MAPPING AQSHA 1

Minggu , 12 Mei 2019

Tim Jaga : dr. Intan / dr. Akmal
Dokter Muda : Ferli / Asyifa

KELAS 1 KELAS 2 KELAS 3 KELAS 4

DR : Riza
DR : dr. Wahyu
COW: T. Fahril
COW : dr. Deddy
DM:
DPJP BEDAH SARAF DPJP ORTHOPEDI DM :
Raber:
Raber :
DPJP: dr. M.Riswan, SpPD ,
DPJP : dr. M. Diah, Sp.PD
KHOM
Nama : Sayed Silahudin Nama : Yusmanidar
TTL : 11/12/1943 (75tahun) TTL : 1/3/1956 (63th)
Alamat : Banda Aceh Alamat : Kota Banda Aceh
CM : 1114847 CM : 0854452
Hari Rawatan : 2 Hari Rawatan : 9

A/ A/
1.Hiponaterima 1. Trombositopenia ec dd
2. PSMBAec dd - ITP
- stress ulcer - MDS
- gastritis erosive - Leukimia akut
- ulkus gaster 2. Anemia mikrositer ec dd
- ulkus duodenum defesiensi asam folat
3. Hipertensi stg. II
Th/ 4. Hepatittis C
- Bedrest
- NGT Th/
- Diet sonde bertahap 6 x 50 cc - Bedrest
- IVFD RL guyur 2000 cc dalam 30 - IVFD RL 30 gtt/menit
menit - Diet rendah garam 1700 kkal/hari
- drip lansoprazole dg kec 6,25 cc/jam - Amlodipin 1x10mg
- iv ceftriaxone 2 gr/24jam - Valsartan 1x80 mg
- Mecobalamin 3x500mg
Lab 11-5-2019 - Asam folat 2x1 tab
Hb/Ht/E/L/T: 14,7/42/4,8/19,4/327
MCV/MCH/MCHC: 88/31/35 Lab 9-5-2019
Diftel: 0/0/091/6/3 Hb/Ht/E/T/L: 10,2/29/2,9/20/4,6
MCV/MCH/MCHC: 103/36/35
Lab 10-05-2019 Diftell : 0/0/0/32/64/4
Hb/Ht/E/T/L: 16,1/45/5,2/27,1/258
MCV/MCH/MCHC: 86/31/36
Diftell: 0/1/0/92/4/3 Lab 8-5-2019
PT/APTT : 17,30/30,90 Hb/Ht/E/T/L: 10,7/30/2,3//319/15,8
Anti-HCV : - MCV/MCH/MCHC: 131/46/35
HBsAg : - Diftell: 7/0/1/48/18/26
GDS : 213 SGOT/SGPT: 52/60
Ur/Cr : 35/0,85 Na/K/Cl: 142/4,5/108
Na/K/Cl: 128/3,6/99
Lab 7-5-2019
Hb/Ht/E/L/T: 10,2/29/2,8/5,8/25
MCV/MCH/MCHC: 103/36/35
Diftell: 0/1/0/34/61/4

Lab 6-5-2019
Hb/Ht/E/L/T: 9,8/28/2,7/4,7/9
MCV/MCH/MCHC: 103/36/35
Diftell: 0/0/0/32/65/3
Ca : 9,4
Na/K/Cl:145/3,8/108

