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MAPPING AQSHA 1

Jumat, 19 JULI 2019


Tim Jaga : dr. Yudis/ dr. Ishak
DokterMuda : Hiya/Andi

KELAS 1 KELAS 2 KELAS 3 KELAS 4


DR : dr. Taufik DR : dr. Taufik
COW : dr.Sabarina COW : dr. Nasriah
DPJP ORTHO RABER EMD DM : DM :
DPJP PULMONOLOGI
DPJP: dr.Masralena Sp.PD/ Raber : GH, B.Vaskular, BTKV,
dr. Mamfaluti, Sp.PD Pulmo
DPJP : dr. Azhari Gani, Sp.PD
Nama : Ismiati Idrus Nama : Tarifuddin Zakaria
TTL : 14-07-1958 TTL : 07-06-1966 (53 tahun)
Alamat : Banda Aceh Alamat : Banda Aceh
CM : 1-21-46-41 CM : 1023800
Hari Rawatan : 5 Hari rawatan : 17

A/ A/
1. CHF FC NYHA II-III ec dd/ 1. Efusi pleura bilateral post punksi
- HHD ec CKD
2. CKD stg V on HD Reguler
- IHD 3. DM Tipe II NW
- DCM 4. Cystitis
2. Hipertensi dalam terapi 5. Anemia sedang ec PGK
3. DM tipe II NW 6. Hipoalbuminemia
4. AKI stg II ec dd/
- Cardiorenal Th/
- Bedrest
- DN
- Diet ginjal 1700 kkal/hari + 1 gr
- HN protein/kgBB/hari + extra putih telur
5. Anemia sedang NN ec dd/ ( 6telur/hari)
- Penyakit ginjal kronik - O2 2-4 l/menit
- threeway
- Perdarahan
- IV levofloxacin
-Drip albumin 25% 100 cc/hari
Th/ - IV Omeprazol 40 mg/12 jam
-Bed rest - Lenal ace 169 mg
-IVFD NaCL 0,9% 10gtt/i -As.folat 2x400
-Lansoprazole 30mg/12j - Gabapentin 1x100 mg
-ceftriaxone 2gr/12 jam - Fluimucyl 3x200
-nitrokaf R 2,5/12jam - Lactulac syr 3 x CII
- clopidogrel 75mg/24jam - Cendistatyn drop 3x2gtt
- aspilet 80 mg/12 jam -vitrolenta 4xgt
- furosemid 40mg/12 jam - c.lyters ED 4x1
- bisoprolol/12 jam po - Paracetamol 1gr/drip
- amlodipin 10 mg/ 24 jam -furosemid 1amp/12jam
- lactulac syr 3xC1 -HD (senin, rabu, jum’at)
- atorvastatin 1x20mg
- catarlen 4x10mg Lab 17/07/2019
- Noncort 4x10mg Hb/Ht/E/L/T: 8,6/25/3,6/10,2/234
MCV/MCH/MCHC : 70/24/34
Lab 18/07/2019 Diftel : 11/2/0/65/13/9
PT : 15,10 Albumin : 2,76
APTT : 33,40 Ca: 7,9
Na/K/Cl: 136/3,4/104
Lab 16/07/2019
Lemak darah Lab 15/07/2019
Kolesterol total : 217 Hb/Ht/E/L/T: 7,9/24/3,4/8,2/290
HDL : 63 MCV/MCH/MCHC : 69/23/33
LDL 189 Diftel : 9/2/0/66/13/10
Trigliserida 167 Albumin : 2,69
Lab 14/07/2019
Lab 15/07/2019 Hb/Ht/E/T/L: 8,3/24/3,5/258/7,6
Urinalisis MCV/MCH/MCHC : 69/24/34
Warna : kuning Diftel: 6/1/0/68/14/11
Kekeruhan: keruh Albumin: 2,38
PH: 5 Lab 11/07/2019
Protein (+1) : 6-8 Protein total 4,30
Eritrosit: 10-20 Albumin 2,74
Epitel 4-6 Globulin 1,56
Granular cast (+) Kalsium 8,3
Hyalin cast (+) Ur/Cr : 106/6,34
Na/K/Cl : 130/4,1/99
Lab 14/07/2019 Lab 09/07/2019
Hb/Ht/E/T/L: 8,7/26/2,9//8,5/237 Leukosit : -
MCV/MCH/MCHC : 90/30/33 Protein : ++
GDS : 200 Glukosa : +
Na/K/Cl : 143/5,5/115 Keton : +
Ur/cr : 64/2,21 Darah : -
CKMB: 17 Granular cast : +
Ca oxalat : +
KELAS 5 KELAS 6 KELAS 7 KELAS 8
DR : dr. Riza
DR : dr. Muna
COW : dr. Ganis
COW: dr. Arie
DPJP PULMO RABER GEH DPJP NEUROLOGI DM :
DPJP: dr. Hendra Zufry, Sp.PD
DPJP: dr. Azzaki A, Sp. PD
Raber:
Raber :
Nama: Ayub Sami Nama : M. Dahlan H
TTL : 10/06/1962 (57 thn) TTL : 18/8/1941(77 th)
Alamat : Aceh Tengah Alamat : Banda Aceh
CM : 1-21-42-06 CM : 0-76-42-84
Hari rawatan : 10 Hari Rawatan : 25

