Weekly Report

[15/11/2021] s.d [21/11/2021]

 Weekly Report
15 November 2021 s.d 21 November 2021
Jenis Kasus Rincian

Ruangan Dalam Perawatan Keterangan

Baru Lama Total (a) KRS Meninggal Belum
Terdiagnosa Total
Terdiagnosa
17 12 0 12 4 0 8 0 8
24 A 7 0 7 2 0 5 0 5  
24 C 6 0 6 2 0 4 0 4  
25 0 0 0 0 0 0 0 0
27 13 0 13 3 0 10 0 10
28 14 0 14 3 2 9 0 9  
29 2 2 1 0 1 1  
0 0
 
 

 
 

Keterangan: Baru < 7 hari, Lama > 7 hari, Total (a): Total pasien yang dirawat selama seminggu, baik yang masih dirawat, sudah KRS, meninggal, dunia
 Ruang 17
Chief Ruangan : dr. Astri, dr. Arum, dr. Galih, dr. Ellisma
PPDS Ruangan : dr. Ayu, dr. Reza, dr. Veve, dr. Amang

Pasien Meninggal + Kasus Menarik

Nama/No. RM Problem List Lama Perawatan Problem List Terakhir Causa Mortis
Awal MRS (tgl - tgl)
-

Pasien Belum Terdiagnosis

Nama/No. RM Lama Perawatan Problem List Awal Problem List Saat Ini DPJP
- - - - -

Pasien Kasus Lama

Nama/No. RM Problem List Lama Perawatan Problem List Terakhir Causa Mortis
Awal MRS (tgl - tgl)
- - - - -
 Ruang 24A
Chief Ruangan : dr. Rokhma, dr. Dewi, dr. Fikri, dr. Amanda
PPDS Ruangan : dr. Adam, dr. Firman, dr. Sopa, dr. Ogit

Pasien Meninggal
Nama/No. RM Problem List Lama Perawatan Problem List Terakhir Causa Mortis
Awal MRS (tgl - tgl)
- - - - -

Pasien Kasus Lama

Nama/No. RM Problem List Lama Perawatan Problem List Terakhir Causa Mortis
Awal MRS (tgl - tgl)
- - - - -

Pasien Belum Terdiagnosis

Nama/No. RM Lama Perawatan Problem List Awal Problem List Saat Ini DPJP
- - - - -
Ruang 24 C
Chief Ruangan : dr. Dewi, dr. Della, Dr. Efriko, dr. Ema
PPDS Ruangan : dr. Alid, dr. Satya, dr. Ida, dr. Syafiq

Pasien Meninggal
Nama/No. RM Problem List Lama Perawatan Problem List Terakhir Causa Mortis
Awal MRS (tgl - tgl)
- - - - -

Pasien Kasus Lama

Nama/No. RM Problem List Lama Perawatan Problem List Terakhir Causa Mortis
Awal MRS (tgl - tgl)
- - - - -

Pasien Belum Terdiagnosis

Nama/No. RM Lama Perawatan Problem List Awal Problem List Saat Ini DPJP
- - - - -
Ruang 27
Chief Ruangan : dr. Ade, dr. Affa, dr. Ramadi, dr. Reizal
PPDS Ruangan : dr. Winda,
Divisi Ruangan : dr. Agnes

Pasien Meninggal
Nama/No. RM Problem List Lama Perawatan Problem List Terakhir Causa Mortis
Awal MRS (tgl - tgl)
-1Sdr. Jovan Novardo Putranda/ 20 -Midline granuloma (NK Tcell -MRS : 17/11/2021 -DOC + Desaturation   -Causa mortis : Pulmonary Embolism
th/11507042 Lymphoma) et regio nasal pro
kemoterapi Regimen DA-EPOCH Seri 1 Meninggal (R.26) : 18/11/2021
siklus 5/6 KS 50-60 %

Pasien Kasus Lama

Nama/No. RM Problem List Lama Perawatan Problem List Terakhir Causa Mortis
Awal MRS (tgl - tgl)
- - - - -