Lab 4-5-2019
Hb/Ht/E/L/T: 9,6/28/2,7/5,2/8
MCV/MCH/MCHC: 105/36/34
Diftell: 0/0/0/27/69/4
MDT :
Eritrosit : Normokrom, anisitosis
Leukosit : limfosit atipik (+)
Trobosit : jumlah kurang
Anti HCV/HbsAg : (+)/(-)
 KELAS 5 KELAS 6 KELAS 7 KELAS 8
DR : dr. Wahyu DR : dr. Wahyu DR : dr. Riza
COW : dr. Dedy COW : dr. Dedy COW : dr. Faril
DM : DM : DPJP NEURO DM :
Raber : Raber : Raber :
DPJP : dr. Azzakiq, Sp.PD DPJP : dr. Azzakiq, Sp.PD DPJP : dr. M.Riswan, Sp.PD
Nama : Mardhiah Abdurrahman Nama : Makawiyah Nama : Noverita
TTL : 01-07-1954 (64 th) TTL :31-12-1960 (58 th) TTL ; 16-11-1967
Alamat : Kuta Alam, Banda Aceh Alamat : Aceh Timur Alamat ; Banda Aceh
CM :1206743 CM :1-20-60-73 Hari rawatan : 4
Hari rawatan : 4 Hari rawatan : 30 A/
A/ 1. Februl netropeni ec indius
A/ 1.Tumor esofagus susp. Malignancy kemoterapi
1. CHF ec CAD metastase hepar, paru, dan tulang 2. Metastase breast cancer
2. MR mild 2. OA genu bilateral 3.Anemia ec indius kemo
3. TR Mild 3. PSMBA (perbaikan) 4. Higk ris trombosis
4. ISK 4. Malnutrisi 5. SVT
5. Geriatri problem (inanisi, infeksi, 5. Hipoalbumin berat (3) 6. CAD
imobilisasi,konstipasi) Th/ 7. DM Tipe II
6. Abdoominal pain perbaikan -Bedrest
- Diet sonde 6x200cc/hari Th/
Th/ -IVFD Nacl 0,9% 20 gtt/i - Bedrest
- Bedrest - IVFD Clinimix + clinoleic 1 fls/hari - Bedsite monitor
- Diet jantung II 1700kkal/hari -IV Lansoprazole 30 mg/12 jam - Paracetamol
-IVFD Nacl 0,9% 10gtt/i -Flumucyl 3x1 - Levofloxacin
- Catheter - IV ondansetron 4mg/12 jam - Codein
- IV lansoprazole 30mg/12jam - catarlent 4x1 gtt ODS - CPG 75 mg
-Clopidogrel 1x75 mg - P pred 6x1 gtt ODS
- Spironolactone 1x25 mg -vigamox 6x1 gtt ODS Lab 09-05-2019
-Digoksin 1x0,25 mg -pradaxa 1x40mg Hb/Ht/E/L/T: 9,3/28/3,5/6,9/517
-Atrovastatin 1x20mg -IV Paracetamol 1 gr (extra) MCV/MCH/MCHC: 80/27/33
-coralam 2x5 mg -IV Albumin 25% 100cc/hr Diftel : 0/0/0/57/32/11
- Ramipril 1x25mg - Zometa 1 fls/24j
- Xarelto 1x10mg -IV Cefepime 1g/12 j
- Furosemid 1x40mg
-Laktosa 1xCII Lab 09-05-2019
-Lactulac GDS: 124
-Fosenenema Lab PA 8/5/2019
Kesimpulan : squamous cell
Lab 08-05-2019 carsinoma
Hb/Ht/E/L/Tr: 17,3/50/6,1/8,3/301
MCV/MCH/MCHC: 82/29/35 Lab 07-05-2019
Diftell: 1/1/0/59/33/6 Hb/Ht/E/L/Tr: 11,2/34/5,2/14,5/232
Ur/cr: 99/ 0,80 MCV/MCH: 66/22
Na/K/Cl: 139/5,2/100 Diftell: 2/0/0/84/8/6
GDS : 100
Analisa cairan pleura 07-05-2019
Urinalisa 09/05/2019 makroskopik
pH : 5,0 warna : merah
Berat jenis : 1,015 kejerniham : keruh
Nitrit : negatif bekuan: negative
Protein : +1 mikroskopik
Keton : + hiung jenis sel
Glukosa : - PMN sel :40%
Urobilinogen : - MN sel: 60%
Epitel : 3-5 Leukosit: 1620
Warna : kuning Total protein: 2,9
Darah : + Glukosa: 156
Leukosit : 8-10
Eritrosit : 4-6 Lab 06-05-2019
Lekosit : - Hb/Ht/E/L/Tr: 9,5/29/4,5/16,6/333
Bilirubin : - MCV/MCH/MCHC: 63/21/33
Diftell: 1/0/0/90/4/5
Ur/cr: 33/0,53
Na/K/Cl: 140/3,8/101
Lab 04/05/19
Albumin : 2,38
Na/K/Cl: 133/4,3/98
Lab 28-04-2019
Hb/Ht/E/L/Tr: 8,5/25/4,1/8,7/309
MCV/MCH/MCHC: 61/21/34
Diftell: 2/1/0/79/11/7
PT/APTT: 13,10/32,10
Ur/cr: 20/0,46
Na/K/Cl: 132/5,2/9

