AQSHA 2 (PENYAKIT DALAM PRIA)

Hari/Tanggal : Kamis, 21 Februari 2019

Dokter Jaga : dr. Mirza, dr. Okdimur
Dokter Muda : Ika, Dara
K1B1 K1B2 K1B3 K1B4
DPJP : DPJP : dr. Kurnia Sp.PD DPJP : dr. Kurnia Sp.PD DPJP : dr. Kurnia Sp.PD
COW : COW : dr. Suheir COW : dr. Suheir COW : dr. Nasriah
DR : DR : dr. Taufik DR : dr. Taufik DR : dr. Reyza
DM : DM : Cita DM : Cita DM : Cita

Nama : Fadli M. Taib Nama: Armia Tgk M Isa Nama: Murdani Abubakar
TTL : 07/07/1975 TTL: 1/1/1966 (53tahun) TTL: 03/05/1954 (64tahun)
Alamat : Temanggung Alamat: Langsa Alamat: Bireuen
CM : 1201084 CM: 1199394 CM: 1200780
Hari Rawatan ; 3 Hari Rawatan: 18 Hari Rawatan: 4

A/ A/ A/
1.Sirosis hepatis st dc related hep B 1.Ca rectosigmoid 1. PSMBA ec dd/
dg hepatoma 2. Anemia sedang hipokrom -gastritis erosive (nsaid)
2.Cancer pain mikrositer ec malignancy (8,9) -ulkus gaster
3.Dd/ 3. prolong fever ec malignancy -ulkus duodenum
-Hepatoma 3. hemoroid interna gr I 2 OA Genu bilaterall
-Abses Hepar 3. anemia ringan ec dd/
-Kista hepar Th/ -perdarahan
4.Hepatitis B Kronik -Bedrest -penyakit kronik
5.Anemia hipokrom makrositer ec -Diet lunak 1700 kkal/hari 4.AKI Stage II pre renal
dd 1. Penyakit kronik 2. Def besi 3. -IVFD RL 20tpm 5. Lipoma
Perdarahan -iv ceftriakson 2gr/24j 6.ISK
-IV Omeprazole 40mg/12jam
Th/ - PCT 3x500 mg Th/
-Bedrest - nystatin drop 4x2cc -bedrest
-Diet Hati II 1700 kkal/hari -Kaltropen Supp (K/P) - diet M II 1700kkal/hr
-Three way -pectocyl syr 3xC1 -IVFD Nacl 0,9% 20gtt
-IVFD Aminofusin hepar 1 -iv omeprazole 40g
flash/hari Lab 14/02/2019 - Paracetamol tab 3x500mg
-Curcuma 3 x 1 PO Urinalisis -sucralfat syr 3xCI
-lactulac syr 3xc1 PO -IV Ceftriaxone 2gr/24j
-tramadol 3x1 PO Lab 14/02/2019 -Voltaren jell
Hb/Ht/E/L/T - Kaltropen sup(k/p)
Lab 20/02/2019 8,9/29/3,6/11,3/381 -analgetik topikal
Hb/Ht/E/L/T : 8,2/24/4/7,5/318 MCV/MCH/MCHC -ostriol 2x0,25mcg
MCV/MCH/MCHC : 61/21/34 81/25/30 -lenal ace 2x169mg
RDW : 24 Diftel: 2/0/0/75/16/7
Diftel : 1/0/2/68/20/9 Ur/Cr: 15/1,15 Lab 17/02/2019
Na/K/Cl 139/3,8/105 Hb/ht/e/l/t
Lab 19/02/2019 10/30/3,5/15,4/387
Hb/L/T : 8,5/7,1/293 Lab 06/02/2019 Mcv/mch/mchc
MCV/MCH : 60/21 Hb/Ht/E/L/T 85/29/34
Diftel : 1/1/1/71/19/7 9,3/30/3,8/9,5/377 Diftell: 4/1/0/76/10/9
Bilirubin Direk/Indirek : 1,75/1,16 MCV/MCH/MCHC Ur/cr: 35/2,14
SGOT/SGPT : 548/104 80/25/31 Na/k/cl 137/5,2/97
Alb : 2,77 Diftel: 4/0/0/69/18/9
GDS : 158 MDT: Anemia Normokrom Lab 14/02/2019
Ur/Cr : 17/0,64 Normositter Hb/ht/e/l/t
Na/K/Cl : 138/4,5/95 10/30/3,5/15,4/387
Lab 04/02/2019 Mcv/mch/mchc
Hb/Ht/E/L/T 85/29/34
9,7/30/3,9/8,4/382 Diftell: 4/1/0/76/10/9
MCV/MCH/MCHC Ur/cr: 35/2,14
77/25/32 Na/k/cl
PT/aPTT : 1,00/1,1 137/5,2/97
Gds: 170
AntiHCV/ HbsAg : negatif
Ur/Cr: 29/1,33
Na/K/Cl: 139/4,1/100
 K2B1 K2B2 K2B3 K2B4 K2B5
DPJP : dr. Kurnia Sp.PD DPJP : dr. Kurnia Sp.PD DPJP : dr. Kurnia Sp.PD DPJP : dr. Kurnia Sp.PD DPJP : dr. Kurnia Sp.PD
COW : dr. Suheir COW : dr. Nasriah COW : dr. Suheir COW : dr. Nasriah COW : dr. Nasriah
DR : dr. Taufik DR : dr. Reyza DR : dr. Taufik DR : dr. Reyza DR : dr. Reyza
DM : Cita DM :Cita DM :Cita DM : Cita DM :Cita
Nama : Abdawi Ismail Nama : Syakubat Abdullah Nama: Waliman Nama : Saladi Nama: Mukhsin A Bakar
Umur : 47th TTL : 01/07/1953 Syahbudin TTL : 10/11/1987 Umur:12/09/1962 (56 th)
Alamat : Sabang Alamat : Pidie TTL: 7/7/1973 (45 th) Alamat : Bener Meriah Alamat: Kajhu
CM : 0645223 CM : 1084080 Alamat: Bakongan CM : 1200865 CM: 1138089
Hari rawatan : 16 Hari Rawatan : 4 CM: 1200382 Hari rawatan ; 4 Hari Rawatan: 4
Hari Rawatan: 4
A/ A/ A/ A/
