AQSHA 3 (PENYAKIT DALAM WANITA)

Hari/Tanggal : Selasa, 26 feb 2019

Dokter Jaga : dr. NAdi/ dr/ Taufiq
Dokter Muda Jaga : Tiara, Duma
K1B1 K1B2 K1B3 K1B4
DPJP : dr. M. Darma MS Sp.PD DPJP : dr. M. Darma MS Sp.PD DPJP : dr. M. Darma MS Sp.PD DPJP : dr. M. Darma MS Sp.PD
COW : dr. Febri COW : dr. Febri COW : dr. Febri COW : dr. Febri
DR : dr. Okdimur Hayadi DR : dr. Okdimur Hayadi DR : dr. Okdimur Hayadi DR : dr. Okdimur Hayadi
DM : Tiara DM : Tiara DM : Tiara DM : Tiara
Nama : Herawati Abu Bakar Nama: Darma M. Yunus Nama: Jumarni Bin Samin Nama : Siti Ridwan
Umur : 37th Umur: 46 thn Umur: 49 thn Umur : 04-06-1970 (48thn)
CM : 1109728 CM: 1201113 CM: 1201341 CM: 1200733
Alamat : Kota batam Alamat: Kluet Selatan Alamat: Aceh Tamiang Alamat: Aceh barat daya
Hari rawatan : 3 Hari Rawatan: 5 Hari Rawatan: 4 Hari Rawatan: 8

A/ A/
1.Anemia berat makrositer ec dd/ 1. Trombositopenia ec ITP
-defisiensi vit.B12 2. Hepatitis B kronis
-defisiensi as. Folat 3. Hipertensi stage I
-hepatic failure
2. Sle derajat berat dengan keterbatasan Th/
hematologi - Bedrest
3. dispepsia tipe like ulcer dd tipe - Diet MB 1200 kkal per hari
dismotiliti - IVFD Futrolit 20 tpm
- Lansoprazole 2x30mg
Th/ -amlodipin 1x5 mg
-Bedrest - metilprednisolon 3x16 mg
-Diet MII 1700 kkal/hari - Sukralfat syr 3xCI
-O2 2-3 l/i - Osteocal 2x1 tab
-IVFD NaCl 0,9% 20 gtt/i
-IV omeprazole 40mg/12j Lab 22/02/2019
-IV ondansetron 4 mg/8j Hb/Ht/E/L/TR
-Myfortic tab 2x360 mg 14.0/39/4.7/13.3/27
- methylprednisolone 2x8 mg MCV/MCH/MCHC
-Lenal ace 2x169 mg 84/30/36
- Curcuma tab 2x1 Diftel: 0/0/0/90/9/1
- Transfusi PRC sd HB> 10 gr/dL dengan Bil tot/dir/ind: 0.57/0.81/0.39
leukodepleted dengan premed SGOT/SGPT: 18/24
dexamethasone 1 amp
Lab 21/02/2019
Lab 24/02/2019 Hb/Ht/E/L/T : 14,3/39/4,8/5,7/9
Hb/Ht/E/T/L : 3,3/1/0,1/416/8,5 Difftel : 0/0/0/85/14/1
MCV/MCH/MCHC: 88/413/471
DIFTEL: 0/0/0/65/27/8 Lab 20/02/2019
Hb/Ht/E/L/TR
14,3/40/4,8/7,3/2
MCV/MCH/MCHC
84/30/36
PT/APTT: 9,6 /33,8
HBsAg positif
GDS: 104 mg/dL
A/ A/
1. Penurunan kesadaran (perbaikan) ec dd 1. Massa a.r.scalp et Mammae Sinistra
- uremic ensefalopati et iliaca sinistra ec dd
- sepsis 1. Fibrokistik 2. Ca Mammae
2. sepsis ec urosepsis Dengan suspek metastase tulang
3. CKD stage V dd 2. HT on terapi
- DN 3. Dyspepsia tipe like ulcer
- HN 4. Paraparese inferior
- PNC
Dengan uremic syndrome Th/
4. Hiperkalemia (perbaikan) - Bedrest
- Diet MB 1700kkal hari
Th/ - IVFD futrolit 20 tpm
- Bed rest semifowler - IV omeprazole 40mg/12j
- NGT-Cateter urin - Sucralfat syr 3xCI
- Diet sonde 6x200cc+ 0,6gr - Amlodipine 1x10mg
protein/KgBB/hari - Valsartan 1x160mg
- O2 2-4 l/i (Nasal kanul) - IV metoclopramide 1 amp / 8 jam
- IVFD NaCl 0,9% 10 gtt/i
- IV meropenem 1gr/8jam selanjutnya Lab 21/02/2019
500mg/12jam Hb/Ht/E/T/L : 11.9/37/4.7/15.2/508
- Lenal Ace 2x169mg MCV/MCH/MCHC : 78/25/32
- Asam folat 2x400mg Difftel : 1/0/2/76/12/9
- Kalitake 3x1 GDS : 107
- IV Ondansetron 4 mg/8 jam PT/APTT: 12.7/34.5
- Hemodialisa Ur/Cr : 35/1.51
- Tranfusi PRC 1 kolf on HD Na/K/Cl : 141/3.5/101
- Balance cairan 0
Lab 19/02/2019
Lab 25/02/2019 Hb/HT/E/L/Tr
Procalcitonin: 17, 59 ng/mL 11,4/36/4,5/9,8/504
MCV/MCH/MCHC
Lab 22/02/2019 79/25/32
pH/pCO2/pO2/HCO3:
7.172/14.30/140/5.3 Lab 16/02/2019
Total CO2/BE/SpO2: 5,7/20.5/96.9 Hb/Ht/E/T/L : 8,7/26/3,4/417/11,6
Hb/Ht/E/L/T : 6,5/19/2,6/524/15,3 MCV/MCH/MCHC : 76/25/33
Alb : 3,16 Difftel : 0/0/0/71/21/8
Ur/Cr : 255/9,14 Alb : 3,58
Na/K/Cl : 144/4,4/99 GDS : 105
Ur/Cr : 33/0,85
Lab 22/02/2019 Na/K/Cl : 149/3,9/102
Hb/Ht/E/L/T : 7,3/22/2.9/20.3/558
MCV/MCH/MCHC: 78/25/33
Diftel: 0/0/1/85/9/5
HBsAg/ anti HCV: -/-
GDS: 89
Ur/Cr : 384/13.80
Na/K/Cl: 141/8.1/118
 K2B1 K2B2 K2B3 K2B4 K2B5
DPJP : dr. M. Darma MS DPJP : dr. M. Darma MS DPJP: dr. M. Darma MS DPJP: dr. M. Darma MS DPJP: dr. M. Darma MS
COW : dr. Febri COW : dr. Febri COW: dr. Febri COW: dr. Febri COW: dr. Febri
DR : dr. Okdimur DR : dr. Okdimur DR : dr. Okdimur DR : dr. Okdimur DR : dr. Okdimur
DM : Tiara DM : Tiara DM : Tiara DM : Tiara DM : Tiara
Nama : Siti Fatimah Nama : Ummi Ahmad Nama : Salsa dinda sulisdika Nama : Masnawati Misran
Umur ; 70 th Umur : 75 tahun Umur :18 th Umur : 55 tahun
CM ; 1201347 CM : 1118057 CM :1131103 CM : 1201442
Alamat ; Aceh Tengah Alamat : Pidie Alamat : Tapak tuan Alamat : Aceh Tamiang
Hari Rawatan : 4 Hari Rawatan : 12 Hari rawatan : 1 Hari Rawatan : 2