Endoskopi
Tumor esophagus suspect maligna
 KELAS 9 KELAS 10 KELAS 11 KELAS 12
DR : dr. Muna
DPJP : Orthopedi COW : dr. Suheir
DPJP BEDAH
Raber: EMD DM : DPJP NEUROLOGI
Raber EMD
Raber:
DPJP : dr. Abdullah, Sp.PD-KGH
Nama : Mustafa Khaharuddin
TTL : 27-07-1954 (64 tahun)
Alamat : Ulee Kareng
CM : 0682887
HariRawatan : 14

A/
1. CKD stage V on HD regular
2. CAD
3. Susp recurrent stroke
4. Pneumonia (HCAP)
(perbaikan)
5. Hipoalbuminemia sedang
6. Candidiasis orofaring

Th/
- Bedrest
- O2 2-4 l/i
-Diet sonde ginjal 6x200 cc via oral
-Threeway
-HD Senin-Rabu-Jumat
- drip albuminar 25% 100cc/hari (H3)
-Clindamycin 3x300 mg (H-10)
-Paracetamol 3x1000 mg
-Lenal Ace 2x169 mg
-As. Folat 2x400 mg
-Aspilet1x80mg
-ISDN 3x5 mg
-Clopidogrel 1x75 mg
-Atorvastatin 1x20 mg
-Flumucyl 3x200 mg
- Nebule Combivent 1 resp/8jam
-chlorpromazin 1x25mg (malam)
(tunda)
-citicolin 2x500mg
-mecobalamin 2x500mg
- amlodipine1 x 5 mg