1. CKD stage 5 ec pNC 1. PSMBA e.c. dd 1. A/ 1. Massa intraabdomen ec 1. Hiperferitinemia
2. DM Tipe 2 Overweight Ulkus gaster 2. Ulkus 1. Leukositosis ec dd/ 1. dd 1. Hepatoma 2. 2. CKD stage V HD reguler
3. Hipertensi Stage 2 duodenum 3. Uremic CML 2. CLL 3. CNL Kista hepar 3. dm tipe 2 nw
4. Anemia normokrom bleeding 2. OMI Inferior 3.Carsinoma colorectal 4.diare akut ec dd –infeksi
normositer ec CKD 2. CKD Stage 5 on HD 2. Cancer pain VAS 1-2 virus –infeksi bakteri
5. Hipoalbuminemia regular Th/ 3. PSMBA ec dd 1. Ulkus 5.asites ec ckd
6. BPH 3. Nefrolithiasis bilateral - bedrest gaster 2. Ulkus 6.pneumonia (hap)
7. Cystitis + DJ Stent Insitu - Diet MB duodenum 3. Gastritis
8. Katarak Senilis matur 4. Disuria ec ISK - Sitodrox 2x500mg erosive Th/
ODS 5. Ulkus decubitus a.r. konfirmasi dpjp 4. Hipoalbuminemia - bedrest
9. Candidiasis Oral sacrum grade III - Omeprazole 2x20 mg 5. Efusi pleura bilateral ec - Diet Ginjal 1700 kkal/hari
10. Pneumonia (hap) 6. Hepatitis C dd –malignancy - Drip desferal 1 amp dalam
7. Geriatric problem Lab 13/02/2019 -pleuropneumonia 50 cc NACl 0,9% habis
Th/ (Imobilisasi, infeksi) Hb/Ht/E/L/Tr -hipoalbuminemia dalam 10 jamhari selama 2
- Bedrest 8. Pneumonia (hap) 11,3/33/3,9/159,3/597 hari
- Diet Ginjal 1700 MCV/MCH/MCHC: Th/ -attapulgit 1 tab/ kali BAB
kkal/hari Th/ 83/29/35/ -Bedrest maksimal 12 tab/hari
- Three way -Bedrest Mika-miki / 2j MDT: -Diet hati 1700 kkal/hari - HD regular
- O2 4l/i Diet ginjal 1700 kkal/hari _ -eritrosit normokrom -IVFD Aminofusin hepar 1 -iv ceftriakson 2gr/24j
- IV Ceftriaxone 2 gr/ 24 50 gram protein / hari -leukosit, ditemukan seri fls/hari
jam -IV Cefepim 1 gram post HD granulosit dari blast s.d -IV lansoprazole 30 mg/12 Lab 19/02/2019
- IV Furosemide 40 IV Omeprazole 40 mg/ 12 neutrophil segmen jam Ferritin 1491,22
mg/8 jam jam -Transfusi PrC 1 kolf/hari Besi (Fe/Iron) 21
- Asam folat 2 x 400 mg Lenal Ace 2 x 169 mg target Hb > 10 gram/dL
- Lenal Aceh 2 x 169 mg As. Folat 2 x 400 mg -Curcuma 3 x 1 Lab 18/02/2019
- Valsartan 1x160mg po HD rabu-sabtu -Graphalac Syr 3 x Ci Hb/Ht/E/L/T
- Adalat oros 1 x 20 mg Balance Cairan seimbang -Coditam 3 x 1 7,3/22/2,6/6,0/160
- Hytroz 1 x 2 mg Sucralfat syr 3xc1 MCV/MCH/MCHC
- Omeprazole 2 x 20 mg Asetilsistein 3x200mg Lab 20/02/2019 85/28/33
- Cendo catarlen ED 4 x Urinalisis Diftell: 1/0/0/73/15/11
gtt I ODS Lab 19/02/2019 Ur/cr: 116/10,50
- Cendo Lyters ED 4 x Urinalisis Lab 19/02/2019 Na/k/cl: 137/3,9/96
gtt I ODS Hb/L/T ; 8,9/9,0/557
- Ambroxol Syr 3 x CI Lab 18/02/2019 MCV/MCH : 79/24 Lab 13/02/2019
- Nystatin drop 4 x gtt II Hb/L/T : 7,0/15,5/298 Diftel : 2/0/0/78/12/8 Hb/Ht/E/L/Tr
- Hd senin kamis MCV/MCH : 74/25 HbsAg : negative 8/24/2,8/3,8/153
Diftel : 0/0/0/93/4/3 Bil drek/indirek : 0,12/0,15 MCV/MCH/MCHC
Lab 18/02/2019 Ur/Cr : 127/4,76 SGOT/SGPT ; 27/5 86/28/33
PT/APTT 10,9/51,4 Na/K/Cl : 134/4,8/95 Albumin : 3,19 Feritin: 1241,77
HbsAg (-) HDL/LDL/TG : 23/93/379 Fe: 19
Anti HCV (+) Ur/Cr : 35/0,56 Na/K/Cl: 130/4/107
PT : 11,6 Kontrol 10,8 Asam Urat : 9,7
INR : 1,10 Na/K/Cl : 134/4,6//106
APTT : 38,6
GDS : 138 Lab 18/02/2019
Hb/L/T : 9,5/10,2/614
MCV/MCH : 76/24
Diftel : 1/1/1/75/12
AntiHCV : -
HbsAg : -
GDS : 139
Ur/Cr : 33/0,61
Na/K/Cl : 142/4,4/93
 K3B1 K3B2 K3B3 K3B4 K3B5
DPJP : dr. Kurnia Sp.PD DPJP : dr. Kurnia Sp.PD DPJP : dr. DPJP : dr. Kurnia Sp.PD DPJP : dr. Kurnia Sp.PD
COW : dr. Suheir COW : dr. Nasriah COW : dr. COW : dr. Suher COW : dr. Suher
DR : dr. Reyza DR : dr. Reyza DR : dr. DR : dr. Taufiq DR : dr. Taufiq
DM : Ranti DM : Ranti DM : DM : Ranti DM : Ranti

