AQSHA 2 (PENYAKIT DALAM PRIA)

Hari / Tanggal : Senin, 02 Maret 2020

Dokter Jaga : dr. Andri/ dr. Okdimur
Dokter Muda : Avicenna / Nisrina

*K1B1* *K1B2* *K1B3* *K1B4* *K1B5*

DPJP: Dr.dr.Azhari Gani, SpPD-
DPJP: dr. Diana erlita, Sp.PD DPJP: dr. Azzaki, Sp.PD DPJP: dr.T. Mamfaluti, SpPD DPJP: dr.T. Mamfaluti, SpPD
KKV
COW: dr. Fardhiansyah COW: dr. Munawar COW : dr. Dedi COW : dr. Dedi
COW: dr. T. Fahril
DR: dr. Amelia DR: dr. Zulfikar DR : dr. Amelia DR : dr. Amelia
DR: dr. Viencen
Raber : GEH Raber : Raber: Raber:
Nama: Risno Ariswansyah Nama: Safari Basyah Nama: M. Ali Ishak Nama:M.Yusuf Nama: Nain M Noer
TTL: 05/09/1983 TTL: 01/07/1955 TTL: 25/04/1979 (40th) TTL: 02/09/1947(72th) TTL: 06-02-1968 (52 th)
Alamat: Simeulue Alamat: Aceh besar Alamat: Bireun Alamat: Aceh Barat Alamat: Sabang
CM: 1238759 CM: 1167469 CM: 1239574 CM: 1239166 CM: 1237990
Hari rawatan: 11 Hari rawatan: 1 Hari rawatan: 1 Hari rawatan: 6 Hari rawatan: 17

A/ A/ A/ A/ A/
1. Hepatomegali ec dd 1. PSMBA ec dd / 1. CKD stage V ec dd 1. PSMBA ec dd/ 1. CKD stg V dengan uremic
-Susp.massa suprarenal 1. Ulcus gaster 1. DN 1. gastritis erosif syndrome ec PNC
- Multiple nodul a/r liver sinistra 2. Ulcus duodenum 2. PNO 2. ulkus gaster 2. DM tipe 2 NW
- Nodul a/r corpus panceas 3. Gastritis erosif 3. HN 3. ulkus duodenum 3. Anemia berat NN ec peny.
2. DM tipe 2 NW 2. anemia sedang NN ec dd/ Kronis-Def besi
Th/ 3. Hipertensi Heart Disease 1. perdarahan akut 4. Hipokalemia Berat
- Bedrest Th/ 2. penyakit kronik 5. Hipokalsemia
- Bedrest
- IVFD Aminofusin hepar 1fls/hari Th/ 3. geriatri problem 6. Hiponatremia hipoosmolar
- Coditam 3x1 - Diet MB 1800kkal/hari - Bed rest 4. hipoalbuminemia hipovolemik
- Threeway
- Curcuma 3x1 - Diet DM 1700kkal/hari + 0,8 gr
- Ceftriaxone 1gr/12j - IV Lansoprazole 30mg / 12 jam protein/kgbb/hari + rendah garam Th/ Th/
- Sucralfat syr 3 x CII
- Kaltropen sup K/P - Threeway - Bedrest - Bedrest
- lactulac 3xCII - Domperidon 3 x 10mg - IV Furosemide 1 amp / 8 jam - Diet MB 1700 kkal/hari + - Diet ginjal 1700kkal/hari, protein
-Drip Metronidazole 500 mg/8 jam - Valsartan 1 x 80mg ekstra putih telur 0,8 gr/kgBB/hari
- Albumin 25% / 24 jam - IVFD RL 20 gtt/i - IVFD NaCl 0,9% 20 tpm
Lab 27/02/2020 - IV. Omeprazole 40 mg/12j - Moxifloxacin 400mg/24jam
Hb/Ht/E/L/T: 11/35/4,4/15,3/514 Lab 01/03/2020 - lenal ace 2x169mg
MCV/MCH/MCHC: 79/25/32 Hb/Ht/E/L/T: 7,7/22/2,8/14,5/357 Lab 27/02/2020 - asam folat 2x0,4mg
Diftel : 2/0/1/69/17/11 MCV/MCH/MCHC: 79/27/35 Hb/Ht/E/L/T: - IV ondancetron 4mg/12j
LED : 130 Diftel : 9/1/0/67/16/7 8,3/25/2,9/11,6/211 - Paracetamole 1gr extra
MCV/MCH/MCHC: 87/29/33 -attapulgite 2 tap tiap bab mencret
Lab 24/02/2020 Diftel : 2/0/0/82/10/6 -alprazolam 0.5mg/24jam
AFP : 13,44 INR : 1,28 - Novomix 12-12-12 SC
Kalsium : 6,5 - KCL 25 meq extra
Lab 21/02/2020 GDS: 125
Hb/Ht/E/L/T: 10,6/33/4,1/15,1/532 Na/K/Cl : 140/3,6/112 Lab 29/02/2020
MCV/MCH/MCHC : 80/26/32 Hb/Ht/E/L/T: 7,4/20/2,8/13,2/159
Diftel : 3/1/0/66/19/11 Urinalisis 27-02-2020 MCV/MCH/MCHC: 72/26/37
Anti HCV : nefatif Warna: kuning Diftel : 1/1/0/79/8/11
HbSag : non reaktif Kejernihan: keruh
Bil. Total/direct/indirect : Berat Jenis: 1,027 Lab 28/02/2020
1,21/0,70/0,51 pH: 5,0 Hb/Ht/E/T/L: 6,7/18/2,5/156/21,6
SGOT/SGPT: 100/25 leukosit : positif MCV/MCH/MCHC: 71/26/37
GDS : 116 protein : negatif Diftel : 0/0/0/85/3/12
Ur/cr : 17/0,60 glukosa :negatif Na/K/Cl/Ca : 131/2,0/99
NA/K/cl 140/3,80/103 keton: positif Ur/Cr : 148/6,20
Nitrit : negatif
urobilirubinogen: positif Lab 27/02/2020
bilirubin: negatif Hb/Ht/E/T/L: 5,8/15/2,2/186/17,2
darah: positif MCV/MCH/MCHC: 71/27/38
leukosit: 8-10 Diftel : 0/0/0/84/6/10
eritrosit: 10-15 Na/K/Cl/Ca : 127/1,9/96/5,2
epitel: 3-5 Ur/Cr : 130/5,5
bakteri : positif
Lab 25/02/2020
Na/K/Cl : 133/2,3/103
Lab 26/02/2020
Hb/Ht/E/L/T: 8,3/26/3,0/9,2/231 Lab 24/02/2020
MCV/MCH/MCHC: 87/28/32 Na/K/Cl : 132/2,0/101
Diftel : 2/1/0/78/13/6
MDT Lab 22/02/2020
Erit: Normokrom Normositer, Hb/Ht/E/T/L: 8,1/21/3,1/361/19,3
ansitositosis, Burr cell MCV/MCH/MCHC: 69/27/38
Leu: Jumlah cukup, bentuk Diftel : 1/1/0/91/3/4
normal, Neutrophilia Albumin : 3,7
Tromb: Jumlah cukup, Bentuk Na/K/Cl/Ca : 136/2,1/102/7,5
normal Ur/Cr : 156/7,4