Lab 11-05-2019
Alb: 2,77
Ca: 8,9
Na/K/Cl: 143/3,5/106

Lab 08-05-2019
Hb/Ht/E/L/T : 9,4/27/3,1/9,7/229
MCV/MCH/MCHC: 86/30/35
Difftel : 3/1/0/86/6/4
Ur/Cr: 155/7,32
Na/K/Cl: 139/3,3/104
Albumin: 2,34
Ca: 8,4
Lab 10-05-2019
Hb/Ht/E/L/T : 9,6/28/3,2/9,0/199
MCV/MCH/MCHC: 87/30/34
Difftel : 4/1/0/83/7/4
Ur/Cr: 101/5,43
Na/K/Cl: 142/3,2/106
Calsium : 8,2
Lab 05-05-2019
Hb/Ht/E/L/T : 8,6/25/2,9/6,7/257
MCV/MCH/MCHC: 84/30/35
Difftel : 4/2/0/80/11/3
Ur/Cr: 174/7,59
Na/K/Cl: 135/3,3/102
Albumin: 2,63
Lab30-04-2019
CKMB jantung: 23
Lab 28-04-2019
Hb/Ht/E/L/T : 7,3/20/2,5/7,0269
MCV/MCH/MCHC: 83/30/36
Difftel : 2/1/0/81/12/4
Ur/Cr: 152/6,25
Na/K/Cl: 126/3,3/99
ISO 1
DR : dr. Riza
COW : dr. T.fahril
DM :
Raber :
DPJP: dr. Riswan, Sp.PD-KHOM
Nama: Rahimah
TTL : 20-06-1975 (43 tahun)
Alamat : Banda Aceh
CM : 1205392
Hari Rawatan: 11
A/
1. MBC metastase tulang post kemo
siklus 1
2. trombositopenia (perbaikan)
Th/
-Bedrest
- diet MB 1700kkal/hari
- IVFD RL 20 gtt/menit
- PCT 3x500mg
- coditam 3x1
- tracetat 1x1
- docetaxel 1x1
- doyorobicon 1 x 69 mg
- cyclophosphawde 1 x 690 mg
- IV metil prednisolone 125mg/12jam
- ondansetron 2x4mg
- fosen enema supp (prn)
- ondancetron 2 x 4 mg
- sucralfat syr 3x1
- leukogen 1 mg
Lab 11/05/2019
Hb/Ht/E/L/Tr: 11,5/33/4,2/2,0/19
MCV/MCH/MCHC: 80/28/35
Difftel: 5/0/0/61/33/1
Lab 09/05/2019
Hb/Ht/E/L/Tr: 8,3/24/3,0/4,7/51
MCV/MCH/MCHC: 81/28/34
Difftel: 0/0/1/64/ 33/2
Lab 09/05/2019
Hb/Ht/E/L/Tr: 8,3/24/3,0/4,7/51
MCV/MCH/MCHC: 81/28/34
Difftel: 0/0/1/64/ 33/2
Lab 07/05/2019
Hb/Ht/E/L/Tr: 8,3/24/3/4,7/51
MCV/MCH/MCHC: 81/28/34
Difftel: 0/0/1/64/33/2
Lab 06/05/2019
Hb/Ht/E/L/Tr:9,7/29/3,5/7,8/11
MCV/MCH/MCHC: 81/27/34
Difftel: 0/1/0/48/48/3
Lab 04/05/2019
Hb/Ht/E/L/Tr:11/32/4,0/9,9/16
MCV/MCH/MCHC: 80/28/34
Difftel: 30/3/0/11/50/6
PT/APTT: 15,40/40,90
ISO 2
DR : dr. Riza
COW : dr. T.fahril
DM :
Raber : bedah uro
DPJP: dr. M.Riswan,Sp.PD,KHOM
Nama: Hamdan AS
TTL : 08-01-1951 (68 tahun)
Alamat : Aceh Besar
CM : 0914197
Hari Rawatan: 13
A/
1. Pneumonia (CAP) (perbaikan)
2. Geriatric problem (infeksi,
instabilitas dan jatuh, inanisi)
3. Hipertensi terkontrol
4. Ulkus dekubitus grade I
5. Hiccup (perbaikan)
6. Post op ca prostat
7. CAD
8. Adenocarcinoma Prostat
Th/
-Bedrest
- diet MII 1700kkal/menit
- IVFD NaCl 0,9 % 20 gtt/menit
-IV Omeprazole 40 mg/12 jam
-Domperidon 3x10 mg
-Asetilsistein 3x200 mg
-Amlodipin 1x5 mg
-Valsartan 1x80 mg
-Casodex/24 jam
-Miniaspi 1x80 mg
-Atorvastatin 1x20 mg
-KSR 1x600 mg
-IV Zometa 4 mg/100ml/hr
- mecobalamin 1x500mcg
- gabapentin 1x300mg
- codein 3 x 10 mg
Lab 09/05/2019
Hb/Ht/E/L/Tr: 10,7/29/3,7/10,9/328
MCV/MCH/MCHC: 79/29/36
Difftel: 0/1/0/83/8/8
Albumin: 3,06
Lab 03/05/2019
Hb/Ht/E/L/Tr: 9/25/3,2/9,2/160
MCV/MCH/MCHC: 78/28/36
Difftel: 1/0/1/78/13/7
Na/K/Cl: 128/4,2/107
Lab 02-05-2019
Na/K/Cl: 129/3,6/107
Lab 1-05-2019
Na/K/Cl: 120/3,8/95
Lab 29-04-2019
Hb/Ht/E/L/T : 9,7/26/3,5/6,5/180
MCV/MCH/MCHC: 75/28/37
GDS: 129
Ur/Cr: 49/0,58
Na/K/Cl: 108/4,7/85
ISO 3 ISO 4
DR : dr.Wahyu
DR : dr. Riza
COW : dr. Dedy
COW : dr. T.Fahril
DM :
DM :
Raber : Neurologi, pulmo, GH
Raber :
DPJP: dr.Azzaki Abubakar, Sp.PD,
