Mapping Aqsa 2 (Selasa, 11 Juni 2019)

AQSHA 2 (PENYAKIT DALAM PRIA)
Hari / Tanggal : Selasa / 11 Juni 2019

Dokter Jaga : dr. Mirzal / dr. Akmal
Dokter Muda : Fathia/ Dara/ Jimmi
K1B1 K1B2 K1B3 K1B4

DPJP : dr. M.Diah, Sp.PD DPJP : dr. Taufiq DPJP : dr. Hendra Z, Sp.PD DPJP :
COW : dr. Ari S COW : dr. Fahril COW : dr. TM. Reza Tandi COW :
DR : dr. Taufiq DR : dr. M.Riswan, Sp.PD, K- DR : dr. Okdimur DR :
DM : HOM DM :
DM :
Nama : Mustafa Khaharuddin Nama : M.Juned Nama : Mahyeddin M. Jamil
TTL : 27-07-1954 (64th) TTL : 11-01-1960 (59th) TTL : 9-6-1991 (28 thn)
Alamat : Banda Aceh Alamat : Aceh Besar Alamat : Bireuen
CM : 0-68-28-87 CM : 1-21-09-26 CM : 1-20-95-78
Hari Rawatan : 2 Hari Rawatan : 2 Hari Rawatan : 2
A/ A/ A/
1. Penurunan kesadaran ec dd 1. Observasi febris ec dd 1. Massa Intraabdomen ec dd/
- Syok kardiogenik - Pneumonia - Limfoma Maligna std IIIb
- Uremic ensefalopati - Demam tifoid - Ca Gaster
- Sepsis - Malaria - Ca Colon
- Imbalance elektrolit 2. PSMBA ec dd 2. Hiponatremia hipoosmolar
2. Syok kardiogenik - Stress ulcer euvolemic
3. CKD stg 5 on HD reguler - Ulkus peptikum 3. Faringitis Akut
- Gastritis erosif 4. Hiperkalemia Ringan (5,8)
Th/ 3. Anemia ringan HM ec dd 5. Hipoalbuminemia (3,1) Th/
- Bedrest - Peny. Kronik
- O2 2-4l/i - Def. Fe Th/
- Diet sonde via NGT 6x200cc/hr 4. AKI stg III prerenal - Bed rest
- IVFD Nacl 0,9% 10gtt/i 5. Hiponatremia hipoosmolar - Diet M II 1700 kkal/hari+extra
- Drip vascon 1 amp dlm Nacl 0,9% putih telur
50cc - IVFD NaCl 0,9% 20 tpm
- Drip dobutamin 1amp dlm Nacl Th/ - IV Omeprazole 40 mg/12 jam
0,9% 50cc - Bedrest - Paracetamol 3 x 500 mg
- IV ceftriaxone 2gr/24j - Diet MII 1700kkal/hr - Kalitake 3 x 1 Sachet
- IV omeprazole 40mg/12j - IVFD Nacl 0,9% 20tpm - Flukonazole 1x150mg
- Lenal ace 2x169mg - IV ceftriaxone 2gr/24j - Cefadroksil 2x500mg
- Fluimucyl 3x1 - IV pct 1000mg/8j
- IV metoclopramid 10mg/8j
Lab 10-6-2019 - IV lansoprazole 30mg/12j Lab 9-6-2019
PT/APTT: 18,8/47 - Lactulac syr 3xCII Hb/Ht/E/L/T
D-dimer: >10000 13,3/37/5,1/12,5/235
Procalcitonin : 7,71 MCV/MCH/MCHC
Lab 73/26/36
Lab 09-6-2019 Diftell : 0/0/0/86/4/10
Hb/Ht/E/L/T: 8,4/26/2,7/7,5/132 Albumin : 3,11
MCV/MCH: 93/31 GDS : 193
Diftel: 0/1/0/81/14/4 Ur/Cr : 97/0,98
Ca/GDS: 8,7/80 Na/K/Cl: 111/5,8/76
Ur/Cr: 140/8,69
Na/K/Cl: 130/4,7/98
K2B1 K2B2 K2B3 K2B4 K2B5
DPJP : DPJP : dr. Azhari Gani DPJP : Kurnia FJ, Sp.PD DPJP: dr. Islamuddin, Sp. DPJP : dr. Azhari Gani,
COW : Sp.PD-KKV COW : dr. Rahmi PD Sp.PD
