72
Alb/AST/ALT: 2,5/18/31
PCT: 0,272

Analisa CP
07/12/23
Kesan :
Polyp Gallblader
Efusi Pleura Bilateral

58
 Foto Toraks post WSD
16/11/23

Foto toraks 23/11/23

Foto toraks 27/11/23

Kesan:
Eksudat
Foto Toraks
29/11/23

Foto Toraks
4/12/23

59
 Foto toraks 7/12/23

22. Jasmin Tn. Asdin A: 8/12/23 Hb/Leu/Ht/Trom : R: dr. Sri dr

1.8.1 Sinaga/58th/05- ⁻ KSS Paru kanan 10,9/6,73/33,6/463 ⁻ Tampung CCT urin Melati
06-1965/ T4N3M1b (Costae, B/E/N/L/M : 06.00 9/12/23 sampai Munir,
01132598 Pleura) Stage IVA PS 1 0,3/1,0/61,3/23,9/13,5 06.00 10/12/23 Sp.P(K)
⁻ Mikosis Paru Probable NLR/ALC : 2,56/1,61 ⁻ Kemoterapi lini 1 siklus
Pekerjaan : Petani ⁻ PPOK stabil grup E PT/INR/APTT/D- 3 regimen karboplatin
Sawit Dimer :15,9/1,13/29,3/1,59 dan paklitaksel
BB : 45 kg Alb/AST/ALT/GDS: 3,4/14/12/89
TB :165 cm M: Ur/Cr : 21/0,57
• Nyeri kanker VAS 5 Na/K/Cl:139/4,0/106
MRS via IGD • Efusi pleura dextra Foto Toraks 25/09/22
8/12/23 • Hiperkoagulopati Histopatologi 6/10/23
1,59
Hari rawatan ke 2

Jl. SP Proyek
Tasik Serai Foto Toraks 20/10/23
082160451249

60
 Kesan : Foto Toraks 16/11/23
Gambaran histopatologik sediaan
ini sesuai dengan Karsinoma Sel
Skuamosa Berkeratin
Berdiferensiasi Baik

Sitopatologi bilasan 09/10/23

Ct Scan Toraks RSUD
Mandau 14/09/23

Sitopatologi bilasan 05/10/23

61
62
 EKG 16/11/23

Foto Toraks 8/12/23

23. Jasmin Tn. A: 8/12/23 HB/Leu/trom/Ht: : R: Dr. Ananda D

1.8.2 Syarmidi/36TH/05 - CAP SP 86 11,2/11,37/260/4,17 • Kultur sputum dan Febriani
-05-1987/ - Kanker paru kanan PT/APTT/INR: 17,6/27,3/1,25 Mo gram Sampel Aulia,Sp.P
01137230 jenis ? T1BN2M1a Ur/Cr/OT/PT/GDS (-) (K)
(pleura, pericard) Stg 13,0/0,83/19/21/96
Pekerjaan : buruh IVA PS 3 CRP/PCT 90,6/0,826

63
sawit - Syndrom dispepsia pH/PCO2/PO2/HCO3/TCO2/ Foto toraks 29/11/23
M: BE/SO2C
BB : 59 kg - Jenis belum diketahui 7,51/36/87/29/6/98
TB : 162 cm - Nyeri kanker VAS 8 Na/K/Cal/Lac: 127/3,2/1,05/2,30
- Efusi Pericard
MRS via IGD - Hiponatremi (127)
8/12/23 Foto toraks 8/12/23

Hari rawatan ke 2

Alamat :
lenggadai hilir CT Scan toraks kontras
Rimba melintang 18/11/23
rokan hilir

0821 74064004

Ekspertise :

Kesan :

64
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