DPJP: dr. Riswan SP.PD
KGEH
Nama: Miskiah Parto P. Nama: Basri AbdulWahab
TTL: 05/06/1957 (61th) TTL: 07/11/1977 (41thn)
Alamat: Banda Aceh Alamat: UleeKareng, Banda Aceh
CM: 1145613 CM: 1687864
Hari Rawatan : 18 Hari Rawatan :32
A/ A/
1. AKI stg III dd/ hepatorenal 1.NHL post kemoterapi siklus ke-3
syndrome tipe I dengan regimen ugmesna
2. Sirosis hepatis std dekompensata 2.Bisitopenia induced kemoterapi
3. Pneumonia (HAP) 3.High risk trombosis
4. Hemiparese sin ec recurrent stroke 4. PSMBA (perbaikan)
5. Anemia sedang NN ec dd
1. Penyakit kronis Th/
2. Perdarahan -Cetirizin1x10mg
- IV ondansentron 8 mg/hari
Th/ - IV MST 15 mg/12jam
- Bed rest - Domperidone 3x10mg
- Diet hati MII 1700 kkal/hari - Lactulac Syr 2xCII
- Three way - Coleste tab 2x1
- Balance cairan seimbang - trasetat 2 x 1
- Atorvastatin 1x40mg -IV Prosogan 30mg/12jam
- Lactulac syr 3xCI -clindamisin zalf 3x ue
- drip albumin 25% 100cc/hari -IV levofloxacin 750mg/24jam
- Mecobalamin 3x500mg -leukogen 1 vial/24jam
- IV Omeprazole 40mg/12 jam -terapi PCR 2 kolf
- Gabapentin 1x300 mg -terapi TC 2 kolf
- IV Furosemide 40 mg/12 jam
- Levofloxacin 1x500 mg Lab 11-05-2019
- Spironolakton 2x200mg Hb/Ht/E/L/Tr: 7,4/22/2,7/4,8/20
- IV Cefepim 1gr/24jam MCV/MCH/MCHC: 83/28/33
- Flumucyl 3x200 mg Difftel: 0/1/0/37/53/9
- Norepinefrin 0,5 mg/jam
- IV vit-k 10 mg (ekstra) Lab 09-05-2019
- IV asam traneksamat 500mg Hb/Ht/E/L/Tr: 6,2/18/2,2/3,5/76
(ekstra) MCV/MCH/MCHC: 84/29/34
Difftel: 0/0/0/29/64/7
Lab 11-05-2019
Hb/Ht/E/L/Tr: 7,1/20/2,2/6,9/31 Lab07-05-2019
MCV/MCH/MCHC: 94/33/35 Hb/Ht/E/L/Tr: 5,2/16/1,9/3,5/12
Difftel: 2/0/0/83/7/8 MCV/MCH/MCHC: 84/27/32
Albumin :2,35 Difftel: 0/0/0/32/62/6
Ur/Cr :185/4,89
Lab 10-05-2019 Lab06-05-2019
Hb/Ht/E/L/Tr: 7,5/22/2,3/11,0/40 Hb/Ht/E/L/Tr: 5,6/18/2,1/3,2/6
MCV/MCH/MCHC: 93/32/35 MCV/MCH/MCHC: 85/27/32
Difftel: 1/1/0/83/7/8 Difftel: 0/0/0/37/59/4
Albumin :2,60 PT/APTT : 12,7/33,6
Ur/Cr :158/3,99
Lab 09-05-2019 Lab 05/05/2019
Hb/Ht/E/L/Tr: 7,5/22/2,3/8,3/37 Hb/Ht/E/L/T: 5,8/18/2,3/4,0/5
MCV/MCH/MCHC: 93/32/35 MCV/MCH/MCHC : 84/27/32
Difftel: 2/1/0/78/9/10 Diftell: 0/0/1/37/58/4
PT/kontrol/INR: 18,10/13,7/1,43
APTT/kontrol: 45,5/36 Lab 01/05/2019
Urinanalisis : Hb/Ht/E/L/T: 6,1/19/2,3/5,0/6
- Makroskopik : MCV/MCH/MCHC : 84/27/32
Warna : Kuning Diftell: 0/1/0/39/56/4
Kejernihan : keruh PT/APTT: 14,60/36,0
Berat jenis : 1.015
pH : 5 Lab 30/04/2019
leukosit : +1 Hb/Ht/E/L/T: 6,5/20/2,4/4,6/69
protein : +1 MCV/MCH/MCHC : 82/27/33
Darah : +
- Sendimen urine : Lab 28/04/2019
Leukosit : 20 – 25 Hb/Ht/E/L/T: 7/21/2,6/2,5/3
Eritrosit :8 - 10 MCV/MCH/MCHC : 82/27/33
Epitel : 3 - 5 Diftell: 0/2/0/47/49/2
Lab 22/04/2019
Urinalisa
Glukosa (+1)
 ISO 5 ISO 6 ISO7 ISO 8
DR : dr. Reyza DR : dr. wahyu DR :
COW: dr. febri COW : dr. dedy COW :
DPJP BTKV DM: DM : DM :
RABER EMD Raber: Raber : EMD, HOM Raber :
DPJP: dr. Islamuddin, Sp.PD DPJP : dr. M.Diah,Sp.PD KKV DPJP :
Nama : Jalaluddi Nama : Marsalena Nazaruddin Nama :
TTL : 01/07/1965 (53th) TTL : 19/05/1955 (63 Th) TTL :
Alamat : Aceh Utara Alamat : Aceh Besar Alamat :
CM : 1207614 CM : 1189059 CM :
Hari Rawatan : 15 Hari Rawatan :7 Hari Rawatan :