DR : COW : dr. Rahmi DR : dr. Wahyu COW : dr. Febri COW : dr. Rahmi
DR : dr. Wahyu Raber : GH DR : dr. Akmal DR : dr. Wahyu
Raber: Pulmo
Nama :Abdul Karim Nama : Syafruddin M. Saleh Nama : Sarmin D. Nama : Zainal Abidin
TTL : 06-10-1979 (39 thn) TTL : 12-12-1968 (50 thn) TTL : 13-7-1961 (57 thn) TTL : 1-7-1954 (64 thn)
Alamat : Aceh Tamiang Alamat : Bireuen Alamat : Simeulue Alamat : Aceh Utara
CM : 1-18-46-10 CM : 1-21-07-16 CM : 1-19-97-29 CM : 1 21-08-30
Hari Rawatan : 5 Hari rawatan : 4 Hari Rawatan : 2 Hari Rawatan : 3
A/ A/ A/ A/
1. Renal Cell Carcinoma Post 1. Penurunan Kesadaran ec 1. Hodgkin Lymphoma a.r 1. dd/
Kemoterapi Siklus I dd/ colli dex - Ileus Obstruktif
2. Cancer Pain - Uremic Encephalopathy - Ileus Paralitik
3. Neutropenia induced kemo - Sepsis 2. Suspect Cushing
4. Hipokalemia Sedang ec GI 2. CKD Stage V ec dd/ Syndrome
Loss - HN Th/ 3. Trombositosis Reaktif
5. High Risk Thrombosis - PNC - Bed rest dd/ Trombositosis
3. Sepsis ec dd/ - Diet MII 1700 kkal / hari Esensial
- Pneumonia - IVFD NaCl 0,9% 20 tpm 4. Efusi Pleura Dextra dd/
- Urosepsis - IV Omeprazole 40 mg/12 Massa Paru Dextra
4. Anemia Sedang NN ec dd/ jam 5. PSMBA(perbaikan) ec
Th/ - Penyakit Kronik - IV Ceforoxime 1gr/12j dd/
- Bed rest - Perdarahan - Paracetamol 3 x 500 mg - Gastric Ulcer
- Diet sonde 6x200cc/hari 5. DM tipe II NW - Duodenal Ulcer
- IVFD tutofusin 20 tpm 6. Konstipasi - Gastritis erosif
- IV Lansoprazole 30mg/12j 7. ISK 6. HAP
- Ondansetron 3 x 4mg 8. Hipertensi stg II Lab 9-6-2019 7. PPOK eksaserbasi akut
- Drip levofloxacin Hb/Ht/E/L/T 8. Hipertensi stg I
500mg/24j 11,8/35/4,2/16,8/443
- MST 2 x 15mg Th/ MCV/MCH/MCHC
- KSR 2 x 600 mg - Bed rest 83/28/34 Th/
- Pradaxa 1x1 - Three Way Diftell : 1/1/0/77/9/12 - Bed rest
- Sucralfat Syr 3 x C I - NGT, Kateter Bilirubin Total : 0,46 - NGT Dekompresi
- Lactulosa syr 3xCI - Diet Sonde 6 x 200 cc/hari Bilirubin Direct : 0,25 - Kateter
- IV Ceftriaxone 2 gr/24 jam SGOT/SGPT : 58/25 - Diet MB 1700 kkal/hari 
(H4) Albumin : 2,88 Puasa Sementara
Lab 9-6-2019 - IV Omeprazole 40 mg/12j GDS : 164 - IVFD NaCl 0,9% 10 tpm
Hb/Ht/E/L/T - IV Ca Gluconas 1 amp/8j Ur/Cr : 17/0,55 - IV Lansoprazole 1
8,0/22/3,3/1,0/20 - Lenal Ace 2x169 mg Na/K/Cl: 134/3,8/99 amp/12jam
MCV/MCH/MCHC - Asam Folat 2x400 mcg - IV Cefuroxime 1 gr/12 jam
68/25/36 - Amlodipine 1x10mg - IV Paracetamol 1 gr (K/P)
Diftell : 1/1/1/21/53/23 - Valsartan 1x160mg - IV furosemide 20mg/12j
SGOT/SGPT : 24/13 - Lactulac syr 3xCII - Sucralfat 3 x C II