Nama: Muslim Nama: Zakaria Hanafiah Nama : M. Irfan Nama : Samsul Bahri RM
TTL: 25-09-1973 (45th) TTL: 31-12-1952 TTL : 02/05/1993 TTL : 1/6/1972
Alamat: Pidie jaya Alamat: Pidie Alamat : Pidie Alamat : Pidie
CM: 1200329 CM: 0-99-62-66 CM ; 1040438 CM : 1084318
Hari Rawatan: 9 Hari Rawatan: 6 Hari Rawatan : 3 Hari Rawatan : 4

A/ A/ A/ A/
1.trombositopenia ec dd 1.diare akut ec dd/ 1.Efusi pleura sinistra ec dd 1.PSMBA ec dd 1) Gastritis
- ITP -intoleransi makanan 1. Pleuropneumonia 2. erosive 2. Ulkus gaster 3.
- TTP -infeksi virus (rotavirus) Pleuritis 3. Malignansi Ulkus duodenum
- MDS -infeksi bakteri (shigelosis) 2.Sirosis hepatis stadi. 2.Selulitis a.r. cruris dextra
- anemia aplastik Dengan diare ringan-sedang Decompesata Childpug C 3.Anemia sedang
2. hipoalbuminemia 2. anemia aplastic on therapi related Hep b normokrom normositer ec
3.Tinea corporis 3. AKI stage I ec diare akut 3.Hernia umbilical dd 1. Perdarahan 2. Penyakit
4. PPOK stabil 4.Edema scrotalis ec kronik
5.pneumonia (hap) hipoalbuminemia 4.Hipereosinofilia ec dd 1.
Th/ 5.CAP dd/ TB paru dengan Infestasi parasite (cacing) 2.
- Bedrest Th/ Infeksi sekunder Alergi
-Diet MB 1700kkal/hari + ektra - Bedrest 6.hep b kronik
putih telur -diet MB 1700kkal/hari 7.anemia ec peny kronik Th/
- IVFD Nacl 0,9% 20tpm -IVFD RL 30gtt/m -Bedrest
- miconazole zalf -IV Omeprazole 40mg/12j Th/ -Diet MII 1700 kkal/hari
- iv omeprazole 40mg/12j -Sandimun 2x100mg -Bedrest IVFD NaCl 0,9% 20 gtt/i
-Sucralfat syr. 3xCI -Metilprednisolon 3x8mg -Diet Hati III 1700 kkal/hari IV Ceftriaxone 2 gram/24
- Tranfusi TC jika TC < 10.000 -Asam folat 2x0,4mg -O2 2 – 4 Liter/menit jam
atau TC < 20.000+perdarahan -Ca laktat 2x1 IVFD Aminofusin Hepar 10 IV Omeprazole 40 mg/12
-cetirizine 2x10mg -attapulgit 3x1tab PO gtt/hari jam
-tranfusi PRC s/d HB 10gr/dl IVFD nacl 0,9% 10 gtt/i Clindamisin 3 x 500 mg (o)
Lab 15/2/2019 -asetil sistein 3x200mg Propanolol 1 x 10 mg PCT 500 mg (k/p)
Hb/Ht/E/L/Tr: -iv ceftriakson 2gr/24j Spironolakton 1 x 100 mg Sukralfat syr 3 x CII
14/41/4,9/11,1/14 -cetirizine 2x10mg Curcuma 3 x 1 Transfusi PrC s.d. Hb > 10
DIFTEL: 1/1/0/64/28/6 Grapalac Syr 3 x CI gr/dL
PT/APTT: 10,8/38,8 Lab 20/02/2019 Pectosyl 3 x 200 mg -rawat luka
Alb: 2,98 Ur/cr 32/0,83 IV Ceftriaxone 2 gram / 24
GDS: 165 mg/dL jam Lab 19/02/2019
Ur/Cr: 16/0,74 Lab 17/02/2019 Transfusi 1 Kolf Hb/Ht/E/L/T :
Na/K/Cl: 136/5,1/93 Hb/L/T : 6,4/2,3/224 -pct drip k/p 9,1/28/3,1/7,1/212
Anti HCV : negatif MCV/MCH : 87/45 -drip albuminar 25% 100cc MCV/MCH/MCHC
HBSAG : negatif Diftel : 0/0/0/85/10/5 90/29/33
Lab 19/02/2019 Diftel : 12/1/0/51/28/8
Lab 14/2/2019 Lab 16/2/2019 Hb/Ht/E/L/T : Retikulosit 5,1
Hb/Ht/E/L/T Hb/E/L/T 7,7/24/3,5/6,7/134 PT/APTT 9,9/35,9
10,9/33/3,8/6,3/24 6,3/0,5/2,6/256 MCV/MCH/MCHC MDT kesimpulan
MCV/MCH/MCHC 85/28/33 MCV/MCH/MCHC 68/22/32 normokrom normositer
Diftel: 1/1/0/51/37/10 90/126/140 Diftel : 0/0/1/79/8/12
Diftell: 0/1/0/81/14/4 SGOT/SGPT 38/14 Lab 19/02/2019
Lab 14/02/2019 Ur/cr: 57/1,23 Alb 1,98 Hb/LT : 7,9/7,4/204
Urinalisis Na/k/cl: 141/4,9/97 MCV/MCH : 86/30
-Makroskopis: Lab 18/02/2019 Diftel : 12/1/0/52/27
Kuning jernih dengan berat Hb/L/T : 7,9/7,8/122 GDS : 190
jenis 1,015 MCV/MCH : 67/22 Ur/Cr : 20/0,78
Ph 7,5 Diftel : 0//1/0/79/7/13 Na/K/Cl : 146/3,9/104
Glukosa +1 CT/BT : 3/9
-Mikroskopik GDS : 95
Leukosit 2-3 Ur/Cr : 19/0,37
Eritrosit 1-2 Na/K/Cl : 126/4,7/91
Epitel 4-6