A/
dd 1. TB paru, BTA (-)
2. massa paru dextra
2. Preleukemia
Th/
- Bedrest
- Diet lunak 1700kkal/ hari
- Threeway
- -IV omeprazole 40mg/12jam
- Paracetamol 3 x 500 mg (k/p)
- 4FDC 1x3 tab (h5)
- Piridoksin 2x1
- Curcuma 3x1
- Metylrednidsolon
- Omeprazole
Lab 09/05/19
Hb/Ht/E/L/Tr : 10,1/28/3,5/2,1/250
MCV/MCH/MCHC: 81/29/36
Diftel: 1/0/0/32/55/12
Na/K/Cl: 131/3,8/99
Lab 06/05/19
Hb/Ht/E/L/Tr : 9,1/27/3,3/1,3/40
MCV/MCH/MCHC: 81/27/34
Diftel: 0/1/0/60/30/9/1
Na/K/Cl: 135/3,7/106
A/ A/
1. Penurunan kesadaran ec dd
- Imbalance elektrolit
- sepsis
- Metastase proses
2. Ca Mammae post kemo
siklus 4
3. DM Tipe 2 OW
4. Hipoalbuminemia
5. Obs jaundice ec dd
-cholangio ca
-ca kaput pangkreas
-kolelitiasis
Th/ Th/
- Bedrest
- -02 2-4L/i
- Pasang NGT+kateter urin
- Diet DM MII 1700kkal/hari
- Kompres luka dikaki dengan Nacl
0,9%
- IVFD NaCl 3% 10 tpm
- Drip paracetamol 1gr/8 jam (prn)
- IV Omeprazole 40 mg/12 jam
- IV ondansetron 4mg/8jam (kp)
- KSR 2x600mg
- Leukogen 1 vial/24jam (k/p)
- Drip insulin novorapid 1 unit/jam
- IV Levofloxacin 500 mg/24 jam
- Pradaxa 1x110mg
- drip albuminar 25% 1fls/24 jam
- gabapentin 1x300mg
- SC Lantus 0-0-0-12 unit