A/ A/ A/ A/
1.SDA(perbaikan) dengan 1. CKD stage V ec PGOI on 1. CML 1. Hepatomegali ec dd
pencetus infeksi dan dehidrasi HD reguler 2. Anemia sedang ec drug - Hepatomamrelated Hep B
2. CHF FC NYHA II-III ec dd 1. 2. Nephrolithiasis dextra induced dengan cancer pain
CAD 2. DCM 3. HHD 3. Hidronefrosis grd III -metastase proses
3. AF RVR dextra Th/ 2. Efusi pleura dextra ec dd
4. DM Tipe 2 Normoweight 4. Pneumonia -Diet MB 1700 kkal/ hari -pleuropneumonia
5. Hipoalbuminemia sedang 5. Anemia sedang hipokrom - IVFD NACL 0,9% 20 tpm -pleuritis
mikrositer - Tasigna 2x300 mg -metastase proses
Th/ 6. Hipertensi stage I - Traansfusi PRC sd HB≥ 10 3. Post PSMBA ec dd
- Bedrest gr/dL -varises esofagus
- - kateter urin Th/ - varises fundus bleeding
- Diet Sonde Jantung 6 x -Bedrest Lab 25/02/2019 - gastropati hipertensi portal
200 kkal/hari via oral -Diet ginjal 1700 kkal/hari + 45 Hb/Ht/E/L/Tr: 7,7/21/2,6/4,3/30 4. AKI stg 3 dd/ hepatorenal
- O2 2-4 l/I (nasal kanul) gram protein / hari DIFTEL: 0/0/1/8/89/2 syndrome
- IVFD Futrolit 15 gtt/i -Threeway + kateter urine MCV/MCH/MCHC: 82/30/36
- IV Omeprazole 40 -IV. Ceftriaxone 2 gr/ 24 jam PT?APTT: 9,8/52,3 Th/
mg/12 jam -IV omeprazole 40 mg/12 jam - Bedrest
- IV Ceftriaxone 2 gram/ -Asam folat 3x400mg - Diet Hati III 1900 kkal/hari
24 jam - ondancetron 4mg/12jam - O2 2 – 4 liter/menit Nasal
- Flumucyl syr 3 x CI -Balance cairan = 0 Kanul
- Spironolakton 1 x 25 mg -HD setiap senin-kamis - IVFD Aminofusin hepar 1
- Digoxin 1 x 0,25 mg -transfusi PRC sd Hb > 10gr/dl fls.hari 10 gtt/menit
- Balance Cairan 0 -Amlodipin 1x5 mg - IV Ceftriaxone 2 gram/24
jam
Lab 22/02/2019 Lab 22/02/2019 - Lactular Sur 3 x CI
Hb/Ht/E/L/Tr :9.9/29/3.6/4.5/131 Hb/HT/E/L/Tr - Curcuma 3 x 1
MCV/MCH/MCHC: 79/27/35 8,8/26/3,5/11.3/355 - Coditam 2x1 tab
Difftel : 0/0/1/56/37/6 MCV/MCH/MCHC - Balance cairan
GDS: 160 76/25/33 - - spironolakton 2x100 mg
Ur/Cr: 24/0.46 Alb: 3.30 - IV omeprazole 40 mg/ 12
Na/K/Cl: 144/4.2/103 Ur/Cr: 46/5.59 jam
Na/K/Cl: 135/4,0/89
Lab 25/02/2019
Lab 19/02/2019 PT/APTT: 20/63,7 detik
Hb/HT/E/L/Tr
8,8/27/3,5/10,9/365 Lab 23/2/2019
MCV/MCH/MCHC Hb/L/T : 13,5/12,4/368
77/26/33 Diftel : 3/0/0/73/14/10
Alb: 3,23 HbsAg (+)
Ca: 9,8 SGOT/SGPT : 439/37
Ur/Cr: 126/8,45 Alb : 3,29
Na/K/Cl: 135/4,4/101 GDS : 52
Ur/Cr : 98/5,21
Lab 17//2/2019 Na/K/Cl : 143/5,1/99
Ca 9,6
Na/K/Cl 134/5,8/94