Bil.Total : 11,47 - Valsartan 1 x 160 mg
Bil. Direct / Ind : 7,73/3,74 Lab 10-6-2019 - Amlodipine 1 x 5 mg
Hb/Ht/E/Tr/L: - Nebule Ventoline 1 resp / 8j
Lab 7-6-2019 9,8/29/3,6/252/14,6 - Nebule Flexotide 1 resp/12j
Na/K/Cl: 127/2,8/99 MCV/MCH: 81/28 - Fosen Enema Supp (K/P)
Diftell:2/0/0/79/9/10 - Domperidone 3x10mg
Lab 6-6-2019 Alb/Ca: 3,43/8,4
Hb/Ht/E/L/Tr : Ur/Cr/as.Urat: 175/12,86/11 Lab 10-6-2019
9,1/26/3,8/2.3/62 Na/K: 143/3,9 Urinalisis
MCV/MCH : 70/24 Warna/kejernihan:
Diftel : 2/0/0/71/25/2 Lab 8-6-2019 kuning/keruh
PT pasien/kontrol : 15,90/13,4 Na/K/Cl : 135/4,6/105 Leukosit +
INR : 1,07 Ca/Mg : 5,6/1,5 Keton +
apTT : 50,30/32,4 Darah +
anti HCV/ HbsAg : -/- Lab 7-6-2019 Leukosit 10-15
GDS : 103 Hb/Ht/E/Tr/L: Eritrosit 40-50
Ur/Cr : 40/0,75 7,7/21/2,7/220/9,9 Epitel 2-4
Na/K/Cl : 127/2,6/100 MCV/MCHC: 78/28
Diftell:1/0/0/83/4/12
PT/APTT:14,50/58,60 Lab 8-6-2019
D-dimer : 2360,89 Hb/Ht/E/Tr/L:
SGOT/SGPT:21/14 10,9/32/39/718/16,8
Albm: 3,04 MCV/MCHC: 81/28
Ca/Mg: 5,7/1,5 Diftell: 4/0/0/72/16/8
Ur/Cr: 169/12,39 Ur/Cr:18/0,99
Na/K/Cl: 137/4,4/103 Na/K/Cl: 133/4,2/109
DPJP: dr. Islamuddin, DPJP : dr. T. Mamfaluti, DPJP : dr. T. Mamfaluti, DPJP : dr. Azhari Gani DPJP : dr. Chacha, Sp.PD
Sp. PD Sp. PD Sp. PD Sp.PD-KKV COW : dr. Febri
COW : dr. Febri COW : dr. TM Reza Tandi COW : dr. TM Reza Tandi COW : dr. Rahmi DR : dr. Akmal
DR : dr. Akmal DR : dr. Okdimur DR : dr. Okdimur DR : dr. Wahyu
Raber : GH Raber : GEH
Nama : Marzuki M. Juned Nama : Samsuar A Rahman Nama : Sarbini Ilyas Nama : Riza Faisal Nama : Irfan Moulida
TTL : 13/6/1970 (48 thn) TTL : 1-7-1964 (49 thn) TTL : 19/7/1965 (53 thn) TTL : 17-8-1972 (46 thn) TTL : 23-3-1997 (22 thn)
Alamat : Aceh Besar Alamat : Aceh Besar Alamat : Aceh Besar Alamat : Banda Aceh Alamat : Banda Aceh
CM : 1-19-97-51 CM : 1-06-61-15 CM : 1-18-84-85 CM : 0-77-24-51 CM : 1-21-09-33
Hari Rawatan : 7 HariRawatan : 4 Hari rawatan : 8 Hari rawatan : 2 Hari Rawatan : 2
A/ A/ A/ A/ A/
1. Edema Anasarka ec dd/ 1. Right Upper Quadrant 1. Obs Jaundice ec dd/ 1. CKD Stage V on HD 1. Trombositopenia ec dd/
- Hipoalbuminemia Pain ec dd/ - Cholangiocarcinoma Regular dengan - Viral infection
- CHF - Cholelithiasis dengan 2. Ascites ec dd/ Uremic Syndrome - Autoimmune
- Sindrom Nefrotik Cholecystitis - Sirosis Hepatis 2. Post PSMBA ec dd/
2. Hipoalbuminemia ec - Cholecystitis - Hipoalbuminemia - Uremic Bleeding Th/
Renal Loss - Choleducholithiasis - Metastase Process - Gastritis Erosif - Bed rest