Lab 11/05/19
Hb/Ht/E/L/Tr : 7.0/19/2,3/10,3/41
MCV/MCH/MCHC: 82/30/37
Diftel: 0/1/0/90/6/3
Alb: 2,19
Ca: 7,5
Na/K/Cl: 140/2,9/108

Urinalisa 09/05/2019
pH : 5,0
Berat jenis : 1,010
Nitrit : negatif
Protein : +1
Keton : -
Glukosa : -
Urobilinogen : -
Epitel : 3-5
Warna : kuning
Darah : +
Leukosit : 10-20
Eritrosit : 6-8
Lekosit : +
Bilirubin : -

Lab 09/05/2019
Bilirubin total/direct/indirect:
10,10/7,22/2,88
SGOT/SGPT: 52/43
Lab 08/05/2019
LDH: 291
As. Urat: 5,4
Lab 06/05/2019
Hb/Ht/E/L/Tr : 9,4/26/3,1/10,3/48
MCV/MCH/MCHC: 85/30/36
Diftel: 0/0/0/96/2/2
 ISO 9 ISO 10 ISO 11 ISO 12
DR : dr. Wahyu DR : dr. Wahyu DR : dr.muna DR : dr. Taufiq
COW : dr. Deddy COW : dr. Deddy COW : dr. suheir COW:dr. Delfi
DM : DM : DM : DM :
Raber : Raber : Raber : PTI Raber: Bedah plastic, PTI
DPJP: dr.M.Diah,Sp.PD DPJP: dr.M.Diah, Sp.PD DPJP: dr. Mahriani, Sp.PD DPJP: dr. Azhari Gani, Sp. PD.
Nama: Suhandi Nama: Indra Lesmana Nama : Murniana Zakaria Nama : Rahmat Hidayat
TTL : 01-08-1988 TTL : 19-09-1987 (31 th) TTL : 03/12/96 (22th) TTL : 01/03/1991(28th)
Alamat : Aceh Selatan Alamat : Aceh Tamiang Alamat : Aceh Utara Alamat : Aceh Pidie
CM : 1-20-88-80 CM : 1-20-89-01 CM : 1193908 CM : 1035032
Hari Rawatan: 2 Hari Rawatan: 2 Hari Rawatan: 5 Hari Rawatan : 9