Pasien Belum Terdiagnosis

Nama/No. RM Lama Perawatan Problem List Awal Problem List Saat Ini DPJP
- - - - -
Ruang 28
Chief Ruangan : dr. Ponda, dr, Fredo, dr.Hana, dr. Ikke
PPDS Ruangan : dr. Tina, dr. Tohari, dr. Debora, dr. Tommi, dr. Reyhan

Pasien Meninggal
Nama/No. RM Problem List Lama Perawatan Problem List Terakhir Causa Mortis
Awal MRS (tgl - tgl)

Pasien kasus lama

Nama/No. RM Problem List Lama Perawatan Problem List Terakhir Usulan
Awal MRS (tgl - tgl)
- - - - -

Pasien Belum Terdiagnosis

Nama/No. RM Lama Perawatan Problem List Awal Problem List Saat Ini DPJP
- -
Ruang 29
Chief Ruangan : dr. Jefri, dr. Arde, dr. Dipto, dr. Tia,
PPDS Ruangan : dr.Bilal, dr. Sofi, dr.Afina

Pasien Meninggal
Nama/No. RM Problem List Lama Perawatan Problem List Terakhir Causa Mortis
Awal MRS (tgl - tgl)
- - - - -

Pasien Kasus Lama

Nama/No. RM Problem List Lama Perawatan Problem List Terakhir Causa Mortis
Awal MRS (tgl - tgl)
- - - - -

Pasien Belum Terdiagnosis

Nama/No. RM Lama Perawatan Problem List Awal Problem List Saat Ini DPJP
- - - - -
 Ruang 26
Chief Ruangan : dr. Novi, dr. Surya
Divisi : dr. Firman

Pasien Meninggal

Nama/No. RM Problem List Lama Perawatan Problem List Terakhir Causa Mortis
Awal MRS (tgl - tgl)

1Sdr. Jovan Novardo Putranda/ 20 Midline granuloma (NK Tcell MRS : 17/11/2021 . DOC + Desaturation   Causa mortis : Pulmonary
th/11507042 Lymphoma) et regio nasal pro Embolism
kemoterapi Regimen DA-EPOCH Meninggal : 18/11/2021
Seri 1 siklus 5/6 KS 50-60 %

Pasien Kasus Lama

Nama/No. RM Problem List Lama Perawatan Problem List Terakhir Causa Mortis
Awal MRS (tgl - tgl)
- - - - -

Pasien Belum Terdiagnosis

Nama/No. RM Lama Perawatan Problem List Awal Problem List Saat Ini DPJP
- - - - -
 Chief Ruangan : dr. Novi, dr. Surya
Ruang 26 Divisi : dr. Firman

Kasus Menarik
Nama/No. RM Lama Perawatan Problem List Awal Problem List Saat Ini DPJP
1. HOM Raber Mata / MRS : 17/11/2021 1. Midline granuloma (NK Tcell 1. DOC + Desaturation    DPJP: dr.
Lymphoma) et regio nasal pro 1.1 Pulmonary embolism    
Sdr. Jovan Novardo 1.2 Septic encephalopathy Herwindo
Putranda/ 20 Meninggal : kemoterapi Regimen DA-EPOCH Seri 2. Shock Condition (resolved)   Pudjo
1 siklus 5/6 KS 50-60 %   2.1 Hypovolemic Shock   
th/11507042 / Ruang 26 18/11/2021 2. CAP PSI Score 48 RC II Brahmantyo,
2.2 Septic Shock
Ciliwung bed 13 3. Ulkus et regio fasialis sinistra dt 3. Septic condition    Sp.PD
no.1   3.1 Pneumonia CAP PSI Score 80 RC III   
4. OS Blefaritis sinistra dt no.1 3.2 Secondary Infection Related No. 6
5. Mild Cancer Pain 4. Midline Granuloma (NK Tcell Lymphoma) KS 20-30 %
5. Pneumonia CAP PSI Score 80 RC III
6. OS Proptosis e.c Suspect Infiltrasi Massa dd Selulitis Orbita
7. Anemia Hipokrom Mikrositer   
7.1 Def. Fe   
7.2 Related to Malignancy
8. Hematemesis 
   8.1 SMRD   
8.2 Iatrogenic dt post NGT Insertion
9. Mild Cancer Pain
Causa mortis : Pulmonary Embolism
Weekly Report
Sdr. TWH / 22th / R. 27 Pangandaran
Ruang 27 Pangandaran
 Timeline Sdr. TWH/ 22 th
Hari 4 Hari 11 Hari 18
Hari 0 (11/11/2021) (15/11/2021) (22/11/2021) (29/11/2021)
MRS melalui IGD Reguler Hasil USG Doppler pasien menunjukkan tidak Kultur luka dan sputum tidak
dengan leukocytosis dan adanya sumbatan, didapatkan multiple Pasien didaftarkan BMP
lymphadenopathy dan disarankan pemeriksaan
menunjukkan adanya infeksi
thrombocytosis dan ulkus
TCM dan keluarga belum acc
regio cruris