3. CKD Stage III ec PNC - Cholangitis 3. Pneumonia dd/ Infeksi Paru - Ulcus Gaster - Diet MB 1700 kkal/hari
4. Efusi Pleura Dextra ec 2. AKI Stage II Spesifik 3. Anemia berat ec dd - IVFD RL 30 tpm
dd/ 3. Hipertensi Stage II 4. Hipoalbuminemia - Perdarahan - Paracetamol 3 x 500 mg
- Hipoalbuminemia 5. HE Grade I dengan - Peny. kronis
- Pleuropneumonia Pencetus Infeksi
Lab 10-6-2019
Th/ Th/ Th/ Hb/Ht/E/L/T
- Bedrest - Bed rest - Bed rest 9,4/28/5,1/5,6/61
Th/ - Diet M II 1700 kkal/hari - Three way - Three way MCV/MCH/MCHC
- Bed rest - IVFD Nacl 0,9% 20 tpm - Diet hati lunak 1700 kkal/hr - Diet Ginjal 1700 kkal/hari 55/18/33
- Three way - IV Omeprazole 40 mg/12j - O2 2-4 lpm - IV Metoclopramide ½ Difftel : 2/2/0/27/60/9
- Diet Ginjal 1700 - Amlodipine 1 x 5 mg - IVFD Comafusin Hepar 1 amp / 8 jam MDT:
kkal/hari + Protein 60 - Paracetamol 3 x 500 mg fls/hari - IV Omeprazole 20 mg / 8 Eritrosit: Hipokrom/
gr/hari + Diet Kolesterol - Sucralfat Syrup 3 x C I - IVFD Albumin 25% 100 jam sebagian
<600 mg/hari + Rendah cc/hari - IV Furosemide 20 mg normokrom/anisositosis
Garam - IV Cefoperazone Sulbactam (K/P) Target cell(+) stomatosit(+)
- Drip Albumin 25 % 1gr/12j (H8) - Sucralfat Syr 3 x C II Ovalosit (+) schistosit(+)
100cc/hr Lab 10-6-2019 - IV Furosemide 20mg/8j - Lenal Ace 2 x 169 mg Leukosit: reaktif
- IV Cefuroxime 1 gr/12 j Hb/Ht/E/L/T - IV Omeprazole 40mg/12j - Asam Folat 2 x 400 mcg limfositosis
- N-Acetylcystein 3x200 12,9/38/4,8/7/230 - Lactulac Syr 3 x C II - Valsartan 1x160mg Trombo: jl. Kurang/ bntk
mg MCV/MCH/MCHC - Curcuma 3x1 tab - Amlodipin 1x10mg normal
- Omeprazole 2 x 20 mg 79/27/34 - Spironolactone 2x100mg Kesimpulan: anemia
- Candesartan 1 x 8 mg Difftel : 5/0/0/67/22/6 - Domperidone 3x10 mg Lab 10-6-2019 hipokrom mikrositer dg
- Spironolactone 2 x 100 Ur/Cr/As.urat: 96/4,44/10,4 - N-Acetylcystein 3x200 mg Urinalisa trombositopenia+reaktif
mg Urinalisa Warna/kejernihan: limfositosis
- Bicnat 3 x 500 mg Warna/kejernihan: Lab 10-06-2019 kuning/keruh IgM/igG: (+)/(+)
kuning/jernih Analisis cairan asites Leukosit (+) Ca: 9,2
Lab 10-6-2019 Berat jenis/pH : 1,010/5 Warna :keruh Protein +3 Na/K/Cl: 143/4/108
Retikulosit: 1,7 Epitel: 2-4 Kejernihan: keruh Glukosa +1 Urinalisis
Kolestrol total/HDL/LDL: Bekuan: - Darah + Warna/kejernihan:
155/30/137 Lab 7-6-2019 PMN/MN/Leukosit: 30/70/230 Leukosit : penuh kuning/keruh
Ur/Cr: 79/1,26 Hb/Ht/E/L/T : Total protein/glukosa: 1/126 Eritrosit 30-35 Leukosit/keton/urobilinogen