Lab 15//2/2019
Hb/L/Tr: 8,5/13,5/372
MCV/MCH/MCHC
80/25/32
Na/K/Cl: 134/7,1/95
Urinalisis
Makro : kunig, keruh, Berat jenis
(1,010), pH (6,5), leukosit (+),
protein (+1)
Mikro :
Laukosit : 30-40
Eritrosit : 20-25
Epitel 3-5

HbsAg : negatif
Anti HCV : negatif

Lab 14//2/2019
Hb/L/T : 9,3/13,4/387
MCV/MCH : 78/26
Diff. Count : 0/1/0/76/12/11
GDS : 127
Ur/Cr : 193/11,27
 K3B1 K3B2 K3B3 K3B4 K3B5
DPJP : dr. M. Riswan DPJP : dr. M. Riswan DPJP : dr. M. Riswan DPJP : dr. M.Riswan DPJP : dr. M. Riswan
COW : dr. Rahmi COW : dr. Rahmi COW : dr. Rahmi COW : dr. Rahmi COW : dr. Rahmi
DR : dr. Munawwarah DR : dr. Akmal DR : dr. Munawwarah DR : dr. Munawwarah DR : dr. Munawwarah
DM : Dara DM : Dara DM : Dara DM : Dara DM : Dara
Nama : Nini Andriyani Nama : Nurmawati Tugiman Nama : Sadiah Hasan Nama : Alawiyah Yahya Nama : Sumiati Yusuf
Umur : 25 tahun Umur : 60th Umur : 82 tahun Umur : 90 th Umur : 01/09/1978 (40 th)
CM : 1200514 CM : 0708022 CM: 0804491 CM : 1028419 CM: 1201111
Alamat: Bener Meriah Alamat : Kota Sabang Alamat: Aceh Besar Alamat : Pidie Jaya Alamat: Aceh Utara
Hari rawatan : 2 Hari rawatan : 2 Hari Rawatan: Hari rawatan ke : 13 Hari Rawatan: 5