Lab 25/02/2020 Lab 20/02/2020

Hb/Ht/E/L/T: 8,1/25/2,8/8,4/202 Ur/Cr : 158/7,50
MCV/MCH/MCHC: 88/29/33 Na/K/Cl : 134/1,9/105
Diftel : 5/0/0/71/18/6
Albumin : 2,70 Lab 18/02/2020
Anti HCV/HbsAg : Negatif/Non Ca : 5,5
reaktif Ur/Cr : 159/8,00
Na/K/Cl: 144/3,6/113 Na/K/Cl : 116/2,1/85
Ur/Cr : 23/0,70
 *K2B1* *K2B2* *K2B3* *K2B4* *K2B5*

DPJP: dr Abdullah SpPD-GH DPJP: dr. M. Diah, Sp.PD- KKV DPJP: dr. Diana erlita, Sp.PD DPJP: dr. Kurnia Fitri, Sp.PD DPJP: dr.T. Mamfaluti, SpPD
COW: dr Aidil COW: dr. Muhamaji COW: dr. Fardhiansyah COW: dr. Nadi COW : dr. Dedi
DR: dr Teguh DR: dr. Dedi DR: dr. Amelia DR: dr. Riyanda DR : dr. Amelia
Raber : Raber : Raber : HOM, GEH Raber:
Nama : Basyarudin Matbari Nama : Suherly Usman Nama: Basyari puteh Nama: M. Tali Nama: Al Faizar
TTL : 01-07-1974 (34th) TTL : 27-06-1957 (62th) TTL: 31/12/1871(48 th) TTL: 08/05/1967 (52th) TTL: 03/08/1991 (28th)
Alamat : Aceh selatan Alamat : Aceh Barat Alamat: aceh timur Alamat: Simeulue Alamat: Jaya baru
CM: 1-00-00-86 CM: 1-23-45-69 CM: 1216813 CM: 1-23-79-95 CM: 1-03-66-64
Hari Rawatan: 10 Hari Rawatan: 1 Hari rawatan:2 Hari rawatan:17 Hari rawatan: 1