Pasien mengeluh kedua tangan GenXPert tidak didapatkan adanya M.

bengkak dan nyeri dan direncanakan Pasien dikonsulkan ke Rehab Medik Tuberculosis, Terdapat nyeri pada jari-jari
tangan dan kaku dan pasien dikonsulkan ke
pemeriksaan USG Doppler
Reumato dan pasien didaftarkan FNAB
guiding USG
Hari 1 Hari 7 Hari 14/15
(12/11/2021) (18/11/2021) (25-26/11/2021)
Kamis 11 November 2021 (H0) ASSESSMENT Pdx : Bloodsmear, BMP Tunggu hasil Blood
PPDS : dr. Winda 1. Leukocytosis + Thrombocytosis smear, Kultur dasar luka
Divisi : dr. Agnes 1.1 Reactive
1.2 Hematological malignancy Ptx :
HOM/ Sdr. Tri Widyanto Hadi/ 22tahun/ DPJP : dr. Herwindo P.B, SpPD 1.2.1 CML - Bedrest
1.2.2 CLL -Moist dressing
SUBJECTIVES: 2. Anemia NN -Diet TKTP 1800 kkal/hari
- Nyeri pada kaki kanan dan kiri 2.1 Chronic Disease -IVFD NS 1500cc/hari
- Lemas 2.2 Bone Marrow Supression -PO Paracetamol 3x500mg
- Nyeri kepala 3. Chronic limb ischemia -PO Aspilet 1x80mg
- Sariawan 4. Candidiasis Oral -PO Nystatin 4x400.000 IU Kumur telan
-PO Clindamycin 4x300mg (H1)
OBJECTIVES:
KU Tampak Sakit sedang | GCS 456 Pmo :
TD 120/73 mmHg | N 98 x/mnt | Suhu 36,8 oC S, VS, VAS, tanda-tanda thrombosis
RR 18 x/mnt | SpO2 98% on Room Air
VAS 3/10
-K/L :Konjungtiva anemis (+), Oral thrush (+)
-Thorax pulmo : Vesikular (+/+), Ronkhi (-/-)
-Cor : Ictus cordis teraba di MCL S, ICS V
-Abd : Soefl, flat, BU (+)/ Liver Span 10 cm, traube space tymphany
-Ext : Rash pedis bilateral, nyeri tekan (+), VAS 3/10, ulkus regio cruris dextra 4x2cm