A/ A/
1. Pneumonia (HAP) 1. Ca Caput pancreas metastase
2. Ulkus diabetikum ar cruris dextra hepar dan paru
3. DM tipe 2 Normoweight 2. Gastritis erosif
4. Hipertensi stg 2 3. Diverticulus
5. efusi pleura bilateral ec dd 4. Esofagitis grade B
Pleuropneumonia 5. Hemorrhoid externa
6. Gastropati diabetik 6. Hipoalbuminemia

Th/
1. Bedrest Th/
- Bedrest
2. Diet DM 1700 kkal/hari + ekstra
- Diet sonde 6x200cc
putih telur
3. SC Lantus 0-0-0-14 unit - MST 10mg/12j
4. Klindamisin cap 3x300 mg - Lactulac syr 1xC1
5. Flumucyl syr 3xcI - IV Omeprazole 40mg / 12 jam
6. Amlodipin 1x5mg - IV Aminoleban 1 fls / 24 jam
7. Iv ceftazidime 2x1 gr - Curcuma 3x1
8. Valsartan 40 mg/24 jam - IV Novalgin 3x1
9.Nebule ventolin 1 resp/8 jam - Duragesic patch 12,5mg / 3 hari
10.Fluconazole 1x200mg
11. Rawat luka dengan - Urdafalk 500mg 3x1
burnazin/hari - KSR 1x600mg
- Liverprime 3x1
Lab 15/07/2019 - Sucralfat 3xC1
Hb/Ht/E/L/T : 9.3/26/3.5/9,3/431
MCV/MCH/MCHC : 76/27/35 - IV Clinimix + clinolic 1fls/24jam
Diftell : 9/2/0/61/19/9 - IV Clinolec acid 1x1
Lab 13/07/2019 - Drip Albumin 25% 100cc/hari
Ur/Cr : 48/1,58 - Interhistin 3x1
- Bedak Salisilat 2x1
Lab 12/07/2019: - Cefoperazine 1gr/8jam
Urinalisis
Protein : +2 Lab 13/07/2019
Glukosa : +3 Hb/Ht/E/T/L: 12,3/35/4,2/244/8,2
Darah : positif MCV/MCH/MCHC : 83/30/36
Keton: negatif Diftell : 5/0/0/66/16/13
Bilirubin/urobilinogen: -/- Albumin: 2,41
Leukosit : negatif
Leukosit : 2-3 LPB
Eritrosit : 2-4 LPB Lab 09/07/2019
Epitel : 0-2 LPK Hb/Ht/E/T/L: 12,2/34/4,1/210/6,8
granular cast : positif MCV/MCH/MCHC : 83/30/36
hyalin cast : positif Diftell : 0/0/0/74/12/14
Ur/Cr : 26/0,60
Lab 11/07/2019: Na/K/Cl : 136/2,8/99
LED: 77
Kolestrol total/ HDL/
LDL/trigiserida: 180/43/150/106