A/ A/ A/ A/ A/
1. CKD stage V on CAPD 1. Penurunan kesadaran ec dd 1. CKD stage 5 ec PNC on HD resus 1. Diare kronis ec dd: 1. Obs. Febris ec dd
2. Pneumonia HAP 1. Stroke 2. hipertensi stage 1 - Colitis TB 1. Pneumonia
3. Hipertensi std I on terapi 2. SDA 3 efusi pleura dextra ec dd - Ca Colon 2. ISPA
-pleuropneumonia 2.Hipoalbumin sedang ec dd/ 2. Angioderma ec dd
Th/ Th/ -pleuritis TB 1. Low intake 1. Drug Eruption
- Bedrest - Bedrest -CHF 2. Liver failure 2. Dermatitis
- Diet ginjal 1700 Kkal/hari + - Diet sonde 3. Hiponatremia dengan
0,8 gr protein /kgbb/hari - IVFD Nacl 20 gtt/i Th/ hipoosmolar (perbaikan)
- Lenal Ace 169 mg/12j - Ceftriaxone 2 gr/ 24 jam Bed rest 4.TB paru dengan sekunder infeksi
Th/
- AS folat 400 mcg /12j - Omeprazole 40mg / 12 jam Diet ginjal rendah garam 1700kkal/hr 5. Hepatitis B kronik
- KSR 600mg/12j - Citicolin 500mg / 12 jam + protein 1,2gr/kgbb/hari 6. Syndrome frailty (sarkopenia) - Bedrest
- Diet MB 1700kkal/hari
- Curcuma /8j - Flumucyl 200mg / 8 jam IV ceftriaxone 2g/24jam
- Fluconazole on CAPD - Citirizine 10 mg / 24 jam Lenal ace 2x169mg Th/ - IVFD NaCl 0,9% 20gtt/i
- Paracetamole 500mg/8 jam
- Ceftriaxone 2gr/24jam - Asam folat 400mg / 24 jam Asam folat 2x0,4mg -IVFD NaCl 0,9% 30tpm
- Atorvastatin 20mg/ 24 jam N asetilsistein 2x200 mg -Diet hati III 1800kkal/hari (30gr - Omeprazone 40mg/12 jam
- Ceftriaxone (skintest +) 2gr/24
Lab 28-02-2020 Valsartan 1x80 mg protein/hari) + ekstra putih telur 6
Hb/Ht/E/L/T: 7,9/24/2,9/24,4/707 Lab 26-02-2020 butir / hari jam
- Cetirizine 10mg/24 jam
MCV/MCH/MCHC: 84/27/33 Hb/Ht/E/L/T: 10,7/34/3,8/12,9/600 Lab 29-02-2020 -attapulgite 1 tab/x BAB cair
Diftel: 1/0/0/86/8/5 MCV/MCH/MCHC: 88/28/32 Hb/Ht/E/L/T: 9,4/31/3,8/7,2/190 -PCT 500mg/8j - Metilprednisolon 4mg/8jam
- Paracetamole 100mg extra
Diftel: 6/1/0/75/13/5 MCV/MCH/MCHC: 80/25/31 -Ceftriaxone 2gr /24j
Lab 25-02-2020 Diftel: 3/2/0/64/19/12 -Albumin 25% 200cc/24j
Lab 01-03-2020
Hb/Ht/E/L/T: 7.7/23/2.8/18.6/681 Ur/cr 70/6,3 - Zinc 10mg/12j
MCV/MCH/MCHC: 83/27/33 NA/K/Cl : 148/4,7/105 - Aminofluid 1fl/24j Hb/Ht/E/L/T: 13,7/39/4,6/6,5/194
MCV/MCH/MCHC: 84/30/35
Diftel: 5/0/0/78/9/8 -Albumin 25 % 200 cc/ hari
- Vit K 1 amp/24 jam Diftel: 1/1/0/71/21/6
Lab 21-02-2020 - Asetilsistein 200mg 3x1
Anti HCV negatif - Vit D 0,25mg/24 jam
HBsAg Non reaktif
Albumin 2,49 Lab 28/02/2020
Ca : 8,1 LED : 10
Bilirubin tot/direk/indirek :
Lab 20-02-2020 2,47/1,75/0,72
Hb/Ht/E/L/T: 8.3/24/2.9/17.3/631 SGOT/SGPT : 40/26
MCV/MCH/MCHC: 83/38/34 Albumin : 2,34
Diftel: 3/1/1/79/8/8
Albumin 3,20 Lab 25/02/2020
GDS 100 Ratio PT /APTT :1,2/1,45
Ur/cr 83/14.10 protein total: 5,0
NA/K/CL 140/2,7/96 albumin: 2,0
globulin: 3,0

Lab 24/02/2020
PT : 17,00
APTT :53,50

Lab 22/02/2020
Ratio PT/APTT : 1,24/1,75
D-dimer : 470

Lab 21/02/2020
SGOT/SGPT : 43/25
ALP : 232
Albumin 1,05
Na/K/CL : 133/4,3/102

Lab 18/02/2020
Anti HCV : Negatif
HBsAg : reaktif

Lab 17/02/2020
Analisa Tinja
Warna : hijau
Bau : Khas
Eritrosit : negatif
Leukosit : negatif
Telur cacing : negatif
Parasit : negatif
Konsistensi : Lunak
Darah : negatif
Lendir : negatif

*K3B1* *K3B2* *K3B3* *K3B4* *K3B5*

 DPJP: dr. Kurnia Fitri Jamil,
DPJP: dr. Kurnia Fitri, Sp.PD DPJP : dr.T.Mamfaluti,Sp.PD DPJP: dr.M Riswan, SpPD DPJP: dr.Azhari Gani
Sp.PD-KPTI
COW: dr. Nadi COW : dr. Dedi COW: dr. Reza COW: dr. T. Fahril
COW:
DR: dr. Riyanda DR : dr. Amelia DR: dr. Nelvi DR: dr. Viencen
DR: dr. Rianda
Raber : GEH Raber: GH Raber: Raber : GH
Raber: Bedah Urologi, hom
Nama : Muratip Simin Nama: Abdullah Ahmad Nama: Abdul Karim Nama : Zaino Syamaun Nama :Zakaria Yahya
TTL : 16-04-1954 (65th) TTL: 07/02/1955 (65th) TTL: 24-05-1999 (60th) TTL :03/07/1957 TTL :01-07-1966 (53th)
Alamat:Aceh Tengah Alamat: Bireun Alamat: Banda Aceh Alamat : Pidie Jaya Alamat : Bireuen
CM: 1-23-88-70 CM: 1-23-88-57 CM: 1238869 CM : 1-23-90-37 CM : 1-23-90-37
Hari Rawatan: 9 Hari rawatan: 9 Hari rawatan: 9 Hari rawatan : 4 Hari rawatan :7