A/ A/ A/ A/
A/ 1.CKD stg V on HD reguler 1. Asites ec dd 1. Meigh 1. hematoskezia dd/ 1.Sepsis ec dd 1. Selulitis 2.
1. Diare kronik ec dd/ 2. Hipertensi on terapi Syndrome 2. TB Peritoneal - ca colorectal Pneumonia 3. Urosepsis
- colitis TB 3. Pneumonia (HCAP) dd infeksi 3. CHF 4. Sirosis Hepatis - ca recti 2. Selulitis pedis dextra
- Colitis infeksi paru spesifik 5. Malignancy 2. Anemia sedang normokrom 2. CKD stg V ec dd:
- Colitis ulseratif 4. AF MVR 2. Efusi pleura sinistra ec dd 3. Geriatri problem -diabetik nefropati
1. Pleuritis TB 2. Phteig -Infeksi -PNC
Th/ Th/ Syndrome 3. -Impairment of vision -HN
-bedrest -Bedrest Pleuropneumonia 4. -konstipasi 3. DM tipe 2 NW
-IVF?D NaCl 0,9% 20 tpm -O2 2-4 l/mnt Malignancy 4. Hipertensi stage 1 4. Anemia sedang NN ec PGK
-PCT 3x500 mg (K/P) bila -Threeway 3. Nefrolithiasis bilateral 5. Hiperkalemia (perbaikan)
demam -Diet ginjal lunak 1700 kkal/ hari + Th/ 6. Pneumonia
-protap kolonoskopi 40 gr protein/ hari Th/ -Bed rest 7. ISK
-IV cefepime 1 gr/48jam (post HD) - Bedrest -Diet MB 1700 kkal/hari
Lab 14/02/2019 - Nebul ventolin 1 resp/8jam - Diet sonde oral 6 x 200 cc - IVFD Futrolit 20 tpm Th/
Hb/Ht/E/L/TR: -Asam folat 2x400mg @200 kkal/hari - Amlodipin 1x5 mg -Bedrest
10,4/35/4,9/10,3/504 -Lenal ace 2x169mg - IVFD Clinimix + Clinoleic - Paracetamol 3x500 mg (K/P) -Diet ginjal 1700kkal/hari +n50
MCV/MCH/MCHC: -vectrin 3x1 20 gtt/i - Cetirizine tab 2x1 (K/P) gr prtein per hari
71/21/30 -cetirizin 2x10mg - IVFD Futrolit 20 gtt/i -Lactulac syr 3xCII IV meropenem 500 mg/ 24 jam
LED: 46 -amlodipin 1x5mg - IV Omeprazole 40 mg/12 - Transfusi PRC sd Hb > 10 gr/dL -threeway
DIFTEL: 0/0/0/72/19/9 jam pakai blood set khusus - IV omeprazole 40mg/12j
CT/BT: 8/3 Lab 24/02/2019 - IV Furosemid 20 mg/12 -Drip albuminar 25% 100cc 1
Anti HCV/HBsAg: negative Hb/Ht/E/T/L :10/30/3,3/261/9,7 jam Lab 23/02/2019 fls/hari
Ur/Cr: 11/0,61 GDS : 145 - Domperidone 3 x 10 mg Hb/Ht/E/L/T : 11,6/34/4/9,7/301 -SC insulin apidra 6-6-6 Unit
Ur/Cr : 35/3,8 - Sukralfat Syr 3 x CI -SC insulin lantus 0-0-0-8 Unit
Na/K/Cl : 146/3,4/98 - Balance cairan -250 cc/24 Lab 21/2/2019 -HD rabu sabtu
Lab 15/02/2019 MCV/MCH/MCHC: 90/30/33 jam Hb/L/T : 8,3/16,8/205 -Transfusi PRC 1 kolf on HD
SGOT/PT:13/7 - -PCT 3x500 mg MCV/MCH : 86/29 - IV meropenem 500mg/24jam
GDS: 121 - Diftel : 3/1/0/77/12/7 - Balance cairan
Ur/Cr: 9/0,58 Lab 25/02/2019 (urinalisa) -valsartan 1x160 mg
As urat: 3,7 -kuning Lab 20/2/2019 - amlodipine 1x5 mg
-keruh PT : 10,1
-BJ: 1,010 Kontrol : 10,6 Lab 25/02/2019
PH: 6,5 INR : 0.96 Procalcitonin: 6,60 ng/mL
Protein: +1 APTT : 28,6
Kontrol 36,7 Lab 22/02/2019
Lab 23/02/2019 Hb/Ht/E/T/L :
Albumin : 4,32 Lab 18/02/2019 5,7/16/2,4/372/56,7
Hb/L/T 5,4/12,3/238 MDT
Lab 22/2/2019 MCV/MCH/MCHC 89/31/35 Eritrosit : mikrositer hipokrom,
Hb/L/T : 12/6,2/398 PT/APTT: 9,9/30,5 anisositosis
MCV/MCH : 87/30 Anti HCV: negative Leukosit : Neutrofilia, bentuk
Diftel : 0/1/0/84/6/9 HbsAg: negative normal, blas –
HbsAg : - Alb: 3,02 Trombosit : jumlah cukup,
SGOT/SGPT : 78/18 Ur/Cr: 63/1,72 tersebar merata, giant –
Alb/Glob : 3,52/2,04 Na/K/Cl: 144/3,4/108
GDS : 79 Lab 20/02/2019
Ur/Cr : 34/1,00 Lab 15/02/2019 Hb/Ht/E/L/Tr:
Na/K/Cl : 140/4,2/90 Hb/Ht/E/L/Tr: 5,9/18/2,5/64,2/407
8,4/25/2,8/12,7/291 MCV/MCH/MCHC:
DIFTEL: 0/0/0/87/9/4 69/23/34
MCV/MCH/MCHC
89/30/34 Lab 16/02/2019
Hb/Ht/E/L/Tr
Lab 12/02/2019 6,8/20/2,4/294/996
Hb/Ht/E/L/Tr: MCV/MCH/MCHC
7,2/21/2,3/19,1/336 82/28/35
MCV/MCH/MCHC Diftel : 4/10/0/73/7/6
93/31/34 Ur/Cr : 11/0,59
DIFTEL: 2/1/0/76/14/7 Na/K/Cl : 147/3,5/97
GDS: 165
Lab 12/02/2019 (RS
MEURAXA)
Hb/L/Tr: 7,1/330,1/1164
MCV/MCH/MCHC
81/28/34
LED: 90 mm/jam
 K4B1 K4B2 K4B3 K4B4 K4B5
DPJP :dr. M. Riswan DPJP :dr. M. Riswan DPJP : dr. M. Riswan DPJP : dr. M. Riswan DPJP : dr. M. Riswan
COW : dr. Rahmi COW : dr. Rahmi COW : dr. Rahmi COW : dr. Rahmi COW : dr. Rahmi
DR : dr. Munawwarah DR : dr. Munawwarah DR : dr. Munawwarah DR : dr. Munawwarah DR : dr. Munawwarah
DM : Dara DM : Dara DM: Dara DM: Dara DM: Dara
Nama: Sairah M Amin Nama : Nurmala Ibrahim Nama : Ti Rahmah Nama : Aflah Nama : Sadiah Tafauddin
Umur: 57 th Umur : 46 tahun Umur : 63th Umur : 50th Umur : 45 tahun
CM: 1153971 CM : 11018166 CM : 1201506 CM : 1201356 CM : 1199964
Alamat: Aceh Besar Alamat : Simpang tiga, Aceh Besar Alamat : Aceh Utara Alamat : Aceh Selatan Alamat :LhokseumaweBesar
Hari Rawatan: 8 Hari rawatan : 6 Hari rawatan : 2 Hari rawatan : 4 Hari rawatan : 1