Na/K/Cl: 141/3,6/112 14,2/41/5,2/11,1/203 Epitel 15-20 : (+)/(+)/(+)
Analisa tinja MCV/MCH :78/27/35 Leuko/Eritro/epitel:
Warna: coklat Diftel : 2/0/0/72/18/8 Lab 8-6-2019 Lab 9-6-2019 8-10/1-2/2-3
Eri/leukost : (-)/(-) Ur/Cr: 86/5,53 Hb/Ht/E/L/T : Hb/Ht/E/L/T :
Telur/parasit: (-)/(-) Na/K/Cl : 142/4,3/109 8,0/23/2,9/22,4/237 6,0/17/2,1/8,9/314
MCV/MCH : 78/27 MCV/MCH/MCHC
Lab 8-6-2019 Diftell : 0/1/0/78/9/12 81/29/35
Hb/Ht/E/L/T Ur/Cr: 21/0,73 Diftell : 4/2/0/77/11/6
10,8/32/3,8/11,6/393 Albumin : 2,31 CT/BT : 8/3
MCV/MCH/MCHC Na/K/Cl : 131/2,9/95 GDS : 134
86/29/34 Ur/Cr : 151/16,22
Difftel : 1/0/0/3/11/4 Lab 3-6-2019 Na/K/Cl : 141/4,2/104
Anti HCV / HbsAg : (-)/(-) Hb/Ht/E/L/Tr :
Albumin : 2,10 8,8/24/3,3/32,4/331
MCV/MCH : 74/27
Lab 6-6-2019 Diftell : 0/0/1/88/5/6
Hb/Ht/E/L/T : Anti HCV : -
8,3/25/2,9/14,3/463 Bilirubin total/direct/indirect :
MCV/MCH/MCHC : 15,09/10,5/4,58
85/29/34 Albumin/globulin : 1,75/4,02
Difftel: 0/0/0/88/10/2 Ur/Cr : 22/0,70
Bilirubin total : 0,13 Na/K/Cl : 133/3,2/105
Direct/ Indirect: 0,06/0,07
SGOT/SGPT: 23/8
DPJP : dr. Hendra Z, Sp.PD DPJP : dr. Kurnia FJ, Sp.PD DPJP : dr. Chacha, Sp.PD DPJP : dr. T. Mamfaluti, DPJP : dr. Kurnia, Sp.PD
COW : dr. TM. Reza Tandi COW : dr. Rahmi COW : dr. Febri Sp. PD COW : dr. Rahmi
DR : dr. Okdimur DR : dr. Wahyu DR : dr. Akmal COW : dr. T.M Reza Tandi DR : dr. Wahyu
DR : dr. Okdimur
Nama : Ismail Kota Nama : Nurdin M. Ali Nama : Salamudin Sardin Nama : Saiful Abdullah Nama: Zainun Ahmad
TTL : 1-7-1956 (62 thn) TTL : 01/07/1963 (55 thn) TTL : 1-7-1976 (42 thn) TTL : 1/07/1965 (53 thn) TTL : 1-7-1934 (84 thn)
Alamat : Aceh Tamiang Alamat : Aceh Utara Alamat : Simeuleu Alamat : Aceh Besar Alamat : Aceh Besar
CM : 1-20-54-41 CM : 1-20-97-61 CM : 1-21-08-51 CM : 1-12-08-71 CM : 1-21-07-84
Hari Rawatan : 2 Hari rawatan : 20 Hari rawatan : 2 Hari Rawatan : 12 Hari Rawatan : 5
A/ A/ A/ A/ A/
1. Ca Buli stad IV A Pro 1. Penurunan Kesadaran 1. Anemia Berat HM ec dd/ 1. Hipokalemia Ringan ec dd/ 1. Penurunan Kesadaran
Kemoterapi Siklus II dengan (perbaikan) ec dd/ - Defisiensi Besi - Pseudohipokalemia (perbaikan) ec dd/
Regimen Gemcitabine + - Sepsis - Penyakit Kronis - Hiperaldosterone - SDA
Carboplatin - Uremic Encephalopathy - Occult Bleeding - Gitelman Syndrome - Sepsis
2. Ulcus ar Suprapubik Post 2. Sepsis ec dd/ 2. Hipoalbuminemia Berat - Bartter Syndrome 2. SDA dengan Pencetus
Cystostomy - Urosepsis 3. Skizofrenia Paranoid - GI Loss Infeksi (penumonia)