A/
1. PSMBA (perbaikan) ec dd
- Gastritis Erosif
- ULkus gaster
-Ulkus Duodenum
-Ca gaster
2. Anemia Berat NN ec PSMBA
3. PPOK derajat sedang stabil
Th/
-IVFD NaCl 0,9% 30 tpm
-Diet MII 1700 Kkal/hari
-IV Ceftriaxone 2gr/24 jam
-Sucralfat syr 3xCII
- Nebule Combivent 1 resp/12 jam
- Paracetamole 1000mg/24 jam
-Omeprazole 40mg/12j
- Asetil sistein 3x200mg
Lab 28-02-2020
Hb/Ht/E/L/T: 11,2/34/4,1/7,1/317
MCV/MCH/MCHC: 83/28/33
Diftel: 9/1/0/68/13/9
Lab 25-02-2020
Hb/Ht/E/L/T: 6,9/21/2,4/6,7/282
MCV/MCH/MCHC: 86/29/34
Diftel: 5/0/0/69/14/12
Lab 23-02-2020
Hb/Ht/E/L/T: 4,9/15/1,7/7,2/219
MCV/MCH/MCHC: 89/29/33
Diftel: 2/0/0/71/15/12
PT/APTT: 14,20/32,70
Anti Dengue IgM : negatif
Anti Dengue IgG: Negatif
Anti HCV :negatif
HBsAg: Non reaktif
Bilirubin total : 0,28
Bilirubin Direct : 0,06
Bilirubin Indirect : 0,22
GDS: 190
Ur/cr : 46/1,10
A/
1.AKI stg 3 renal dd akut on CK
D egali ec dd
2.Pneumonia
3.post ureterolitotomi a/r BSK
4. ISK
5. Anemia sedang NN ec dd
- Perdarahan
- Penyakita kronik
6.Hipoalbumin
Th/
Bedrest
-Diet ginjal 1700 kkal/hari + 35
gr protein
- IV Omeprazole 40mg/12 jam
- Bicnat 3x1
- Fluimucyl 200mg/8jam
- Allopurinol 100mg/ 24 jam
- Kalitake 3x1 sach
-Ramipril 5 mg / 24 jam
- Asitelsitein 200mg/8j
- Gentamycin 1 gram?/8 jam
- Fluconazole 200 mg/24 jam
- Anti hemoroid supp / 12 jam
Lab 01-03-2020
Hb/Ht/E/L/T:
7,3/22/2,5/11,3/469
MCV/MCH/MCHC: 87/29/33
Diftel: 1/1/0/71/16/11
Lab 29-02-2020
Hb/Ht/E/L/T:
7,1/22/2,5/12,5/525
MCV/MCH/MCHC:88/29/32
Diftel: 1/1/0/76/13/9
Albumin : 2,9
Lab 26-02-2020
Hb/Ht/E/L/T:
8,2/24/2.9/18.3/428
MCV/MCH/MCHC:84/24/34
Diftel: 1/0/1/78/9/11
Psa total 6,57
ur/cr 117/2,54
Lab 23-02-2020
Hb/Ht/E/T/L:
8,7/25/3,1/22,4/159
MCV/MCH/MCHC: 81/28/35
Diftel: 2/0/0/78/10/10
Anti HCV : negatif
HBsAg : Non reaktif
Bilirubin total : 4,35
Bilirubin Direct : 3,11
Bilirubin Indirect : 1,24
Albumin : 2,50
Na/K//Ca : 137/5,3/7,5
Ur/cr: 199/4,50
A/ A/ A/
1. Pansitopenia dengan hepatosplenom 1. Pansitopenia ec dd 1. AKI stage III post Re
- Anemia aplastik acute on CKD
- Thalasemia - MDS 2. HT Stage II
-MDS - Acute leukimia 3. BSK
-Chronic Leukimia 2. Herpes zooster dd impetigo 4.DM Tipe 2 NW
- Aplastik bulosa
2. CAD (septal iskemik) kompensata 3. Hiperglikeia reaktif induced Th/
3. Nefrolithiasis dextra steroid dd MDT2 dengan critical -Bedrest
4.. DM Tipe II NW ill - diet ginjal 1700kkal/ha
5. Hipoalbuminemia ringan (3,2) 4. AKI stage I prenal gr/ KGBB/Hari
6. PPOK stabil 5. Hipoalbumin - IVFD NaCl 0,9% 10 t
7. Susp HCC dd 6. Candidiasis oral - Bicnat 500 mg/ 8 jam
- Cholelithiasis -Allopurinol 300mg/ 24
- Cholesistitis chronic Th/ - Fluimucyl 200 mg/ 8 j
- Bedrest -Amlodipin 10 mg/ 24 j
Th/ - Diet DM 1700 kkal/hari - Lenal Ace 16 mg/ 12 j
Bedrest - IVFD NaCl 0,9% 30gtt/i - IV Levofloksaxine 500
-Diet DM 1700 kkal/hari - Tab Metylprednisolon 3x8mg jam
- IVFD Nacl 0,9% 20 gtt/i - Drip Albummin 25% 100cc - resfar 1000mg + 200c
- Tramadol 50mg/12 jam /24jam 0,9% habis dalam 4 jam
- IV Ceftriaxone 2gr/24 jam - Drip novorapid 50unit - Sucralfat syr C1 / 8 jam
- Nebul combivent 1 supp/12 jam - Novalgin drip dalam 50 cc NaCl
- Tramadol 2x50mg 0,9% 500cc Lab 27-02-2020
- Asetil sistein 3x1 - IV ceftriaxone 1gr /12jam Hb/Ht/E/L/T: 11,8/33/4
- Sandimun 2x100cc MCV/MCH/MCHC:75/
Lab 01-03-2020 - Nystatin drop 4x 2cc Diftel: 2/1/0/68/23/6
Hb/Ht/E/L/T: 9,3/29/5,0/3,0/88 Kalsium :L 8,4
MCV/MCH/MCHC: 59/19/32 Lab 28-02-2020 Na/K//Ca : 139/4,6/101
Diftel: 2/1/10/59/27/11 Hb/Ht/E/T/L: 4,6/13/1,6/8/3,4 Ur/cr: 188/16,20
MCV/MCH/MCHC: 81/29/35
Lab 26-02-2020 Diftel: 0/1/0/82/12/5 Lab 26-02-2020
Bilirubin total : 1,71 Albumin : 2,2 Glukosa puasa 111
Bil. Direct/ indict : 0,84/0,87 GDS : 565 glukosa darah 2 jam pp
SGOT/SGPT: 283/149 Na/K//Ca : 132/5,8/97
Ur/cr: 126/1,6 Urinalisis 25-02-2020
Lab 25-02-2020 Warna: kuning
Ratio PT/APTT : 2,0/1,57 Kejernihan: keruh
Albumin : 3,24 Berat Jenis: 1,008
pH: 5,0
Urinalisis 24-02-2020 leukosit :positif
Warna: kuning protein : positif (1)
Kejernihan: jernih glukosa :positif (1)
Berat Jenis: 1,019 keton: negatif
pH: 6,0 Nitrit : negatif
leukosit : negatif Urobilirubinogen: posit
protein : negatif bilirubin: negatif
glukosa : negatif darah: positif
keton: negatif leukosit:10-15
Nitrit : negatif eritrosit: 8-10
Urobilirubinogen: negatif epitel: 3-5
bilirubin: negatif
darah: negatif Lab 24-02-2020
leukosit:1-2 Hb/Ht/E/L/T: 12,6/35/4
eritrosit: 0-1 MCV/MCH/MCHC:75/
epitel: 2-3 Diftel: 0/1/0/907/2
Anti HCV : negatif
Lab 23-02-2020 HBsAg : Non reaktif
Hb/Ht/E/T/L: 7,7/25/4,5/4,1/98 GDS : 174
MCV/MCH/MCHC: 54/17/31 Na/K//Ca : 131/5,3/97
Diftel: 2/1/0/64/25/8 Ur/cr: 250/20
 *K4B1* *K4B2* *K4B3* *K4B4* *K4B5*