A/ A/ A/ A/ A/
1. Prolonged fever ec dd 1. NHL Ann-Arbor 3B 1. HE grade 2 dengan pencetus 1.DHF grade II 1. ASites e\ce dd/
1. Pneumonia 2. ISK 3. konstipasi dan infeksi -/malignancy
Infeksi paru spesifik 4. Th/ 2. Sirosis hepatis stadium Th/ - peritoneal rupture
Endokarditis 5. -Bedrest dekompensata related hepatitis B -bedrest -CHF
Malignansi - Diet sonde 6x200 cc per NGT dengan kecurigaan degenerasi -diet MII 1700 kkal/hr - Sirosis Hepatis
2. CHF NYHA II-III ec dd 1. -IVFD clinimix + clinoteic 1 fls/hr maligna (HCC) -IVFD RL 30tts/mnt - Hipoalbumin
IHD 2. HHD 3. DCM 20 gtt/i 3. AKI stg 2 dd/ hepatorenal -IV omeprazole 40mg/12jam 2. Susp Efusi pericard ec dd/
- IVFD Futrolit 20 tpm syndrome -Paracetamol 3x500mg (k/p) -metastase proses
Th/ - IV Omeprazole 40 mg/24 jam 4. Pneumonia dd/ TB paru dengan Bila T > 38 - autoimun disorder
-Bedrest -Sucralfat syr 3xCII 30’ AC infeksi sekunder -domperidon 3x10mg -pericardial inflammation
-diet 1500 kkal - -IV ondansetron 4 mg/8jam 3. Anteroseptal myocard infarct
- IVFD NaCl 0,9 % 20 tpm Lab 22/02/2019 - lactulac syr 3Xci ec dd/
- IV ceftriaxone 2gr/24 jam LDH: 420 Th/ -CAD
- PCT 3x500mg As urat: 3.2 -Bedrest, NGT LaB 25/02/2019 -Inflamasi
- sucralfat syr 3Xci Diet sonde hati 6x200 cc @2oo Hb/Ht/E/L/Tr: 4. Low voltage of
Lab 21/02/2019 kkal/ hari via NGT 10,2/29/3,5/5,2/114 ECG ec dd
Lab 25/02/2019 Anti HCV : negatif -IVFD aminofusin hepar 1 fls/ MCV/MCH/MCHC: -Efusi perikard
Hb/Ht/E/L/Tr: HbsAg : negatif hari 20 tpm 81/29/36 -Efusi Pleura
8,3/26/2,7/8,5/467 SGOT/SGPT : 28/7 - IV omeprazole 40 mg/ 12 jam DIFTEL: 1/1/0/40/49/9 % -Hipolabumin
MCV/MCH/MCHC: 96/31/32 Albumin : 3,15 - lactulac syr 3x30 cc PO
DIFTEL: 1/0/0/62/32/5 - coditam 3x1 tab PO Lab 24/02/2019 Th/
Procalcitonin: 0,19 ng/Ml Lab 19/02/2019 - Curcuma 2x1 Hb/Ht/E/L/T : 9,6/27/3,4/4,2/48 -Bedrest
LDH: 295 U/L Hb/Ht/E/L/Tr: - IV Furosemid 20 mg/24 jam Difftel : 1/1/1/36/55/6 -threeway
10/30/3,7/5/199 - IV Cefotaxime 1 gr/8 jzm -O2 2-4 L/i
MCV/MCH/MCHC - spironolakton 2x100 mg -Tab spironolactone
Lab 19/2/2019 80/27/34 - balance cairan -IV omeprazole
Hb/L/T :8,1/7,3/283 GDS: 90 - fosen enema bila tidak BAB - Diet MB 1700 kkal rendah
MCV/MCH : 100/31 Ur/Cr: 13/0,56 garam
Diff. Count : 1/0/0/62/32/5 Na/K/Cl Lab 25/02/2019
Billirubin total/direk/indirek 138/3,8/93 PT/APTT: 26,3/58,6
0,55/0,29/0,26 Anti HCV: negative
SGOT/SGPT : 26/22 Bil tot/bil dir/bil indir:
Albumin : 2,59 9,73/6,56/3,17
Ur/Cr : 13/0,57 Alb: 2,05
Urinalisa
Makro : kuning,jernih, berat Lab 24/02/2019
jenis (1,015), pH (7,5) Hb/Ht/E/L/T :
Mikro : 10,8/29/3,3/10,3/292
Leukosit : 1-2 HbsAg : positif
Eritrosit : 0-1 SGOT/SGPT : 1812/214
Epitel : 2-3 GDS : 85
Ur/Cr : 88/2,46
Lab 14/2/2019 Na/K/Cl : 135/3,5/88
Hb/L/T : 9,6/20,7/152
MCV/MCH : 79/27
Diff. Count : 0/0/0/88/7/5
Ur/Cr : 99/4,26
Na/K/CL : 134/4,8/97