Lab 12/2/2019
Hb/Ht/E/L/T
14.0/41/4.9/11.1/14
MCV/MCH/MCHC
83/29/34
Diftel: 1/1/0/64/28/6
Ur/Cr: 16/0,74
IgM: (-)
IgG(-)
Alb: 2.92
GDS: 165
Na/K/Cl: 136/5.1/93
 K4B1 K4B2 K4B3 K4B4 K4B5
DPJP : dr. Mamfaluti DPJP : dr. Mamfaluti DPJP : dr. Mamfaluti DPJP : dr. Mamfaluti DPJP : dr. Mamfaluti
COW : dr. Ganis COW : dr. Ganis COW : dr. Ganis COW : dr. Ganis COW : dr. Ganis
DR : dr. Husna DR : dr. Husna DR : dr.Husna DR : dr. Husna DR : dr. Husna
DM : Ranti DM : Ranti DM : Ranti DM : Ranti DM : Ranti

Nama: Zubaili Nama : Fahmi Yusuf Abdullah Nama : Aili Haryadi Ali Nama: Safrita Mukhtar Nama : Rusli AliBasyah
TTL: 19 th TTL : 21th TTL : 31/12/1972 (46 tahun) TTL: 09/05/1974 (44tahun) TTL : 01/07/1949 (69 tahun)
Alamat: Aceh Barat Daya Alamat : Kota lhokseumawe Alamat : Bireuen Alamat: Aceh singkil Alamat : Aceh Utara
CM: 1200675 CM : 1200602 CM : 1194792 CM: 1-20-00-36 CM : 1200693
Hari Rawatan: 6 Hari Rawatan : 7 Hari Rawatan : 6 Hari Rawatan: 6 Hari Rawatan : 7