DPJP: Dr.dr.Azhari Gani, SpPD-

DPJP : dr.T.Mamfaluti,Sp.PD DPJP : dr. Diana Erlita, Sp.PD DPJP: Dr.dr.Azhari Gani,
KKV DPJP : dr. Diana Erlit
COW : dr. Dedi COW : dr. Fardiansyah SpPD-KKV
COW: dr. T. Fahril COW : dr. Fardiansya
DR : dr. Amelia DR: dr. Amelia DIVISI KARDIO
DR: dr. Viencen DR: dr. Amelia
Raber: Raber : Pulmo, EMD, KKV Raber : pulmo, remato, GH
Nama : Busra Sofyan Nama : Ibrahim Samad Nama : Irsandi Nama: Syamsul Mak Arif Nama : Ajibullah M Ali
TTL : 9/5/1987(32 th) TTL : 31-12-1920 (99th) TTL : 2/2/1992 (28 thn) TTL: 05-01-1943 (77th) TTL : 01/07/1950 (69th)
Alamat :Sabang Alamat : Aceh Pidie Alamat : Banda Aceh Alamat: Aceh Besar Alamat : Aceh Besar
CM : 1175652 CM : 1-23-91-39 CM : 1239404 CM: 00995255 CM : 0897842
Hari Rawatan : 1 Hari Rawatan : 8 Hari Rawatan : 4 Hari rawatan: 18 Hari rawatan : 10