Laboratorium 11/11/2021:
DL :9.50/36.490/28,30%/720.000
MCV/MCH: 87,9/29,5
DC: 0,5/0,2/87,4/6,4/5,5
SGOT/SGPT : 28/88
Ur/Cr : 22,7/0,45
Jumat 12 November 2021 (H1) ASSESSMENT Pdx : BMP, kultur dasar luka, USG Doppler
PPDS : dr. Vincent 1. Leukocytosis + Thrombocytosis manus S/D, cruris D, HIV, Albumin
Divisi : dr. Agnes 1.1 Reactive
1.2 Hematological malignancy Ptx :
HOM/ Sdr. Tri Widyanto Hadi/ 22tahun/ DPJP : dr. Herwindo P.B, SpPD 1.2.1 CML - Bedrest
1.2.2 CLL -Moist dressing
SUBJECTIVES: 2. Anemia NN -Diet TKTP 1800 kkal/hari
- Bengkak pada kedua tangan, nyeri (+) 2.1 Chronic Disease -IVFD NS 1500cc/hari
- Sariawan 2.2 Bone Marrow Supression -PO Paracetamol 3x500mg
- Lemas 3. Candidiasis Oral -PO Aspilet 1x80mg
- Nyeri kaki (-) 4. Bilateral arm swelling -PO Nystatin 4x400.000 IU Kumur telan
4.1 Lymphedema -PO Clindamycin 4x300mg (H2)
OBJECTIVES: 4.2 Cellulitis -PO Codein 2x10mg
KU Tampak Sakit sedang | GCS 456 4.3 DVT
TD 117/74 mmHg | N 87 x/mnt | Suhu 36,5 oC 5. Ulkus regio cruris dextra grade 2 Pmo :
RR 20 x/mnt | SpO2 98% on Room Air S, VS, VAS, tanda-tanda thrombosis
VAS 5/10
-K/L :Konjungtiva anemis (+), Oral thrush (+)
-Thorax pulmo : Vesikular (+/+), Ronkhi (-/-)
-Cor : Ictus cordis teraba di MCL S, ICS V
-Abd : Soefl, flat, BU (+), liver Span 10 cm, traube space tymphany
-Ext : Swelling manus sinistra dan dextra, hangat (-), kemerahan (-), nyeri (-), ulkus
regio cruris dextra 4x2cm

Laboratorium 11/11/2021:
DL :9.90/27.820/30,30%/810.000
MCV/MCH: 88,9/29,0
DC: 0,5/0,2/87,1/6,3/5,9
SE : 130/3,9/102

Evaluasi Hapusan darah tepi

-Eritrosit: Normokrom anisopoikilositosis, Mikrositik (+), Eliptosit (+), Target cell (+),
Fragmentosit (+)
-Leukosit: Kesan jumlah meningkat, Neutrofilia (+), hipersegmentasi Neutrofil (+)
-Trombosit: Kesan jumlah meningkat
Senin 15 November 2021 (H4) ASSESSMENT Pdx : Kultur dasar luka terkirim 13/11/2021, kultur
PPDS : dr. Vincent 1. Leukocytosis + Thrombocytosis sputum terkirim 14/11/2021, TCM GenXpert 
Divisi : dr. Agnes 1.1 Reactive Menunggu acc keluarga
1.2 Hematological malignancy
HOM/ Sdr. Tri Widyanto Hadi/ 22tahun/ DPJP : dr. Herwindo P.B, SpPD 1.2.1 CML Ptx :
1.2.2 CLL - Bedrest
SUBJECTIVES: 2. Anemia NN -Moist dressing
- Bengkak pada kedua tangan, nyeri (+) 2.1 Related to malignancy -Diet TKTP 1800 kkal/hari, extra protein
- Lemas 2.2 Chronic disease -IVFD NS 1500cc/hari
- Sariawan 3. Candidiasis Oral -PO Paracetamol 3x500mg
4. Ulkus regio cruris dextra grade 2 -PO Aspilet 1x80mg
OBJECTIVES: 5. Bilateral arm swelling -PO Nystatin 4x400.000 IU Kumur telan
KU Tampak Sakit sedang | GCS 456 5.1 Lymphedema -PO Clindamycin 4x300mg (H5)
TD 117/76 mmHg | N 82 x/mnt | Suhu 36,5oC 5.2 Hypoalbuminemia -Transfusi albumin 20% 100cc hingga Albumin >2,5
RR 20 x/mnt | SpO2 99% on Room Air 6. Severe Hypoalbuminemia g/dL
VAS 5/10 6.1 Hypercatabolic state -PO Codein 2x10mg
-K/L :Konjungtiva anemis (+), Oral thrush (+) 6.2 Low intake
-Thorax pulmo : Vesikular (+/+), Ronkhi (-/-) 7. Multiple lymphadenopathy + weight loss Pmo :
-Cor : Ictus cordis teraba di MCL S, ICS V 7.1 TB S, VS, VAS, tanda-tanda thrombosis, albumin
-Abd : Soefl, flat, BU (+), liver Span 10 cm, traube space tymphany evaluasi
-Ext : Swelling manus sinistra dan dextra, hangat (-), kemerahan (-), nyeri (-), ulkus regio
cruris dextra 4x2cm