A/ A/ A/ A/ A/
1.abses hepar 1.dvt ar pedis sin dd 1. AKI stg III dd akut on 1. SOL intrakranial 1. Penurunan kesadaran
2.skizofrenia limfoedima CKD 2. dd – CML (perbaikan) ec dd 1. Sda
2.limfoma hodgkin ar colli 2. Anemia sedang -CLL 2. sepsis 3. Imbalance
Th/ 3.obs seizure dd hipokrom mikrositer ec elektrolit
-bedrest -metastase otak dd 1. Penyakit Kronik 2. Th/ 2. Efusi pleura dextra ec dd
-diet mb 1700kkal/hari -infark serebri ec emboli Def Fe -Bed rest 1.massa paru kanan
-ivfd nacl 0,9% 20tpm 4.abdominal distensi ec dd 3. DM Tipe II NW - Diet MII 1700kkal/hari 2.Pleuropneumonia
-drip metronidazole 500 mg/ -metastase 4. Angina pectoris stable - IVFD NaCl 0.9% 20gtt/i 3. AKI Stage II dd acute on
6 jam -obstruksi partial pada colon 5. Hipertensi st 2 -IV omeprazol 40mg/12j ckd
-drip novalgin 1 gr/8 jam limfoma intraabdomen 6. Non proliferatif diabetik -IV dexamethasone 5mg/8j 4. Hipokalemia berat
-iv omz 40mg/12jam 5.leukositosis ec dd retinopati -Citicolin 500mg/12j 5. Hipoalbuminemia berat
-reaksi dekomoid 7. Severe hipertensive -IV paracetamol 1gr/8j 6. Geriatric problem
Lab 20/02/2019 -limfoma maligna retinopathy ods - cytodrox 2x500mg 7. Anemia sedang HM
AFP 1,06 -cll -allopurinol 1x300mg
6.hipertensi stg 2 Th/ -aspilet 1x80mg Th/
Lab 15/02/2019 - Tirah Baring -hidroxinurea 2x100mg - Tirah baring, head up
Hb/L/T : 10,5/10,0/430 Th/ - 02 2 – 4 l/menit 45%
MCV/MCH : 84/29 -Bedrest - Diet Ginjal 17 kkal/hari Lab 18/02/2019 - O2 2 – 4 liter/i
Diff. count : 20/1/0/44/27/8 -Diet MB 1700 kkal/hari + 30 gram protein/hari Hb/L/T : 9,8/418,3/207 - NGT, kateter terpasang
Ur/Cr : 16/0,54 -Ivfd nacl 0,9% 20 tpm - Three way MCV/MCH: 85/30 - Diet mII rendah garam
Na/K/Cl : 146/4,1/102 -ciprofloxacin 2x500mg PO - IV Ceftriaxon 2 gram Diftel : 2/6/-1/90/1/2 - IVFD 2 : 1 20 gtt/i
GDS : 98 -Valsartan 1x80mg /24 jam - N-asetil sistein 3x 200 mg
SGOT/SGPT : 46/27 -IV citicolin 500 mg/12 jam - Lenal Ace 2 x 169 mg Lab 17-02-2019 - IV Ceftriaxone 2 gram/
Bil. Direk/Indirek: 0,36/0,48 Kaltropen supp (K/P) - Asam folat 2 x 400 mcg Hb/Ht/E/L/T 24 jam
- cilostazol 2x1 - Domperidone 3 x 10 mg 9,5/28/3,3/328,5/195 - Nystatin drop 4 x 2 cc
-coditam 3x1 - IV Omeprazole 40 MCV/MCH/MCHC - Clopidogrel 1x75 mg
mg/12 jam 84/29/34 - Iv cefepime 1gr/8j
Lab 19/02/2019 - Bicnat 2 x 500 mg Diftell: 3/5/0/88/2/2 - Drip albumin 1 fls/hari
PT : 17,5 - Valsartan 1x80mg
Kontrol : 10,4 - Flumucyl 3x30mg Lab 11/02/2019 Lab 20/02/2019
INR : 1,66 - Sc apidra 6-6-6 Hb/Ht/E/L/T Urinalisis
APTT : 61,8 9,7/25/3,1/641,1/435
Kontrol : 36,1 Lab 16/02/2019 MCV/MCH/MCHC Lab 15/02/2019