Lab 10/07/2019
Hb/Ht/E/T/L: 9,3/27/3,5/450/11,1
MCV/MCH/MCHC : 76/27/35
Diftell : 2/1/0/75/15/7
HBsAg : -
Bilirubin total: 1,08
Bilirubin direk: 0,52
Bilirubin indirek: 0,56
SGOT/SGPT: 29/29
GDS : 140
Albumin : 3,45
Na/K/Cl : 130/4,6/97
KELAS 9 KELAS 10 KELAS 11 KELAS 12

DR : dr. Reyza DR : dr. Muna


DR : dr.Reyza COW : dr. Arie
DR : dr.Akmal COW : dr. Emier
COW : dr.Emir DPJP : dr. T. Mamfaluti, Sp.PD
COW : dr.Laura DPJP : dr. M. Riswan Sp.PD-
DM : Raber : GH, BTKV, NEUROLOGI
DM : KHOM
DPJP: dr. M. Riswan, Sp.PD
DPJP: dr. Fauzi Yusuf, Sp. PD Raber : GEH

Nama : M. Nasir Hasan Nama : Rusdi Sulaiman Nama : Fuadi Johan Nama :Salman Gade
TTL : 13-06-1955 (64th) TTL : 26/07/1951 (67th) TTL : 23/06/1973 (46th) TTL : 20/4/1963 (56th)
Alamat : Banda Aceh Alamat : Aceh Besar Alamat : Lhokseumawe Alamat : Aceh Pidie
CM : 0-88-90-22 CM : 1-11-29-36 CM : 0-06-29-09 CM : 1-21-31-87
Hari rawatan : 29 (1 hari DPJP Hari rawatan : 4 Hari rawatan : 14 Hari Rawatan : 18
IPD)
A/
A/ A/
1. acute on CKD dd CKD stage 5 ec.
A/ 1. Obs Vomitus induced chemotherapy Ca 1. Hodgkin lymphoma stage IV DN
1. Candidiasis oral esophagus Prostat 2. efusi pleura sinistra ec.dd/
2. AKI stage II dd/acute on CKD Th/
2. Cholelithiasis - Pleuropneumonia
- Bedrest - Pleuritis TB
3. Pneumonia Th/ 3. Anemia sedang HM ec. PGK
- Diet MB 1700 TKTP
4. Diare akut perbaikan - Bedrest
- IVFD NaCl 0,9 % 20 gtt/i
4. ISK
5. DM Tipe 2 Normoweight
- O2 2-4 l/I
- Iv. Omeprazole 40mg/12 jam 6. Hemiparesis (D) ec Stroke Iskemik
Th/ - Diet lunak 1700 kkal/hari
- Sucralfat syr/8 jam
- Bedrest - IVFD NaCl 0,9% 30 gtt/i Th/
- Domperidone 10mg/8 jam
- Diet MB 1700 - IV Ondansentron 40 mg/12 jam - Bedrest
- MST 10mg K/P
kkal/hari - Kallitake 3x1 - Diet ginjal 1700 kkal/hari + 60 gr
- Fosenenema 1 fls K/P protein/hari
- IV Omeprazole 40mg/12 jam
- Tracetat2x1
Curcuma 20 mg /8jam
- Transetat 2x1
- Threeway
Sukralfat syr - IV Furosemide 20mg/12jam - Drip Paracetamol 1 gr/8 jam
Seretide 500mg /12jam - Sucralfat Sirup 3x1 CI
Triopusin 500 mg /24 jam - Pradaxa 75 1x1 - Lenal ace 2x169 mg
Lab 18-7-2019
Akilen 2mg /12 jam - Fenitoin 3x100 mg Ur/Cr: 87/2,60 - Asamfolat 2x400 mg