3. Hipokalemia sedang - Pneumonia 4. Hipokalemia Sedang 2. Pneumonia 3. Pneumonia Geriatri
4. Fistula Vesicocutaneous 3. Pneumonia (HCAP) 3. DM Tipe 2 4. CHF FC NYHA I-II ec dd/
5. Hiponatremia hipovolemik 4. ISK 4. Osteomielitis Kronis ar - IHD
hipoosmolar 5. CKD Stage V dgn Uremic Th/ Pedis - HHD
Encephalopathy ec dd/ - Bed rest
- PGOI - Diet MB 1700 kkal/hari Th/
- HN - Transfusi PRC s/d Hb>10 Th/ - Bed rest
Th/ 6. Hipoalbuminemia g/dL - Bedrest - O2 2-4 lpm
- Bed rest 7. Post Dj stent sinistra - IVFD NaCl 0,9% 20 tpm - Diet DM 1700 kkal/hari - Three way
- Diet M II 1700 kkal / hari 8. Hidronefrosis grd I sinistra - Drip Albumin 25% 100 cc - IVFD NaCl 0,9% 20 tpm - NGT, Kateter
- IVFD NaCl 0,9% 20 tpm 9. Anemia sedang NN ec dd / hari - Drip Levofloxacin 500 mg - Diet Jantung 1700
- KSR 2 x 600 mg - Perdarahan - KSR 3 x 600 mg / 24 jam (H7) kkal/hari + Rendah Garam
- Rawat luka/12jam - Peny. kronik - Triflouperazine 3x5mg - IV Omeprazole 40 mg/12j - IV Ceftriaxone 2gr/24j
10. Hematuria ec dd - Lorazepam 1x2mg - SC Novorapid 3-3-3-3-3-3 (H5)
- ISK unit - IV Lansoprazole 30 mg/12
- BSK Lab 10-6-2019 - SC Levemir 0-0-0-20 unit jam
Ferittin 2,84 - KSR 3 x 600mg - IV Furosemide 40 mg /12j
Lab 9-6-2019 Th/ - Fluimucyl 3 x 200 mg - Simvastatin 1 x 20 mg
Hb/Ht/E/L/T - Bed rest Lab 8-6-2019 - Spironolactone 2 x 100 mg - Clopidogrel 1 x 75 mg
11,2/32/4,0/4,9/137 - Three way, Kateter Hb/Ht/E/L/T - Nystatin Drop 3 x 2 gtt - Nebule Combivent 1 resp /
MCV/MCH/MCHC - Diet Ginjal Sonde 6x 200 4,2/17/2,8/10,7/371 8j
79/28/36 cc/hari, 2 jam setelah makan, MCV/MCH/MCHC - Vectrin 3x1 tab
Diftell : 1/1/0/58/20/20 NGT dekompresi 61/15/24 Lab 10-6-2019 - Lactulac Syrup 3 x C I
GDS : 117 - IVFD Nacl 0,9% 20tpm Diftell : 18/0/0/59/13/10 Mg: 2 - Fosen Enema Supp (K/P)
Ur/Cr : 18/0,94 - IV Meropenem 1 gr/12j Albumin : 2,32 Na/K/Cl: 133/3,3/89
Na/K/Cl: 130/2,9/94 (H10) Globulin : 3,19 Kalium urin: 15 Lab 7-6-2019
- IV Omeprazole 40 mg/12 j Hb/Ht/E/L/T
- IV Diazepam ½ amp + 4 cc Lab 9-6-2019 15,7/49/5,4/6,9/161
Dex 5% (K/P) Na/K/Cl : 132/3,0/90 MCV/MCH/MCHC
- Amlodipin 1 x 10 mg 91/29/32
- Asam Folat 2 x 400 mcg AGDA 8-6-2019 Diftell : 1/1/0/52/30/16
- Lenal Ace 2 x 169 mg pH : 7,582 GDS : 153
- Tanapress 1 x 5 mg pCO2 : 44,90 Ur/Cr : 36/1,13
- HCT 1 x 25 mg pO2 : 69 Na/K/Cl : 142/4,7/109
- Allopurinol 1 x 300 mg HCO3 : 42,7
- Clonidine 3x100 mcg Total CO2 : 44,1
- Nebule Combivent 1 resp/8j BE : 19,6
- Nebule Flexotide 1 resp/8j SaO2 : 94,2
- Fosen enema supp/24j
- HD Selasa – Kamis Lab 7-6-2019