Laboratorium 13/11/2021:
Albumin : 2,20
HIV : Non Reaktif

USG Doppler 12/11/2021

-Vena extremitas superior dextra et sinistra
Kesimpulan:
- Tidak tampak trombosis maupun stenosis vena extremitas superior bilateral
- Limfadenopati multiple regio shoulder bilateral, axilla bilateral, brachii bilateral, hingga
regio proximal antebrachii dextra
- Tampak edema pada subcutan regio antebrachii dextra dan sinistra

- Arteri extremitas inferior dextra

Kesimpulan:
-Tidak tampak gambaran stenosis arteri ekstremitas inferior dextra
-Limfadenopati reaktif regio inguinal dextra
Kamis 18 November 2021 (H7) ASSESSMENT
PPDS : dr. Vincent 1. Leukocytosis + Thrombocytosis
Divisi : dr. Vidi 1.1 Reactive
1.2 Hematological malignancy
HOM/ Sdr. Tri Widyanto Hadi/ 22tahun/ DPJP : dr. Herwindo P.B, SpPD 1.2.1 CML
1.2.2 CLL
SUBJECTIVES: 2. Anemia NN
- Bengkak pada kedua tangan, nyeri (+) 2.1 Chronic Disease
- Lemas 2.2 Bone Marrow Supression
- Sariawan (+) berkurang 3. Candidiasis Oral
4. Ulkus regio cruris dextra grade 2
OBJECTIVES: 5. Bilateral arm swelling
KU Tampak Sakit sedang | GCS 456 5.1 Lymphedema
TD 117/76 mmHg | N 82 x/mnt | Suhu 36,5 oC 5.2 Hypoalbuminemia
RR 20 x/mnt | SpO2 99% on Room Air 6. Severe Hypoalbuminemia
VAS 5/10 6.1 Hypercatabolic state
-K/L :Konjungtiva anemis (+), Oral thrush (+) 6.2 Low intake
-Thorax pulmo : Vesikular (+/+), Ronkhi (-/-) 7. Multiple lymphadenopathy + weight
-Cor : Ictus cordis teraba di MCL S, ICS V loss
-Abd : Soefl, flat, BU (+), liver Span 10 cm, traube space tymphany 7.1 TB
-Ext : Swelling manus sinistra dan dextra, hangat (-), kemerahan (-), nyeri (-), ulkus
regio cruris dextra 4x2cm
Pdx : Kultur dasar luka terkirim 13/11/2021, kultur
sputum terkirim 14/11/2021, TCM GenXpert 
Menunggu acc keluarga
Ptx :
- Bedrest
-Moist dressing
-Diet TKTP 1800 kkal/hari, extra protein
-IVFD NS 1500cc/hari
-PO Paracetamol 3x500mg
-PO Aspilet 1x80mg
-PO Codein 3x20mg
-PO Nystatin 4x400.000 IU Kumur telan
-Konsultasi Rehab Medik (Menunggu Acc
Keluarga)
Pmo :
S, VS, VAS, tanda-tanda thrombosis, albumin
evaluasi

Laboratorium 16/11/2021:
Albumin : 2,96
Senin 22 November 2021 (H11) ASSESSMENT Pdx : TCM GenXpert  Menunggu hasil
PPDS : dr. Vincent 1. Leukocytosis 25/11/2021
Divisi : dr. Vidi 1.1 Infection
2. Anemia Macrociter Ptx :
HOM raber Rehab Medik/ Sdr. Tri Widyanto Hadi/ 22tahun/ DPJP : dr. Herwindo P.B, 2.1 Folate deficiency - Bedrest
SpPD 2.2 Vit B12 deficiency - Moist dressing
3. Bilateral arm swelling (Improved) - Diet TKTP 1800 kkal/hari, extra protein
SUBJECTIVES: 3.1 Lymphedema - IVFD NS 1500cc/hari
- Bengkak pada kedua tangan berkurang, nyeri (+) 3.2 Hypoalbuminemia - PO Paracetamol 3x500mg
- Lemas 4. Moderate Hypoalbuminemia - PO Aspilet 1x80mg
- Sariawan (-) 6.1 Hypercatabolic state - PO Nystatin 4x400.000 IU Kumur telan 
6.2 Low intake Stop
OBJECTIVES: 5. Multiple lymphadenopathy + weight - PO Folic Acid 1x5mg
KU Tampak Sakit sedang | GCS 456 loss - PO Vit B12 3x50mcg
TD 115/78 mmHg | N 80 x/mnt | Suhu 36,7 oC 5.1 TB
RR 20 x/mnt | SpO2 98% on Room Air 6. Thrombocytosis Ptx Rehab Medik:
VAS 3/10 6.1 Reactive -Active mobilization
-K/L :Konjungtiva anemis (+) 7. Ulkus regio cruris dextra grade 2 -AAROM AGA II/S
-Thorax pulmo : Vesikular (+/+), Ronkhi (-/-) -AROM AGB II/S
-Cor : Ictus cordis teraba di MCL S, ICS V -AROM Wrist D
-Abd : Soefl, flat, BU (+), liver Span 10 cm, traube space tymphany -PROM Wrist S
-Ext : Swelling manus sinistra dan dextra, hangat (-), kemerahan (-), nyeri (-), ulkus -Breathing exercise
regio cruris dextra 4x2cm -Sensory resensitization