D-Dimer : 1244,31 AntiHCV : negatif 82/32/39 Hb/L/T : 8,7/14,4/349
Diftl: 2/8/0/86/1/3 MCV/MCH : 69/22
Lab 17/02/2019 Lab 15/02/2019 MDT: Diftel : 1/0/0/89/6/4
Hb/Ht/E/L/T Hb/L/T : 8,6/6,3/541 -eritrosit : Normokromik GDS : 105
11,6/35/4,4/56/362 MCV/MCH : 81/28 anisositosis Na/K/Cl : 152/2,7/104
MCV/MCH/MCHC Diff. Count : 3/1/0/72/15/9 -Lekosit : Meningkat, sel Ur/Cr : 111/2,04
80/26/33 HbsAg : negative muda+, Blast+ (mieloblast
Diftell: 0/0/0/92/3/5 GDS : 409 5,6%)
Ur/Cr : 82/3,37 Trombosit : Normal, giant-
Lab 14/02/2019 Na/K/Cl : 138/4,7/100 Kesimpulan: susp. CML
Hb/Ht/E/L/Tr CT/BT : 2/7 fase kronik
11,7/34/4,4/51,2/315 Gds: 254
MCV/MCH/MCHC Ur/Cr: 21/0,77
77/26/34 Na/K/Cl : 136/3,4/90
Gds 120
Ur/cr 39/0,67
Na/K/Cl: 133/4,6/91
 K5B1 K5B2 K5B3 K5B4 K5B5
DPJP : dr. Mamfaluti DPJP : dr. Mamfaluti DPJP : dr. DPJP : dr. Mamfaluti DPJP : dr. Mamfaluti
COW : dr. Ganis COW : dr. Ganis COW : dr. COW : dr. Ganis COW : dr. Ganis
DR : dr. Husna DR : dr. Husna DR : dr. DR : dr. Husna DR : dr. Husna
DM : Mahathir DM : Mahathir DM : DM : Mahathir DM : Mahathir
Nama: Muhktarizal jamil Nama: Usman Syamsah Nama: Zulkarnaini Nama: Sofyan Itam
Umur: 24th Umur: 25/1/1969 (50thn) Umur: 55th Umur: 67th
Alamat: bireun Alamat:Aceh Timur Alamat: bireun Alamat: banda aceh
CM: 1190895 CM: 1199070 CM: 1201212 CM: 1095491
Hari Rawatan: 2 Hari Rawatan: 22 Hari Rawatan: 2 Hari Rawatan: 2

A/ A/ A/ hepatomegali ec dd A/
1) Hepatomegali ec dd -hepatoma dg cancer pain 1.lower left quadrant
1. Metastase proses -abses hepar abdominal pain ec kolitis
2. Hepatoma -metastase proses ke hepar ulseratif
Th/ 2) Limfadenopati ar colli 2.diare kronis ec kolitis
dextra dd Th/ ulseratif
a. Limfoma maligna -bedrest 3.dyspepsia type like ulcer
Lab b. Limfadenitis -diet hati 1700kkal 4.hipertensi st 2
3.Susp ca buli -ivfd aminofusin hepar 5.hemoroid interna gr 2
COLONOSCOPY HARI 1fls/hari
INI Th/ -curcuma 3x1 Th/
-Bed rest -lactulac syr 3xcII -bedrest
-IVFD Aminofusin hepar 1 -coditam 3x1 -diet mb
fls/hr -ivfd rl 20tpm
-IV cefepime1g/8jam (H7) Lab 20-2-2019 -iv omz 40mg/12j
-Kaltropen sup 3x1 Hb/Ht/E/L/Tr -iv ondansetron 4mg/8j
-Tab Curcuma 3x1 9,2/27/3,1/14,5/212 -amlodipin 1x10mg
-lactulosa 3x30cc MCV/MCH/MCVC 86/30/34 -valsartan 1x80mg
-duragesic patch 12,5 (H3) Bil dir 0,53 -coditam 3x1tab
- N asetilsistein 3x1 Sgot/sgpt 76/57 -attapulgit
Gds 97 -kaltropen supp extra
Lab 15/02/2019 Ur/Cr: 38/1,52 -antihemoroid supp
PSA Total 0,43 Na/K/Cl: 148/4,7/104
Lab
Lab 13/02/2019
Hb/Ht/E/L/Tr
12,3/37/4,7/24,9/273
MCV/MCH/MCVC
78/26/34
Ur/Cr: 46/0,52
Na/K/Cl: 128/4,8/98