H2O2 4mg /6jam Na/K/Cl : 135/2,2/97 - Bicnat 3x500 mg
Omeprazole 40mg/ 24 jam Lab 16-7-2019 - Lactulacsyr 3xC1
Furosemide 2 amp /8 jam Ca : 10,2 Lab 13-7-2019
Levofloxacin 500 mg /24jam Na/K/Cl : 127/5,1/104 - Flumucyl syr 3 x CI
Ur/Cr: 66/1,84
Aprazolam 0,5mg /12 jam - Nystatin drop 2cc/6jam
Diaforn (k/p) Lab 14-7-2019 - IV Levofloxacin 250 mg/24 jam
Lab 08-7-2019
Flucomazol 150mg /24jam Hb/Ht/E/L/T : 12,5/35/6,4/13,6/290 - Mecobalamin 500gr/12jam
Hb/Ht/E/L/T : 9,5/28/3,3/5,9/276
Zinc 20mg MCV/MCH/MCHC : 87/31/36 - Clopidogrel 75mg/24jam
MCV/MCH/MCHC : 84/28/34
Liprolac Diftell : 2/0/0/74/16/8 Diftell : 1/1/0/86/5/7 - IVFD Nacl 3% 1fls (ekstra)
Vit. B compl. 2 tab Ur/cr: 56/2,15 PT pasien/control/INR : - Fluconazole 1x100mg
Clinimic 1 fls /hari Na/K/Cl : 129/5,8/103 15,5/13,3/1,19 - Hemodialisis (senin,rabu,jumat)
Ivelip fls /hari APTT pasien/kontrol : 25,4/34,9
Kaltopren supp. D-Dimer : 1070,93
- Gabapentin 1x100
–Alprazolam 1x05
Na/K/Cl : 140/3,5/106 – KSR 600mg/12J
Lab 10-7-2019
AGDA Lab 07-7-2019 Lab (17/07/19)
PH: 7,5 Hb/Ht/E/L/T : 7,3/21/2,5/5,9/259 Hb/Ht/E/L/Tr: 9,6/28/3.7/15,2/175
PCO2: 41,6 MCV/MCH/MCHC : 83/29/35 MCV/MCH/MCHC: 76/26/35
PO2: 95 Diftell : 0/0/0/89/5/6 Diftel: 2/1/0/84/1/12
HCO3: 95 PT pasien/control/INR : Ur/cr : 70/2,21
Total CO2: 36,3 17,5/13,4/1,38 Na/k/cl : 133/3,8/98
BE: 11,6 APTT pasien/kontrol : 42,1/33,9 Ca : 9
SaO2 :98 Albumin : 2,74
Lab 04-7-2019
Hb/Ht/E/L/T : 7.9/23/2.8/8.3/285 Lab (12/07/19)
Lab 05-7-2019 MCV/MCH/MCHC : 82/28/35 Hb/Ht/E/L/Tr: 8,8/25/3.3/13./119
Hb/Ht/E/L/T : Diftell : 0/1/0/91/3/5 MCV/MCH/MCHC: 76/27/35
11,9/36/4,4/11,9/353 APTT/INR : 52.8/2.07 Diftel: 1/1/0/83/2/13
MCV/MCH/MCHC : 82/27/33 Ur/cr : 74/2,52
Na/k/cl : 133/3,2/102
Diftell : 0/0/0/78/13/9 Lab 04-7-2019
Albumin: 3,26 Hb/Ht/E/L/T :5,8/17/2,2/106/438 Lab (9/07/19)
Ur/Cr: 66/0,83 MCV/MCH/MCHC: 79/27/34 Hb/Ht/E/L/Tr: 8.8/25/3.3/11.9/146
Na/K/Cl : 140/4,7/106 Diftell: 0/0/0/89/5/6 MCV/MCH/MCHC: 76/27/36
GDS: 127 GDs: 136 Diftel: 0/1/0/76/1/22
Anti HCV : - Ur/Cr: 141/2,55 Ur/cr : 156/4.33
HbsAg: - Na/K/Cl: 134/3,9/100 Na/k/cl : 123/4/90