A/ A/ A/ A/ A/
1. CKD stage V on CAPD ec dd 1. Penurunan Kesadaan ec dd : DD/ 1. CHF Fc NYHA II ec dd 1. PSMBA (perbaikan)
1.HN, 2. PNC dengan udem paru akut - Sepsis - Flebitis -IHD 2. AKI stage III renal
2. Hipertensi Stage 1 on terapi - Stroke - Selulitis -HHD 3. Anemia sedang ec dd
3. Anemia sedang NN on PGK 2. Sepsis ec dd : - Erisipelas - DCM - perdarahan akut
4. Hipoalbumin - Urosepsis - Facies necrotizing 2.CKD Stage 5 ec dd –PNC – HN - penyakit kronis
- Pleuropneumonia 2. Dyspepsia ec dd 3.Efusi genu dextra
Th/ 3.PSMBA ec dd : - tipe dismotility 4.Efusi pleura post punksi Th/
Bed rest - Gastritis Erosif - tipe mixed 5.LBP -Bedrest
Threeway - Ulkus Gaster -Diet ginjal 1700 kkal/h
O2 2-4 l/i K/P - Ulkus Duodenum Th/ Th/ 0,8gr protein /kgbb/hari
Diet ginjal 1700 kkal / hari + 50 gr 4.Emfisema sinistra ec dd -Bed rest - Bedrest putih telur
protein / hari 1. Pleuropneumonia - Diet MB 1700 kkal - Diet Ginjal 1700 kkal/hari+ Sucralfat syr 3xCII Drip
Diet NTG 10mg dalam Nacl 0,9% 2. Neunitus TB - IVFD NaCl 0,9 % 20 gtt/i protein 60gr/hr -IV Transamin 1 amp /
50cc mulai dari 5 meq 5. CHF FC NYHA III EC DD - Paracetamol 500 mg/8 jam PO -Threeway -Vit K 1 amp/8j
Drip Furosemid 2cc / jam HHD - Clindamycin 400 mg/ 6 jam - Lansoprazole 30mg/24j Albumin 25% /24j
Amlodipine 10mg/24 jam IHD - Ceftriaxon 2 gram/24 jam - Domperidone /8j Ceftriaxone 2gr/24j
6. CAP (Pneumonia) - Iv omeprazole 40mg/ 12jam - Lactulac syr CI/24j Metronidazole 1500mg/
Lab 01-03-2020 7.Hipertensi Stg 1 on terapi - Domperidone 2 x 10mg - Clopidogrel 75mg/24j Omeprazole 20 mg/12 j
Hb/Ht/E/L/T:6,1/18./2,2/10,1/156 8.Hipoalbuminia - Sucralfat syr 3x CI - ISDN 5mg/8j - Ondasetron 1 amp/8ja
MCV/MCH/MCHC: 82/28/34 9.nefrolitiasis Bilateral - Fluimucyl 200mg/8j - Lansoprazole 6,25mg
Diftel: 5/0/0/77/12/6 10.Geriatri problem Lab 28-02-2020 - Bicnat 500mg/8jam
Na/K/Cl : 141/3,8/101 Hb/Ht/E/L/T: 14,6/42/4,8/18,4/306 - Allopurinol 100mg/24j Lab 29-02-2020
Ur/Cr : 167/21,00 Th/ MCV/MCH/MCHC: 87/31/35 - Metyl Prednisolon Hb/Ht/E/L/T:
GDS: 119 -Bedrest, senifouler Diftel: 0/0/1/87/6/6 - Ceftriaxone 2gr/24j 11,6/35/4,1/13,8/205
- NGT, kateter GDS ; 158 - Moxifloxacin 400mg /24jam IV MCV/MCH/MCHC: 85
- O2 3-4 L/i nasal canul Diftel: 3/1/0/77/14/5
-IV Omeprazole 80 mg + 50 cc Analisa Cairan Pleura 2
0,9 % 6/02/2020 Lab 26-02-2020
- Sukralfat Syrup CII/ 8 jam Warna : Kuning Hb/Ht/E/L/T: 8,9/27/3,1
- Nebule Combivent resp/ 8 jam Kejernihan : keruh MCV/MCH/MCHC: 86
-Albumin 25%/24jam Bekuan : Negatif Diftel: 3/0/0/85/6/6
- Lactulac sy c1I /8jam PMN :18 Albumin/Globulin : 2,7
- Ramipril 5mg/24jam MN: 82 Mg 1,5
- Meropenem 1gr/8j Leukosit 79 Na/K/Cl : 145/3,4/117
- Funconazone 200mg/24 jam Total protein 4,1 Ur/Cr : 192/5,8
- Transamin 1 amp/8jam Glukosa 134
- Vit K 1amp/8jam
- N- Asetil sistein 200mg/12 jam Ur/Cr : 235/3,5

Lab 01-03-2020
Bil total/Bil direct/ Bil indirect :
0,64/0,31/0,33
SGOT/SGPT : 77/39

Lab 28-02-2020
Hb/Ht/E/L/T: 7,5/24/2,9/14,4/245
MCV/MCH/MCHC: 82/26/32
Diftel: 1/1/0/79/9/10

Lab 27-02-2020
Procalcitonin 2,33

Urinalisis 26-02-2020
Warna: kuning
Kejernihan: keruh
Berat Jenis: 1,009
pH: 5,0
leukosit : positif
protein : negatif
glukosa : negatif
keton: Postifi
Nitrit : negatif
Urobilirubinogen: Negatif
bilirubin: negatif
darah: positif
leukosit: 50-60
eritrosit: 6-8
epitel:3-5
Sel ragi 3-5

Lab 26-02-2020
Albumin 2.10
 *K5B1* *K5B2* *K5B3* *K5B4* *K5B5*

DPJP: dr. Kurnia Fitri Jamil, DPJP: dr. Azzaki, Sp.PD

Sp.PD-KPTI DPJP: dr.M Riswan, SpPD COW: dr. Munawar DPJP: dr.M Riswan, SpPD
COW: COW: dr. Reza DR: dr. Zulfikar COW: dr. Reza RUSAK
DR: dr. Rianda DR: dr. Nelvi Raber : DR: dr. Nelvi
Raber: Raber:

Nama: Eldo Rado Nama : Abdul Mutaleb Nama: T. Nurzaman Nama: Muhamad Abubakar
TTL: 12/12/1951 TTL : 01/07/1952 (67 th) TTL : 10/07/1957 (62th) TTL : 05-03-1992
Alamat: Aceh Tamiang Alamat : Pidie Jaya Alamat : Aceh Barat Alamat : Aceh Barat
CM: 1238790 CM : 1238936 CM : 1238315 CM : 1010844
Hari rawatan: 4 Hari rawatan : 6 Hari rawatan : 13 Hari rawatan : 11