Lab 10/2/2019
Hb/L/T : 8,4/20/92
MCV/MCH : 78/28
Diff. Count : 1/1/0/84/5/9
Alb : 2,59
GDS : 335
Ur/Cr : 122/4,50
Na/K/CL : 129/4,0/105

Lab 08-02-2019
Bil tot: 0,40
Bil direct: 0,18
Bil indirect: 0,22
SGOT/SGPT: 35/31

Lab 07-02-2019
Na/k/cl 130/4,6/103

Lab 05-02-2019
Hb/Ht/E/L/T
8,3/23/3,1/26,4/33
MCV/MCH/MCHC
75/27/36/
Diftel : 1/0/0/92/4/3
GDS : 68
Ur/Cr : 250/7,71
Na/K/Cl : 126/6,1/88
 K5B1 K5B2 K5B3 K5B4 K5B5
DPJP : dr. M. Riswan Sp.PD DPJP : dr. M. Diah Sp.PD DPJP : dr. M. Diah Sp.PD DPJP : dr. M. Diah Sp.PD DPJP : dr. M. DiahSp.PD
COW : dr. Rahmi COW : dr. Sabarina COW : dr. Sabarina COW : dr. Sabarina COW : dr. Sabarina
DR : dr. T Fahril DR : dr. Akmal DR : dr. Akmal DR : dr. Akmal DR : dr. Akmal
DM : Ranti DM : Ranti DM : Ranti DM : Ranti DM : Ranti

Nama : Maulidani Nama : Rihan M Salim Nama : Juita Rusdi Saiman Nama: Lasmi Darmi Nama : Sisri Nasep
Umur : 18 tahun Umur : 54 tahun Umur : 29 tahun Umur : 48 thn Umur : 47 th
CM : 1-20-14-25 CM : 1-19-76-00 CM : 1192111 CM: 1201353 CM : 1200951
Alamat : Aceh Utara Alamat : Aceh Selatan Alamat : Aceh Besar Alamat: Alamat : Nagan raya
Hari Rawatan : 4 Hari rawatan : 8 Hari Rawatan : 3 Hari Rawatan: 3 Hari rawatan ke : 3

A/ A/ A/ A/ A/
1. Trombositopenia ec dd 1. 1. PSMBA ec dd (perbaikan) 1. CKD Stage V on HD 1. AKI stage II prerenal ec 1.Ikterus obstruktif ec caput
Demam dengue 2. ITP 3. -Gastritis erosive regular - akut on CKD pancreas dd/ metastase proses
TTP -Ulkus gaster 2. Anemia berat normokrom - kardiorenal syndrome 2. Ca mammae std IV post kemo
-Ulkus duodenum normositer ec PGK - diabetic nefropati siklus II
Th/ 2.OA genue bilateral grade 4 3. CDL terinfeksi 2. Pneumonia ec dd TB Paru
- Bed rest 3. DM tipe 2 obese grade I 4. DM tipe 1 3. DM type 2 NW Th/
- Diet MB 1700 kkal/hari 4. HCAP dd Tb paru 4. Hipertensi on terapi - Bed rest
- IVFD Futrolit 20 gtt/i 5.Hipoalbumin (3,1) Th/ 5. Anemia ringan NN ec penyakit - Diet hati MII 1700kkal/hari
- Paracetamol 3 x 500 mg - Bedrest kronis - IVFD RL 20gtt/i
- Transfusi Tc 10 kolf Th/ - Diet ginjal 1700 kkal/hari 6. Hepatomegali dd - IV cefoperazon sulbactam
- IV Metilprednisolone 6,25 -Bed rest + protein 60 gram/hari - Hepatoma 1g/12jam
mg/12 jam -Diet MII 1700 kkal/hari - IV Ceftriaxone 2 gram/24 - Kista hepar - IV omeprazole 40mg/12jam
- IV Omeprazole 40 mg/12 -IVFD NaCl 0,9% 20 gtt/menit jam -Congestif heart failurre - Urdafalk 3x1
jam - IV ceftriaxone 2gr/12 jam - PCT 3 x 500 mg - Cetirizin 2x1
- IV Omeprazole 40 mg/ 12 jam - Transfusi PRC s.d. Hb > Th/
- SC Levemir 0-0-0-14 Unit 10 gr/dL -Bedrest Lab 22/02/2019
Lab 25/02/2019 - SC Novorapid 16-16-16 Unit - Asam folat 2 x 1 - Diet ginjal 1700 kkal/hari + 0,6 CA 19-9 <3.00
Hb/HT/E/L/Tr: -Sucralfat syr 3xCI - Lenal Ace 2x1 gr protein /kgBB/hari
10/30/3,9/10,7/2 - Transfusi PRC sd Hb≥ 10 - threeway Lab 18/02/2019
MCV/MCH/MCHC: 77/26/34 Lab 25/02/2019 gr/dl 1 kolf diruangan , 1 - IV ceftriaxone 2 gr/ 24 jam Hb/Ht/E/L/Tr
MDT: LED: 45 mm/jam kolf on HD - N- asetil sistein 3x1 10,1/29/3.3/7.1/456
Eritrosit: Normokrom, normositer, Bil direct: 0,19 mg/dL - - Bisoprolol 1x2,5 mg MCV/MCH/MCHC
anisositosis SGOT/PT: 36/30 U/L Lab 23/02/2019 - Fluimucyl 3x1 88/30/15
Leukosit: atipik limfosit (+) blas – Hb/Ht/E/L/T : - SC levemir 0-0-10 Diftel: 3/1/0/68/22/6
PT/APTT: 3,7/31,5 Lab 23/2/2019 4,5/12/1,5/10,1/349 HBsAg/Anti HCV: -/-
Anti HCV/HBsAg: negative Alb : 3,10 Lab 22/02/2019 Bil tot/ dir/ind: 16.77/12.54/4.23
SGOT/PT: 31/65 Hb/Ht/E/L/Tr SGOT/SGPT:211/140
Ur/Cr: 16/0,60 Lab 22/02/2019 9.4/29/3.6/8.6/352 Alb: 3.21
Hb/Ht/E/L/Tr MCV/MCH/MCHC GDS: 94
Lab 24/02/2019 10,2/30/3.6/6.4/186 81/26/33 Ur/Cr: 29/0.76
Hb/Ht/E/L/T : 10,2/31/4 MCV/MCH/MCHC Diftel: 0/1/0/81/14/4
83/28/34 CT/BT:7/2 Lab 25/02/2019
Lab 22/2/2019 Diftel: 11/1/0/51/27/10 HBsAg/anti HCV: -/- PT/APTT: 14,3/39,1
Hb/L/T : 10,0/10,7/2 GDS: 186
McV/MCH : 77/26 Lab 19/02/2019 Ur/Cr: 77/2.92
Diftel : 5/1/0/65/21/8 Hb/Ht/E/L/T : 6/19/2,2/7,8/123 Na/K/Cl: 138/5.4/104
PT/APTT : 13,7/31,5 Anti HCV : negatif
Anti HCV : - Bil tot/dir/indirect
HbsAg : - 0,96/0,40/0,56
SGOT/SGPT : 31/65 SGOT/SGPT
Ur/Cr : 16/0,60 134/109
Alb : 2,44