Lab 07-07-2019
Hb/Ht/E/T/L: 8.5/24/3.1/175/14.8
MCV/MCH/MCHC : 76/27/36
Ur/Cr : 266/6.96

Lab 03-07-2019
Ca: 8,5
As. Urat: 10,8
Urinalisis:
BJ/pH: 1,015/7,0
Leukosit/protein: positif/positif (+1)
Darah: positif
ISO 1 ISO 2 ISO 3 ISO 4
DR : dr. Reyza DR : dr. Muna DPJP :
DR : dr. Husna
COW : dr. Emir COW : dr. Arie COW : dr.
COW : dr. Nadi
DM : DM : DR : dr.
DM :
DPJP: dr. M. Riswan, Sp.PD DPJP: dr. T. Mmfaluti, sp.PD Raber :
Raber : EMD, GEH, GH,
Raber: Raber:
BedahPlastik, Pulmo
DPJP : dr. M. Diah, Sp.PD-KKV
Nama : Khatijah Ibrahim Nama : Anshar Patria Nama : Wahidin Baha Iman
TTL : 15-03-1962 (57th) TTL : 26/05/1959 TTL : 10-01-1960
Alamat : Aceh Besar Alamat : Aceh besar Alamat : Aceh Selatan
CM : 0-88-65-79 CM : 0979971 CM : 1202081
Hari Rawatan : 34 Hari Rawatan : 3 Hari Rawatan : 1

A/ A/
A/
1. Ca Colorectal 1. CKD stage V ec dd
1. CKD stg V on HD regular ec PNC
- DN
2.PSMBA ec dd 1. Ulkus Gaster 2. Th/
Ulkus Duodenum - PNC dengan edema paru akut
- Diet MB TKTP 2. CHF fc NYHA III-IV ec CAD
3. Anemia Sedang NN ec PGK et
- IVFD NaCl 0,9 % 3. DM type II NW
perdarahan
- IV Lansoprazole 30mg/12jam 4. Hiperkalemia berat
4. Hipoalbuminia sedang
- IV furosemide 20 mg/12jam
5. Efsi pleura dextra ec
- Ciprofloxacin 2x500mg Th/
adenocarcinoma
-Sucralfat Syr 3xCI (AC) -Bedrest
6. DM tipe 2 normoweight
- metformin 500mg 3x1 - Diet ginjal 1700 kkal/hari
7. CHF fc NYHA II ec HHD
- Glimepirid 2mg 1x1 - Threeway
Th/ - Drip furosemide 2 cc/jam
Lab 16/07/2019 - Lenal ace 2x16mg
- bedrest Hb/Ht/E/T/L: 10,8/32/3,7/11,0/242 -Asam folat 2x400 mg
- Diet ginjal 1700 kkal + protein 50 MCV/MCH/MCHC : 85/29/34 - Nebule Ventolin(ekstra)
gr/ hari Diftel: 1/2/0/71/15/11 -IV ca glukonax 5 amp (ekstra)
- Threeway -Kalitake 3x1
Lab 17/07/2019 - Hemodialisa
- Hemodialisa (selasa dan jumat) Alb: 2,34
- ISDN 5 mg 2x1 Ca : 7,5 Lab 18/07/2019
- Sc Apidra 6-6-6 Ur/cr: 33/0,68 Hb/Ht/E/T/L: 8,5/25/3/330/8,5
- Asamfolat 2x1 Na/K/Cl : 134/3,7/105 MCV/MCH/MCHC : 85/28/33
- Lenal ace 2x1 Diftel: 1/1/0/80/13/5
Albumin :2,88
- Atorvastatin 1x20 mg Ur/cr: 180/15,23
- Valsartan 100mg/24 jam Na/K/Cl : 141/7,3/114
- Furosemid 40 mg/8jam GDS : 93
- Drip Lansoprazole 60mg IV Anti HCV : -
HBsAg :-
- Transamin 50mg / 8jam
- Sukralfat 3x1C
- Vit K /8 jam
- - Ceftriaxone 2 gr/24 jam
- Ocieotide 2 amp
Lab 17/07/2019
Hb/Ht/E/T/L: 9,7/28/3,2/20,4/236
MCV/MCH/MCHC : 88/30/35
Albumin : 2,77
Ca : 7,3
Na/K/Cl : 139/3,8/106
KGDS : 113