Lab 08/02/2019
Hb/Ht/E/L/T
13,2/39/5,0/21,9/325
MCV/MCH/MCHC
78/27/34
Na/K/Cl: 131/4,3/96
PT/APTT: 1,29/1,2
HbsAg negatif

Lab 04/02/2019
Hb/Ht/E/L/T
12,5/37/4,7/17,5/314
MCV/MCH/MCHC
79/27/34
Ur/Cr: 33/0,80
Na/K/Cl: 133/5,0/94

Urinalisis
Warna : kuning
Kejernihan : Keruh
Berat jenis 1,015
pH 6,5
Proteinuria (+1)
Darah negatif
Leukosit 1-2
Eritrosit 6-8
 K6B1 K6B2 K6B3 K6B4 K6B5
DPJP : dr. Mamfaluti DPJP : dr. Mamfaluti DPJP : dr. Mamfaluti DPJP : dr. Mamfaluti DPJP : dr. Mamfaluti
COW : dr. Ganis COW : dr. Ganis COW : dr. Ganis COW : dr. Ganis COW : dr. Ganis
DR : dr.Husna DR : dr.Husna DR : dr. Husna DR : dr. Husna DR : dr. Husna
DM : Mahathir DM : Mahathir DM : Mahathir DM : Mahathir DM : Mahathir
Nama: Selamat Nama: Muhammad Rizky Nama: Ibnu Hajar Nama : T. Iskandar Nama :Taufiq M Daot
TTL: 58th TTL: 18th TTL: 07/07/1982 (36th) TTL : 01/07/1960 TTL : 21-11-1982
Alamat:Pidie jaya Alamat: banda aceh Alamat: Aceh Selatan Alamat : Banda Aceh Alamat :Bireuen
CM: 1200307 CM: 1200201 CM: 1199827 CM : 0891509 CM : 1200771
Hari Rawatan: 9 Hari Rawatan: 10 Hari Rawatan: 12 Hari Rawatan : 3 Hari rawatan : 5