Lab 17/02/2019
Hb/Ht/E/T/L : 4,4/14/1,6/268/20,8
Difftel : 3/0/1/58/31/7
PT/APTT : 11,3/24,2
HBsAg : negatif
GDS : 410
Ur/Cr : 53/0,6
Na/K/Cl :139/4,9/101

Lab 17/02/2019
Hb/Ht/E/T/L : 4,4/14/1,6/268/20,8
Difftel : 3/0/1/58/31/7
PT/APTT : 11,3/24,2
HBsAg : negatif
GDS : 410
Ur/Cr : 53/0,6
Na/K/Cl :139/4,9/101

Lab 14/2/2019
Urinalisa: warna kuning keruh, BJ
1,010, pH 6,5, leu (+), protein
(+1), glukosa (+1), keton (+), L
(30-40), E (2-3), Epitel (20-30)

Lab 13/2/2019
Hb//E/L/T
9,8/3,4/13,5/389
MCV/MCH/MCHC
79/29/36
Gds: 279
Ur/Cr: 39/1,39
Na/K/Cl: 137/3,9/88
 K6B1 K6B2 K6B3 K6B4 K6B5
DPJP : dr. M. Diah Sp.PD DPJP : dr. M. Diah Sp.PD DPJP : dr. M. Diah Sp.PD DPJP : dr. M. Diah Sp.PD DPJP : dr. M.Diah Sp.PD
COW : dr. Sabarina COW : dr. Sabarina COW : dr. Sabarina COW : dr. Sabarina COW : dr. Sabarina
DR : dr.Akmal DR : dr. Akmal DR : dr. Akmal DR : dr. Akmal DR : dr. Akmal
DM : Ranti DM : Ranti DM : Ranti DM : Ranti DM : Ranti
Nama : Warsinah Dulkanan Nama : Nurul hayati Nama : Marlinda M Daud Nama : Fatimah Majid Nama : Julita Jamaludin
Umur : 54 tahun Umur : 57 tahun Umur : 25 tahun Umur : 67 tahun Umur : 53 tahun
CM : 1201005 CM : 0991431 CM : 1200601 CM: 1193077 CM : 1147541
Alamat : Nagan raya Alamat : Ulee kareng Alamat : Aceh Utara Alamat: Aceh Utara Alamat : Simeulu
Hari Rawatan : 5 Hari Rawatan : 1 Hari Rawatan : 11 Hari Rawatan: 4 Hari Rawatan : 3