A/ A/ A/ A/
1. SIDA grd III 1. SIDA std III 1. SLE derajat berat dengan 1. SIDA std IV
2. Candidiasis Oral 2. Pneumonia dd TB paru dengan keterkaitan neuropsikiatri 2. Candidiasis oral
3. Pneumoni dd infeksi paru spesifik infeksi sekunder 2. Oral kandidiasis 3. cholesistitis
4. Hipoalbumin Berat 3. Oral Candidiasis 3. ISK 4. pneumonia dd TB paru dengan
5. Hiponatremi hiposmolar 4. Anemia sedang hipokrom minoter infeksi sekunder
hipovolemik ec dd Th/ 5. anemia berat H.M ec
- def Fe -dif Fe
Th/ - Peny. Kronis - Bedrest -occult bleeding
-Bedrest 5. Hiponatremi hiposmolar - Diet M sonde 6x200cc 6.hiopoalbuminemia ec low intake
- Diet M II 1700 kkal/hr hipovolemik - IVFD Nacl 0,9% 20 gtt/i 7. hepatitis B kronik
- IVFD NaCl 0,9 % 20 tts/i - IV omeprazole 40mg/12jam 8. abses a.r femoral sinistra post
- Omeprazole 40 mg Th/ - IV ceftriaxone 2 gr/24jam (H1) debridemrnt
-Ceftriaxone 960 mg / 2gr - Bedrest - Drip metilprednisolon 1 gr (H1) 9. susp limfoma intraabdomen
-Nygtatin drop 2cc - Diet M II 1700 kkal/hr - Kalsium lactat 2x500mg 10. hypokalemia hipoosmolar
-Paracetamol 500 mg - IVFD NaCl 0,9 % 20 tts/i - Ostriol 2x0,25mg hipovolemik
- Ambumin 25 % - Ceftriaxone 2 gr - Asam folat 2x400mcg
- KSR 600 gr - Omeprazole 40 mg - Nystatin drop 4xgtt2 Th/
- Cotrimoxazole 1 cc - Diazepam ½ amp - Bedrest
- Nystatin 1 gr - Diet lunak 1700 kkal
Lab 11-05-2019 - Paracetamol 1 gr Lab 11-05-2019 - O2 nasal kanul 2-4 Lpm (k/p)
Hb/Ht/E/L/T : 9,2/28/3,8/18,3/147 - Kalibre Albumin: 3,04 - IVFD NaCl 0,9 % 30 gtt/menit
MCV/MCH/MCHC: 74/24/33 Ur/Cr: 22/0,35 - IVFD Aminofusin hepar 1 fls/hari
Diftel : 0/1/0/93/4/2 Lab 11-05-2019 - IV Omeprazole 40mg/12j
SGOT/SGPT: 80/42 Hb/Ht/E/L/T : 9,1/26/3,9/60/2,2 Urinalisa 10/05/2019 - Sistenol 3x500mg
GDS: 101 MCV/MCH/MCHC: 67/23/35 pH : 6,0 - Drip Albumin 25% 100cc/hr
Ur/Cr: 30/1,17 Diftel : 0/1/0/79/15/5 Berat jenis : 1,010 - Nistatin 1 gtt/6 jam
Albumin:2,34 GDS: 108 Nitrit : - - Sucralfat syr 3x1c
Na/K/Ca: 128/3,1/99 Ur/Cr: 48/0,92 Protein : +1 - Drip novalgin 1 amp dalam 500 cc
Na/K/Ca: 130/5,8/106 Keton : - dex 5% 20 tpm
Glukosa : - - cotrimoxazole 1x2tab
Urobilinogen : + - IV ceftazidin 1 gr/8jam
Epitel : 3-5
Warna : kuning Lab 09/5/19
Darah : + Hb/Ht/E/L/T : 7,1/22/2,8/14,3/365
Leukosit : 10-15 MCV/MCH : 78/26
Th/ Eritrosit : + Diftel : 1/0/0/93/2/4
Lekosit : + Ur/Cr: 22/0,38
Bilirubin : - Na/K/Cl : 125/4,3/97

Lab 8/5/19 Lab 8/5/19

Hb/Ht/E/L/T : 11,3/35/5,5/11,7/261 Hb/Ht/E/L/T : 7,6/23/3/10,6/230
MCV/MCH : 63/21 MCV/MCH : 78/26
Diftel : 0/0/0/89/8/3 Diftel : 0/0/0/94/2/4
Lab Ca: 8,6 PT/APTT: 14,00/42,30
Na/K/Cl: 141/4,1/109 SGOT/SGPT: 91/21
Ur/Cr: 23/0,37
Albumin:2,62

Lab 6/5/19
Hb/Ht/E/L/T : 7,6/23/3,0/10,6/230
MCV/MCH : 78/26/33
Diftel : 0/0/0/94/2/4
PT/APTT: 14,00/42,30
SGOT/SGPT: 91/21
Ur/Cr: 23/0,37

Lab 5/5/19
Albumin : 2,28