Laboratorium 20/11/2021: Pmo :

DL :10.50/16.460/34,30%/660.000 S, VS, VAS, tanda-tanda thrombosis
MCV/MCH: 94,20/28,80
DC: 5,3/0,2/72,3/13,5/8,7
Albumin: 2,96

Kultur Sputum 21/11/2021:

- Streptococcus viridans (flora normal)

Kultur Luka 21/11/2021

- Staphylococcus epidermidis (flora normal)
Kamis 25 November 2021 (H14) ASSESSMENT Pdx : -
PPDS : dr. Vincent 1. Leukocytosis (Improved)
Divisi : dr. Vidi 1.1 Infection Ptx :
2. Anemia Macrociter - Bedrest
HOM raber Rehab Medik/ Sdr. Tri Widyanto Hadi/ 22tahun/ DPJP : dr. Herwindo P.B, 2.1 Folate deficiency - Moist dressing
SpPD 2.2 Vit B12 deficiency - Diet TKTP 1800 kkal/hari, extra protein
3. Bilateral arm swelling (Improved) - IVFD NS 2000cc/hari
SUBJECTIVES: 3.1 Lymphedema - PO Paracetamol 3x500mg
- Bengkak pada kedua tangan berkurang, nyeri (+) 3.2 Hypoalbuminemia - PO Aspilet 1x80mg
4. Moderate Hypoalbuminemia - PO Folic Acid 1x5mg
OBJECTIVES: 6.1 Hypercatabolic state - PO Vit B12 3x50mcg
KU Tampak Sakit sedang | GCS 456 6.2 Low intake
TD 117/82 mmHg | N 82 x/mnt | Suhu 36,2 oC 5. Multiple lymphadenopathy + weight Ptx Rehab Medik:
RR 20 x/mnt | SpO2 99% on Room Air loss -Active mobilization
VAS 3/10 5.1 Lymphoma Maligna -AAROM AGA II/S
-K/L :Konjungtiva anemis (+) 6. Thrombocytosis -AROM AGB II/S
-Thorax pulmo : Vesikular (+/+), Ronkhi (-/-) 6.1 Reactive -AROM Wrist D
-Cor : Ictus cordis teraba di MCL S, ICS V 7. Ulkus regio cruris dextra grade 2 -PROM Wrist S
-Abd : Soefl, flat, BU (+), liver Span 10 cm, traube space tymphany -Breathing exercise
-Ext : Swelling manus sinistra dan dextra, hangat (+), kemerahan (-), nyeri (-), ulkus -Sensory resensitization
regio cruris dextra 4x2cm
Pmo :
S, VS, VAS, tanda-tanda thrombosis
Laboratorium 24/11/2021:
DL :9.40/22.620/30,70%/868.000
MCV/MCH: 91,90/28,10
DC: 5,2/0,1/76,6/10,5/7,6
Albumin: 2,76