Lab 12/07/2019
Hb/Ht/E/T/L: 6,8/20/2.3/7,1/246
MCV/MCH/MCHC : 86/29/34
Diftel: 5/1/0/62/23/9

Lab 10/07/2019
Hb/Ht/E/T/L: 8/24/2.8/266/7.6
MCV/MCH/MCHC : 86/29/34
Albumin : 2.9
Ca : 7.7
Na/K/Cl : 140/4.0/106
Ur/Cr: 166/6.5
PT/APTT: 0.97/37.8

Lab 6/07/19
Protein total/alb : 4,84/2,6

Lab 1/07/19
Cairan pleura
Warna kuning, jernih, bekuan –
PNM/MN : 30/70
Protein : 2,1
Albumin : 1
Glukosa : 198
ISO 5 ISO 6 ISO 7 ISO 8
DR : dr. akmal DR : dr. Taufik
COW : dr. COW : dr.
DPJP PULMO DM : DM :
DPJP: Dr.dr. Fauzi Yusuf, Sp.PDKGH DPJP: dr. Azhari Gani, Sp.PD
Raber : Div IPD Kardiologi Raber: Div, PTI, Geriatri
Nama : T. A. Wahid Silang Nama : H. Abdurrahman Hanafiah
TTL : 31-07-1963 TTL : 01/07/1929
Alamat : Sabang Alamat : Nagan Raya
CM : 1210585 CM : 1193577
Hari Rawatan : 4 Hari Rawatan : 9