A/ A/ A/ A/1.CML
1. Penurunan kesadaran 1. Anemia berat hipokrom 1. Jaundice ec dd 2.Abses ar Femur
(perbaikan) ec Hipoglikemi (drug mikrositer ec dd/ - ca caput pancreas
induced glimepiride) 1.ancylostomiasis - ca ampula vateri Th/
2. DM Tipe II NW 2. Peny. Kronis 1. Hidronefrosis ringan ginjal - Bedrest
3. CKD stage III ec dd 3. Dof. FE kanan - Diet MII 1700 kkal/hari
- DN 2. Ancylostomiasis 2. Konstipasi - IVFD NaCl 0,9% 20 gtt/i
- GNC - Tasigna 1x300mg
4. Retensi urine c dd/ Th/ - Paracetamol 3x500mg
- BPH -Bedrest Th/ -Ceftriaxone 2gr/24j
- BSK -Diet MB 1700 kkal/hari -Bedrest -Metronidazole 500mg/8j
- ISK -IVFD NaCl 0,9 % 20 tpm -Diet Hati + aminofusin hepar 20gtt/i
5.Hipernatremia ec dd -IV omeprazole 40 mg / 12 jam --IV aminofusin hepar 1 fls/hari 20 Lab 01-03-2020
- CKD - Albendazole 200 mg/24 jam gtt/i Hb/Ht/E/L/T: 8,4/26/3,3/49,3/47
selama 3 hari -Curcuma 3x1 MCV/MCH/MCHC: 79/26/33
Th/ -IV ondancetron 4 mg/12 jam Diftel : 0/2/0/86/10/3
-Bed Rest Lab 29-02-2020 -IV omeprazole 40 mg/12 jam
-Diet DM 1700 kkal/hari Hb/Ht/E/T/L: - IV cefoperazone 2 gram/12 jam Lab 28-02-2020
- IVFD 2:1 20gtt/i 8,4/28/4,0/10,9/236 - Laxadyn syr 1x CII PO Hb/Ht/E/L/T: 7,5/22/2,9/100,3/31
Ceftriaxone 2gr/24j MCV/MCH/MCHC: 70/21/30 MCV/MCH/MCHC: 78/26/34
Lansoprazole 30mg/24j Diftel: 4/1/0/75/11/9 Lab 24-02-2020 Diftel : 0/1/0/88/7/3
N-Asetil sistein 200mg/8j Ur/Cr : 38/0,5
Curcuma tab/12j Analisa feses rutin 27/02/2020 Lab 27-02-2020
Warna : hijau Lab 22-02-2020 Hb/Ht/E/L/T: 7,2/22/2,8/130,5/28
Lab 29-02-2020 Bau : Khas Ratio PT/APTT : 1,2/1,06 MCV/MCH/MCHC: 81/26/32
Kalsium : 8,2 Eritrosit : negatif GDS : 116 Diftel : 0/2/0/88/6/4
Na/K/Cl : 148/4,3/110 Leukosit : negatif
Parasit : negatif Lab 18-02-2020 Lab 25-02-2020
Lab 27-02-2020 Konsistensi : Lunak Hb/Ht/E/L/T: 13,1/37/4,2/12,2/352 Hb/Ht/E/L/T: 6,5/20/2,5/237,2/37
Hb/Ht/E/L/T: Darah : negatif MCV/MCH/MCHC: 86/31/36 MCV/MCH/MCHC: 80/26/33/18,6
11,3/35/3,7/14,4/260 Lendir : negatif Diftel: 1/1/0/83/8/7 Diftel : 0/2/0/86/8/4
MCV/MCH/MCHC: 93/30/32 Telur cacing : Ancylostoma Du Bil tot/di/in: 16,48/11,90/4,58
Diftel: 0/0/0/84/11/5 odenal (2-3) Albumin: 3,10
Ur/Cr: 44/1,4 Globulin: 3,10
Albumin 3,7 Lab 24-02-2020 Protein tot: 6,20
Na/K/Cl : 151/4,5/114 Hb/Ht/E/T/L: SGOT/SGPT: 96/108
2,8/12/2,2/458/5,7 HbsAg : non reaktif
MCV/MCH/MCHC: 56/13/23
Diftel: 7/0/0/57/26/10

MDT
Erit: Hipokrom, pencil cell,
target cell, cigar shape, ovalosit,
mikrosit, tear drops
Leu: netrofil hiperpigmentasi
Trom: giant trombosit