GenXPert 25/11/2021
- MTB: Not Detected
Jumat 26 November 2021 (H15) ASSESSMENT Pdx : DL, LED. CRP, RF, CCP, ANA, FNAB
PPDS : dr. Vincent 1. Multiple Lymphadenopathy + Guiding USG
Divisi : dr. Vidi Leucositosis + Weight loss
1.1 Lymphadenopathy TB Ptx HOM :
HOM raber Reumato raber Rehab Medik/ Sdr. Tri Widyanto Hadi/ 22tahun/ DPJP : 1.2 Lymphoma maligna - Bedrest
dr. Herwindo P.B, SpPD 2. Thrombocytosis - Moist dressing
2.1 Sekunder dt infection - Diet TKTP 1800 kkal/hari, extra protein
SUBJECTIVES: 2.2 Primer dt Trombositosis - IVFD NS 2000cc/hari
- Bengkak pada kedua tangan berkurang, nyeri (+) essential - PO Paracetamol 3x500mg
- Kaku pada tangan tidak bisa menggenggam 3. Acute inflammatory poliarthritis - PO Aspilet 1x80mg
- Sudah bisa berjalan pelan-pelan 3.1 Reactive arthritis - PO Folic Acid 1x5mg
3.2 Reumatoid Arthritis manifest - PO Vit B12 3x50mcg
OBJECTIVES: awal - Konsul TS Reumato
KU Tampak Sakit sedang | GCS 456 3.3 SLE
TD 120/80 mmHg | N 80 x/mnt | Suhu 36,1 oC 4. Anemia Macrociter PTx Reumato:
RR 20 x/mnt | SpO2 98% on Room Air 4.1 Folate deficiency -PO Paracetamol 3x1000mg
VAS 3/10 4.2 Vit B12 deficiency -PO Methylprednisolone 8mg-0-0
-K/L :Konjungtiva anemis (+) 5. Bilateral arm swelling (Improved)
-Thorax pulmo : Vesikular (+/+), Ronkhi (-/-) 5.1 Lymphedema Ptx Rehab Medik:
-Cor : Ictus cordis teraba di MCL S, ICS V 5.2 Hypoalbuminemia -Active mobilization
-Abd : Soefl, flat, BU (+), liver Span 10 cm, traube space tymphany 6. Moderate Hypoalbuminemia -AAROM AGA II/S
-Ext : Swelling manus sinistra dan dextra, hangat (+), kemerahan (-), nyeri (-), ulkus 6.1 Hypercatabolic state -AROM AGB II/S
regio cruris dextra 4x2cm, ROM aktif terbatas digiti 1-5 6.2 Low intake -AROM Wrist D
7. Ulkus regio cruris dextra grade II -PROM Wrist S
-Breathing exercise
-Sensory resensitization