A/ A/ A/ A/ A/
-Penurunan kesadaran perbaikan 1. Ulkus diabetic ar pedis dextra 1. Cancer pain 1. CML dd CLL 1. PEnurunan kesadaran ec dd
ec dd: 2. DM tipe 2 normoweight 2. Hepatomegali ec dd 2. Pneomonia dd / TB paru -sepsis
-Uremia encephalopati 3. Dyspepsia tipe dismotility ec tipe 1. hepatoma dengan infeksi sekunder -urosepsis
-sepsis like mixed dd gastropati diabetic 2. limfoma maligna -HE grade II-III
-Imbalance elektrolit 3. Kista hepar Th/ -pneumonia
2. CKD stg V ec dd HN, PNC 3. Limfadenopati a.r aksila (S) - Bedrest 2. PSDMBA ec dd
3. HT sterkontrol Th/ dd/limfoma maligna - Diet MII 1700 kkal/hari -varises esophagus bleedin
4. Iskemik inferior lateral 1. Bedrest - IVFD NaCl 0,9% 20 gtt/i - varises fundus bleeding
2. Diet DM MB 1700 kkal/hari Th/ - IV Ceftriaxone 2 gram/ 24 - gastropati diabetic
Th/ - IVFD NaCL 0,9% 20 tpm -Diet MII 1700 kkal/hari jam 3. peningkatan enzim
-Threeway - IV omeprazole 40 mg/ 24 jam -IVFD Aminofusin hepar 1 - Transfusi PRC s.d. Hb 10 transaminase ec dd
- Diet sonde - domperidone 3x10 mg fls/hari gr/dL -sirosis hepatis
- O2 2-4 liter/menit -SC lanthus 0-0-0-0-10 - IVFD NaCl 0,9% + novalgin - Tranfusi Tc jika Trombo < -hepatitis viral akut
- IV furosemide 2 amp/ 8 jam - clindamycin 3x300 mg 20 tpm 20.000 dengan perdarahan 4. hypokalemia ringan
- IV ceftriaxone 2 gr/24 jam - PCT 3x500 mg - Kaltropen sup (k/p) 5. Hipoalbuminemia ringan
- amdlodipin 1x10 mg -IV ondancetron 4mg/8jam (kp) Lab 25/02/2019
- asam folat 2x400 mg - PCT 3x500mg Urinalisa Th/
- calcium laktat 2x1 Lab 24/02/2019 - lactulac syr 3CII Kuning, keruh - Tirah baring, NGT
-kalitake sachef 3x1 Hb/Ht/E/L/Tr - nystatin drip 4x2 cc BJ: 1,015 - Diet hati somde 6x200 cc/
- hemodiallisa 13,2/38/4,8/14,2/280 - lactulac syr 3xCI Ph: 8,0 hari
MCV/MCH/MCHC Protein: +1 -IV cefoperazone sulbactam 1
Lab 21/02/2019 80/28/35 Lab 20/02/2019 Leukosit: 8-10 gr/ 8 jam
Na/K/Cl : 153/6,8/113 GDS: 294 LDH: 718 U/L Eritrosit 4-6 - Drip albumin 25 % 100 cc/
Ca : 9,2 Ur/Cr: 21/0,78 Epitel:3-5 hari
Ur/Cr : 219/10,78 Na/K/CL: 140/4,2/108 - drip amninofusin hepar 1 fls/
Lab 16/02/2019 Lab 24/02/2019 hari
Lab 19/02/2019 Hb/Ht/E/L/T : 9/27/3,3/6,8/241 Hb/Ht/E/L/T : 9,5/30/2,8/63,3/15 -IV omeprazole 40 mg/ 12 jam
Hb/Ht/E/L/Tr Difftel : 1/0/0/59/30/10 - KSR tablet 2x600 mg
11,5/34/4,1/15/259 Lab 23/2/2019 -curcuma 3x1
MCV/MCH/MCHC Lab 15/2/2019 Hb/L/T : 6,9/50,2/12 - lactulac syr 3Xcii
84/28/34 AFP: < 0,50 MCV / MCH : 119/37 - Aspilet 1x80 mg
CT/BT Bil tot/Bil direct/Bil indirect Diftel : 0/0/1/3/95/1 - GPG 1x75 mg
7/2 0,48/0,19/0,29 GDS : 124 -Atrovastatin 1x20 mg
GDS: 130 mg/dL SGOT/SGPT: 24/14 Ur/Cr : 30/0,97 -balance cairan
Ur/Cr: 225/12,36 mg/dL ALP: 125 Na/K/Cl : 143/4,9/99 - fosen enema (K/P)
Na/K/Cl: 145/7,5/112 mmol/L -inj transamin 500/ 8 jam
Lab 14/2/2019 - inj Vit K 1 amp/ 8 jam
Hb/L/T – 8,1/5,6/224 - IV omeprazole 2 ammp (extra)
MCV/MCH : 8,2/27 - Drip Ompeprazole 2 ammp +
Diff.Count 1/1/0/59/29/10 NACL 0.9% sd volume 50 cc 
GDS 87 5 mg/ jam
Na/K/Cl : 144/5,1/150
Ur/Cr : 42/160 Lab 25/02/2019
Hb/Ht/E/L/TR
10,3/29/3/10,6/68
MCV/MCH/MCHC: 97/34/35
PT/APTT: 42,2/142,9
Lab 22/2/2019
Hb/Ht/E/L/T: 10.4/30/3.1/7.4/63
MCV/MCH/MCHC: 96/34/35
Na/K/Cl : 140/3.1/100
Diftel: 12/1/1/43/33/10
HBsAg: -
SGOT/SGPT/Alb: 250/132/1.76
GDS: 147
Ur/Cr: 36/0.49

Lab 24/02/2019
HbSAg negative
SGOT/PT: 250/132
Alb: 1,76
GDS: 147
Ur/Cr: 36/0,49
NA/K/Cl: 140/3,1/100