- Balance Cairan (Target Urin Na/K/Cl: 135/3,0/85
600 cc)
AGDA 7-6-2019
Lab 5-6-2019 pH: 7,582
Hb/Ht/E/L/Tr : pO2:69
7,4/23/2,7/8,9/347 Bicarbonat: 42,7
MCV/MCH/MCHC: 86/28/32 Total CO2:44,1
Diftell: 8/1/0/70/12/9 Saturasi O2:94,2
Alb/Ca: 2,41/8,2
Na/K/Cl: 141/4,7/104 Lab 6-6-2019
Albumin : 3,55
Lab 3-6-2019 Na/K/Cl/Ca : 132/2,4/73/8,0
GDS : 112
Ur/Cr : 117/9,30 Lab 5-6-2019
Na/K/Cl/Ca : 146/5,0/107/8,7 Hb/Ht/E/L/T
10,8/30/3,9/22,8/402
Urinalisa 29-5-2019 MCV/MCH : 77/28
Warna : kuning Diftell : 0/0/0/85/9/6
Kejernihan : keruh Na/K/Cl : 132/2,4/73
Lekosit/Protein : (+)/(+2) Ca : 8,0
Keton/Darah : (+)/(+)
Lab 2-6-2019
Anti HCV/HbsAg : (-)/(-)
DPJP : DPJP : DPJP : dr. Azhari Gani, DPJP : dr. Azzaki, Sp.PD DPJP :
COW : COW : Sp.PD COW : dr.Dedy COW :
DR : DR : COW : dr. Rahmi DR : dr.Muna DR :
DM : DM : DR : dr. Wahyu DM : DM :
DM :
Nama : Munasir Adnan Nama : Hamdan A Rahman
TTL : 01-12-1977 (41th) TTL : 26-05-1962
Alamat : Banda Aceh Alamat : Banda Aceh
CM : 1-00-62-05 CM : 1-20-04-81
Hari Rawatan : 1 Hari Rawatan : 2
A/ A/
1. Dispepsia tipe like ulcer 1. Sirosis hepatis stadium
decompensata
2. Asites permagna
Th/
- Bedrest Th/
- Diet MB 1700 kkal/hari - Bedrest
- IVFD RL 20 tpm - Diet hati lunak 1700 kkal/hr
- IV lansoprazole 30mg/12j - IVFD aminofusin hepar 1
- Sucralfat syr 3xCI fls/hari
- IV lansoprazole 30mg/12j
- IV furosemid 20mg/12j
Lab 10-06-2019 - Spironolacton 2x100mg
Hb/Ht/E/L/T: - Propanolol 2x10mg
13,4/37/4,7/14,6/659 - Valsartan 1x80mg
MCV/MCH: 78/29 - Lactulac syr 3xCII
Diftell: 11/0/1/45/35/8 - Vectrin 2x300mg
GDS: 110
Na/K/Cl: 128/4,1/99 Lab 10-06-2019
Hb/Ht/E/L/T: 9/26/2,6/6,4/161
MCV?MCH: 100/35
Diftel: 3/0/0/77/12/8
PT/kontrol/INR: 18,7/14,8/1,49
APTT/kontrol: 43,60/35,7
Bil.total/direct/indirect:
3,85/1,12/2,73
SGOT/SGPT: 125/31
Protein total/alb/glo:
9,4/2,71/6,69
Gds: 148
Ur/cr: 52/1,87
Na/K/Cl: 133/4,2/108
DPJP : DPJP : DPJP : DPJP : DPJP :
COW : COW : COW : COW : COW :
DR : DR : DR : DR : DR :
DM : DM : DM : DM : DM :

Mapping Aqsa 2 (Selasa, 11 Juni 2019)

Hochgeladen von

Dokumentinformationen

Copyright

Verfügbare Formate

Dieses Dokument teilen

Dokument teilen oder einbetten

Freigabeoptionen

Stufen Sie dieses Dokument als nützlich ein?

Sind diese Inhalte unangemessen?

Copyright:

Verfügbare Formate

Mapping Aqsa 2 (Selasa, 11 Juni 2019)

Hochgeladen von

Copyright:

Verfügbare Formate

AQSHA 2 (PENYAKIT DALAM PRIA)

Hari / Tanggal : Selasa / 11 Juni 2019

K1B1 K1B2 K1B3 K1B4

Das könnte Ihnen auch gefallen