A/ A/ A/ A/ A/
1.obs jaundice ec dd 1.PSMBB ec dd/ 1.CKD stage V ec dd : -CKD stage V ec dd 1/ HN 2/ 1.hipertensi urgency
-kolelithiasis dg kolesistitis - Hemoroid interna - PGOI on HD reguler PNC dengan uremic 2.ckd st v on hd ec nefropati
-ca caput pankreas - Polip recti -PNC syndrome obstruksi
2.esofagitis gr a - malignancy 2. Anemia sedang HM ec - Hipertensi Stage II 3.anemia berat nn ec ckd
3.gastropati 2.anemia berat NN ec PGk -Anemia sedang normokrom 4.hidronefrosis bilateral
4.massa ar duodenum pars perdarahan 3.ISK normositer ec penyakit 5.hiperkalemia ringan
descendens kronik
5.ascariasis Th/ Th/ Th/
6.hipoalbuminemia - Bedrest - Bedrest Th/ -Tirah baring
7.anemia sedang nn ec -Diet mb 1700kkal -Diet ginjal 1700kkal + 30 gr -Bedrest -diet ginjal 1700kkal. Protein
perdarahan -IVFD nacl 0,9% 20tpm protein/hari -Diet Ginjal 1700 kkal/hari 40gr/h
8.status hipokoagulasi -anti hemoroid supp/12j - threeway Three way -threeway
-tf prc sampe hb >10 -IV omeprazole 40mg/24j As. Folat 2 x 400 mg -Drip levofloxacin 750mg/48j
Th/ -iv transamin 500mg/8j -Amlodipin 1x10mg Lenal ace : 2 x 16 gram -iv omeprazole40mg/12j
- Bedrest -pct 500mg tab (k/p) -Paracetamol 3x500mg Lactulac syr 3 x CI -IV ondansetron 40mg/8j
-Diet mb 1700kkal (rendah -ardium 3x2tab -Asam folat 2x400mcg Amlodipin 1 x 10 mg -kalitake sach 3x1
lemak) -Calsium laktat 2x1 tab Candesartan : 1 x 16 mg -tab amlodipine 1x5mg
-IVFDnacl 0,9% 20GTT Lab 20/02/2019 -kaltropen supp HD selasa kamis -tab PCT 3x500mg
-iv ceftriaxone 2gr/24j Hb/Ht/E/L/T -kalitake sachet -Transfusi PRC s/d HB>10g
-iv Omeprazole 40mg/12j 8,7/30/4,1/5,5214 -lenal ace 2x169mg Lab 19-02-2019
-inj vit k 1 amp/8j MCV/MCH/MCHC 73/21/29 -attapulgit 1 tab/mencret Hb/Ht/E/L/T Lab 17-02-2019
-sucralfat syr 3xc1 Diftell 2/1/0/46/45/6 6,9/20/2,3/7,8/356 Hb/Ht/E/L/T
-curcuma 3x1 tab Lab 15/02/2019 MCV/MCH/MCHC 84/30/35 5,4/15/2,4/20,2/177
Lab 17/02/2019 Hb/Ht/E/L/T Diftell 0/0/1/83/9/7 MCV/MCH/MCHC
Lab 17/02/2019 Hb/Ht/E/L/T 7,7/24/3,4/8,1/385 Hbsag – 63/22/36
PT/APTT: 9,9/34 6,6/22/3,1/3,9/87 MCV/MCH/MCHC Gds 127 Diftell 0/0/0/88/6/6
MCV/MCH/MCHC 70/23/32 Ur/cr 248/21,65 Ur/cr 308/19,4
Lab 16/02/2019 71/21/30 Diftell 3/0/0/72/10/15 Na/k/cl 138/5/95 Na/k/cl 138/4,1/90
Hb/Ht/E/L/T Diftell 3/1/0/55/33/8 Ca: 6,3
9,1/27/3,4/16,9/217 Ur/cr/asamurat: 157/7,56/8 Lab 17-02-2019
MCV/MCH/MCHC Lab 13/02/2019 Na/k/cl: 136/4,3/108 Hb/Ht/E/L/T
78/27/34 Retikulosit 3,8 6,2/18/2,8/40,1/112
Diftell 3/1/0/84/6/6 Pt/aptt 10,4.41 Lab 13/02/2019 MCV/MCH/MCHC
Feritin <1,5 Hb/Ht/E/L/T 64/22/35
Lab 13/02/2019 Anti hcv – 6,7/20/3,0/7,3/476 Diftell 0/0/0/95/2/3
afp 1,14 Hbsag – MCV/MCH/MCHC W perdarahan: 3
bil tot/dir/indir 9,17/6,36/2,81 Tinja rutin warna merah 68/23/33 W pembekuan: 9
alp 570 eritrosit 40-50 Albumin : 2,52 Anti hcv: negative
protein tot 4,03 Leukosit 10-15 Ur/Cr : 228/8,75 Hbsag : negative
alb 2,32 Na/K/Cl : 133/4,9/107 Alb: 3,06
glob 1,71 Lab 11/02/2019 GDS: 91
Hb/Ht/E/L/T Lab 12/02/2019 Ur/cr: 452/25,74
Lab 12/02/2019 2,6/11/1,8/6,1/234 Analisa gas darah Na/k/cl: 129/5,9/82
Hb/Ht/E/L/T MCV/MCH/MCHC 59/14/24 pH : 7,184
5,7/16/2,1/15,8/1855 Diftel 1/0/0/58/35/6 pCO2 : 59,00
MCV/MCH/MCHC 77/27/35 Gds 116 pO2 : 29
Pt/aptt 84,1/93,2 Ur/cr 16/0,64 Bicarbonat (HCO3) : 22,4
Hbsag – Na/k/cl 143/3,8/100 Total CO2 :24,2
Bil direct 5,55 Kelebihan basa (BE) : -5,4
Sgot/sgpt 90/43 Saturasi O2 : 44,2
Alb 2,52
Gds 274 Lab 10/02/2019
Ur/cr 56/0,6 Analisa gas darah
Na/k/cl 139/4/9 pH : 7,204
pCO2 : 30,80
pO2 : 110
Bicarbonat (HCO3) : 12,3
Total CO2 : 13,2
Kelebihan basa (BE) : -13,6
Saturasi O2 : 92,1

Lab 09/02/2019
Ca : 9,3
Na/K/Cl : 139/6,5/113