*K6B1*
DPJP: Prof. Dr. dr Maimun
Syukri, Sp.PD-KGH FINASIM
DIVISI GH
Nama : T Abdullah
TTL : 20/05/1976 (43th)
Alamat : Pidie Jaya
CM : 1239505
Hari rawatan : 3
A/
1. CKD Stg V ec dd
- PNC
- HN
2. Hipertensi stage 2
3. Anemia berat ec PGK
4. Pneumonia
5. DM tipe 2
6. Retardasi mental
Th/
- Bed rest
- Diet ginjal 1700kkal /hari,
rendah garam, protein 1,2
gr/KgBB/hari
- IV ceftriaxone 2gr /24jam
- Fluimucyl 3x200mg
- Amlodipin 10mg
- Lenal ace 169mg 2x1
- Valsartan 1x80mg
- Asam Folat 400mg 2x1
Lab 29-02-2020
Hb/Ht/E/T/L : 7,7/22/2,8/11/142
MCV/MCH/MCHC:
Diftel: 0/0/0/74/21/5
DGS : 137
Ur/ Cr : 22/0,7
Na/K/Cl: 149/3,1/110
*K6B2*
*K6B3* *K6B4* *K6B5*
DPJP: dr. Fauzi Yusuf, Sp.PD DPJP: Dr.dr.Azhari Gani, DPJP: dr.T. Mamfaluti, DPJP: dr. Kurnia Fitri, Sp.PD
COW: dr. Derina SpPD-KKV SpPD COW: dr. Nadi
DR: dr. Viencen COW: dr. T. Fahril COW : dr. Dedi DR: dr. Riyanda
Raber : DR: dr. Viencen DR : dr. Amelia
Raber:
Nama : Rahmad Syafii Ahmad Nama : Basri M Alim Nama : Yusri Nama : Abu Bakar Ubit
TTL : 30/12/1995 (24th) TTL : 07/04/1999 (21th) TTL : 01/07/1974 TTL : 24-05-1950 (69th)
Alamat : Pidie Alamat : Nagan Raya Alamat : Bireun Alamat : Aceh Timur
CM : 1186453 CM : 1238689 CM : 1239517 CM : 1239052
Hari rawatan : 10 Hari rawatan : 10 Hari rawatan : 3 Hari rawatan : 7
A/ A/ A/ A/
1.PSMBB ec dd Colitis ulseratif 1. PSMBB 1. Anemia sedang HM ec dd 1. Ca Recti
2. Anemia Sedang NN 2. Anemia sedang HM - Penyakit kronik 2. Hemoroid externa grade I
(perbaikan) ec dd - Thalassemia 3. Hipokalemia ringan ec Low intake (3
- Perdarahan Th/ - Defisiensi Fe 4. Pneumonia dd TB paru dengan seku
- Ocult bleeding - IVFD Nacl 0,9 % 20 tpm 2. Hepatosplenomegali ec dd infeksi
3. Hipoalbumin - IV Lansoprazole 30mg/12 - Thalassemia 5. Anemia ringan NM ec dd/
jam - Siroseis 1. Helminthiasis
Th/ - IV Transamin 500mg /8jam - Metastase hepar 6. Ankilostomiasis duodenale
Bedrest - IV Vit K 1 amp/ 8jam 7. cutaneous Larva Migran
Diet MB II 1700kkal/hari + - IV ondansetron 4mg /12jam Th/
ekstra puih telur - Anti hemoroid supp - Bedrest Th/
IVFD NaCl 0,9% 20gtt/i - Paracetamol drp 1 gr kp - Diet MII 1700 kkal/hari -Bedrest
Iv Lansoprazole 30mg/12j - IVFD NaCl 0,9% 20gtt/i -Diet MII 1700 kkal/hari
Salofak granul 2 x 1 Lab 28-02-2020 - Omeprazole 40gr/12jam -IVFD RL 20gtt/i
Synbio 1x1 tab Hb/Ht/E/T/L : - IV Ceftriaxone 2gr/24 jam
IV Transamin 1 amp / 12 jam 8,3/25/3,0/10/278 Lab 29-02-2020 -Antalpulgit 2 tab/mencret
IV ceftriaxone 2 gr / 24 jam MCV/MCH/MCHC: 83/28/33 Hb/Ht/E/T/L : - Synbio 3x 1
Albumin 25 % 100 cc/ 24 jam Diftel: 7/0/0/69/17/7 7,8/22/2,9/74/5,9 - IV Omeprazole 40 mg/ 24 jam
Fartison 80 mg/12 jam Kalsium/Magnesium: 7,7/2,2 MCV/MCH/MCHC: 75/27/36 - Domperidon 3 x 10 mg
Na/K/Cl: 140/4,3/109 Diftel: 10/1/0/24/61/4 - KSR 600 mg/12 j
Lab 29-02-2020 HbsAg : non reaktif - Fluimucyl 200mg/8j
Hb/Ht/E/T/L : Lab 27-02-2020 Bil. Total : 7,94 -Albumin 25%/24j
9,7/32/4,2/14,2/713 Hb/Ht/E/T/L : Bil direct/ indirect : 5,01/2,93 - Dexametason oint + as. Salisilat 3 %
MCV/MCH/MCHC: 75/23/31 7,8/23/2,8/10,9/240 Albumin : 2,90 - Albendazol 1x400mg
Diftel: 0/0/0/79/17/4 MCV/MCH/MCHC: 82/28/34 GDS : 98
Diftel: 5/1/1/66/18/9 Ur/cr : 59/1,10 Lab 1-3-20
Lab 27-02-2020 Kalsium/Magnesium: 6,8/2,1 Na/k/Cl : 143/4,2/110 Albumin ; 2,90
Albumin 3,23 Na/K/Cl: 137/4,4/107 Na/K/CL : 139/3,9/104
Lab 24-02-2020 Lab 28-02-2020
Hb/Ht/E/L/T : 10,3/33/4,5/15,5/6 LED : 121
75 Bil. Total : 0,59
MCV/MCH/MCHC: 73/23/32 Bil direct/ indirect : 0,26/0,33
Diftel: 6/1/0/68/18/7 SGOT/SGPT: 18/16
Fe : 50
TIBC : 165 Lab 27-02-2020
Albumin : 2,5 Hb/Ht/E/T/L : 9,4/30/3,7//402/11,7
MCV/MCH/MCHC: 80/25/32
Lab 22-02-2020 Diftel: 0/0/1/82/12/5
Hb/Ht/E/T/L : 7,9/26/3,8/774/16 Albumin 2,1
MCV/MCH/MCHC: 70/21/30 Ca/Mg : 7,7/1,9
Diftel: 4/1/0/71/18/6 Na/K/Cl : 141/3,8/104
Ur/Cr: 10/0,9
Na/K/Cl: 138/3,5/103 Lab 25-02-2020
GDS 89 Hb/Ht/E/T/L : 10,3/33/4/389/13,6
Ratio PT/APTT : 1,24/1,21 MCV/MCH/MCHC: 82/26/31
Diftel: 0/0/0/74/21/5
DGS : 137
Ur/ Cr : 22/0,7
Na/K/Cl: 149/3,1/110
Urinalisa 25-02-2020
Warna: kuning
Kejernihan: keruh
Berat Jenis: 1,012
pH: 6,5
leukosit : positif
protein : negatif
glukosa : negatif
keton: negatif
Nitrit : negatif
urobilirubinogen: positif
bilirubin : negatif
darah: negatif
leukosit: 4-6
eritrosit: 2-3
epitel:3-5
Feses Rutin 25-02-2020
Warna : coklat
Bau : Khas
Eritrosit : negatif
Leukosit : negatif
Telur cacing : Ancylostoma Doedenale
3)
Parasit : negatif
Konsistensi : Lunak
Darah : negatif
Lendir : negatif