Pmo :
S, VS, VAS, tanda-tanda thrombosis
Sabtu 27 November 2021 (H16) ASSESSMENT Pdx : FNAB Guiding USG 30/11/2021
PPDS : dr. Vincent 1. Multiple Lymphadenopathy +
Divisi : dr. Vidi Leucositosis + Weight loss Ptx :
1.1 Lymphadenopathy TB - Bedrest
HOM raber Reumato raber Rehab Medik/ Sdr. Tri Widyanto Hadi/ 22tahun/ DPJP : 1.2 Lymphoma maligna - Moist dressing
dr. Herwindo P.B, SpPD 2. Thrombocytosis - Diet TKTP 1800 kkal/hari, extra protein
2.1 Sekunder dt infection - IVFD NS 2000cc/hari
SUBJECTIVES: 2.2 Primer dt Trombositosis - PO Paracetamol 3x500mg
- Bengkak pada kedua tangan berkurang, nyeri (+) essential - PO Aspilet 1x80mg
- Kaku pada tangan tidak bisa menggenggam 3. Acute inflammatory poliarthritis - PO Folic Acid 1x5mg
- Sudah bisa berjalan pelan-pelan 3.1 Reactive arthritis - PO Vit B12 3x50mcg
3.2 Spondiloarthritis perifer
OBJECTIVES: 4. Anemia Macrociter PTx Reumato:
KU Tampak Sakit sedang | GCS 456 4.1 Folate deficiency -PO Paracetamol 3x1000mg
TD 122/80 mmHg | N 80 x/mnt | Suhu 36,4 oC 4.2 Vit B12 deficiency -PO Methylprednisolone 4mg-0-0
RR 20 x/mnt | SpO2 97% on Room Air 5. Bilateral arm swelling (Improved)
VAS 3/10 5.1 Lymphedema Ptx Rehab Medik:
-K/L :Konjungtiva anemis (+) 5.2 Hypoalbuminemia -Active mobilization
-Thorax pulmo : Vesikular (+/+), Ronkhi (-/-) 6. Moderate Hypoalbuminemia -AAROM AGA II/S
-Cor : Ictus cordis teraba di MCL S, ICS V 6.1 Hypercatabolic state -AROM AGB II/S
-Abd : Soefl, flat, BU (+), liver Span 10 cm, traube space tymphany 6.2 Low intake -AROM Wrist D
-Ext : Swelling manus sinistra dan dextra, hangat (+), kemerahan (-), nyeri (-), ulkus 7. Ulkus regio cruris dextra grade II -PROM Wrist S
regio cruris dextra 4x2cm, ROM aktif terbatas digiti 1-5 -Breathing exercise
-Sensory resensitization
Laboratorium 26/11/2021:
DL :8.80/22.050/28,50%/921.000 Pmo :
MCV/MCH: 90,50/27,90 S, VS, VAS, tanda-tanda thrombosis
DC: 2,0/0,1/75,9/12,7/9,3
LED: 48
CRP: 13,47
Rheumatoid factor: Negative
Anti CCP 3: 3,0
ANA: 0,20
Senin 29 November 2021 (H18) ASSESSMENT Pdx : FNAB Guiding USG 30/11/2021, BMP
PPDS : dr. Vincent 1. Multiple Lymphadenopathy +
Divisi : dr. Vidi Leucositosis + Weight loss Ptx :
1.1 Lymphadenopathy TB - Bedrest
HOM raber Reumato raber Rehab Medik/ Sdr. Tri Widyanto Hadi/ 22tahun/ DPJP : 1.2 Lymphoma maligna - Moist dressing
dr. Herwindo P.B, SpPD 2. Thrombocytosis - Diet TKTP 1800 kkal/hari, extra protein
2.1 Sekunder dt infection - IVFD NS 2000cc/hari
SUBJECTIVES: 2.2 Primer dt Trombositosis - PO Paracetamol 3x500mg
- Bengkak pada kedua tangan berkurang, nyeri (+) essential - PO Aspilet 1x80mg
- Kaku pada tangan tidak bisa menggenggam 3. Acute inflammatory poliarthritis - PO Folic Acid 1x5mg
- Sudah bisa berjalan pelan-pelan 3.1 Reactive arthritis - PO Vit B12 3x50mcg
3.2 Spondiloarthritis perifer
OBJECTIVES: 4. Anemia Macrociter PTx Reumato:
KU Tampak Sakit sedang | GCS 456 4.1 Folate deficiency -PO Paracetamol 3x1000mg
TD 114/76 mmHg | N 73 x/mnt | Suhu 36,3 oC 4.2 Vit B12 deficiency -PO Methylprednisolone 4mg-0-0
RR 20 x/mnt | SpO2 97% on Room Air 5. Bilateral arm swelling (Improved)
VAS 3/10 5.1 Lymphedema Ptx Rehab Medik:
-K/L :Konjungtiva anemis (+) 5.2 Hypoalbuminemia -Active mobilization
-Thorax pulmo : Vesikular (+/+), Ronkhi (-/-) 6. Moderate Hypoalbuminemia -AAROM AGA II/S
-Cor : Ictus cordis teraba di MCL S, ICS V 6.1 Hypercatabolic state -AROM AGB II/S
-Abd : Soefl, flat, BU (+), liver Span 10 cm, traube space tymphany 6.2 Low intake -AROM Wrist D
-Ext : Swelling manus sinistra dan dextra, hangat (+), kemerahan (-), nyeri (-), ulkus 7. Ulkus regio cruris dextra grade II -PROM Wrist S
regio cruris dextra 4x2cm, ROM aktif terbatas digiti 1-5 -Breathing exercise
-Sensory resensitization

Pmo :
S, VS, VAS, tanda-tanda thrombosis
TERIMA KASIH