A/ A/
1.Penurunan kesadaran ec dd 1.Penurunan kesadaran ec dd
- Sepsis - demensia senilis
- Imbalance elektrolit - Sepsis
- Stroke - uremic encepalopati
2. Sepsis ec dd gangrenb diabetic pedis - sda
dextra 2. Sepsis ec dd
3. DM tipe 2 underweight dengan critical – Pneumonia
ill - Urosepsis
4. Stroke dengan sequel hemiparese 3. Pneumonia geriatri
dextra 4. Akut on CKD dd AKI stg III renal
5. parotitis ec sepsis
6. AKI Stage I 5. trombositopenia ec dd/
7. hipoalbuminemia - induced heparin
- Sepsis
6. Geriatri Problem (Inanisi, Infeksi,
Th/ Imobilisasi, Instabilitas)
- Bed rest 7. Hipoalbumin
- O2 2-4 l/i 8. Hipertensi stg 1I
- Diet sonde 6x200ml 9. Brain Atropi
- IVFD 2:1 20gtt/i 10. Hipokalemia ringan
- IV meropenem 1gr/8jam
IV omeprazole 40mg/12jam Th/
-Drip novorapid 50 unit dalam 50 cc NaCl - Bed Rest
0,9 % 0,5 cc/jam Target gds 140-180 - O2 2-3 l/i
mg/dl - Diet ginjal 1700 kkal/hari + protein
-IV albumin 25% 100cc/24 jam 1gr/bb/hr
- Threeway
Lab 17/07/2019 - IV omeprazole 40mg/24jam
Hb/Ht/E/L/T : 8,8/29/3,5/19,2/382 - Bicnat 3x500mg
MCV/MCH/MCHC : 84/25/30 - Asam folat 2x0,4mg
Diftel : 0/0/092/6/2 - Lenal Ace 2x169mg
Protein total : 5,09 - Hemodialisa
Alb/glo : 1,88/3,21 - Balance cairanseimbang
Na/K/Cl : 172/3,1/137 - IV Meropenem 500mg/ 12jam
Ur/cr: 92/0,71 - Vectrin 3x1
-transfusi PRC sd Hb >10 g/dl
Urinalisis - HD (senin, rabu, jumat)
Warna : kuning - Amlodipin 1x10mg
Kekeruhan: keruh - Nystatin drop 3x1\
PH: 5 - albumin 25 % drip
Protein : negatif - TRansamin /8j
Leukosit: 4-6 - Vit K /8j
Eritrosit: 8-10 -Citicolin 1gr/12jam
Epitel 2-3 -Mecobalamin 500mg/12jam
- valsartan 80mg/24 jam
Lab 14/07/19 - Arisep 5 mg/24 jam
Hb/Ht/E/L/T : 10,2/32/4,1/33/502
MCV/MCH/MCHC : 78/25/32 Lab 17/07/2019
Diftel : 1/0/0/94/2/3 Hb/Ht/E/L/T : 10/29/3,4/3,6/43
Gds : 393 MCV/MCH/MCHC : 86/30/34
Na/K/Cl : 150/3,9/117 Diftel : 2/0/0/66/21/11
Ur/cr: 160/1,64 Ca : 14,8
Na/K/Cl : 140/3,4/102
Ur/cr: 55/2,58
Asam urat : 5,7

Urinalisis
Warna : kuning
Kekeruhan: keruh
PH: 6
Protein : negatif
Keton : positif

Leukosit: 8-10
Eritrosit: 10-15
Epitel: 4-6
Sel ragi: positif
Lab 15/07/19
Hb/Ht/E/L/T : 9.2/27/3.2/4,6/53
MCV/MCH/MCHC : 84/29/35
Diftel : 2/0/1/76/14/7
Protein/Albumin : 7.51/2,54
Kalsium 13,1
Ur/Cr : 84/3,88
Na/K/CL : 141/3.3/102

Lab 12/07/19
Hb/Ht/E/L/T : 6,3/18/2,2/7,4/-
MCV/MCH/MCHC : 86/29/34
Diftell:2/0/0/84/10/4
Ur/Cr : 94/4,54
Na/K/Cl : 144/3,5/106

ISO 9 ISO 10 ISO 11 ISO 12


DR : dr.Reyza DR : dr. Riza
COW : dr.Emir DR : dr. Taufiq COW : dr. Ganis
DM : COW : dr. Nazria DM : EMD DPJP BEDAH SARAF RABER GH
DPJP: dr. M. Riswan, Sp.PD DPJP: dr. Azhari Gani, sp. PD DPJP: dr. Azzaki Abubakar, Sp PD
Raber: PULMO Raber: B.Ortho, EMD Raber: B.Ortho, EMD
Nama : Ruhani Ibrahim Nama : Sulkhaidi Abu Bakar Nama : Marzuki Husen
TTL : 31-12-1936 TTL : 16/07/1978 (40th) TTL : 31/12/1954 (64th)
Alamat : Aceh Pidie Alamat : Blang Pidie Alamat : Aceh Pidie
CM : 1214047 CM : 1155434 CM : 1212970
Hari Rawatan : 9 Hari Rawatan : 18 Hari Rawatan : 19

A/ A/ A/
1. Sepsis ec dd pneumonia (CAP) 1.Tension pneumothoraks post steril 1. Post BKA dextra a.i ulkus
2. Pneumonia ec dd infeksi paru chest tube dekubitus
spesifik 2. OA Genu D kelas III 2. DM Tipe 2 NW
3. Pansitopenia ec dd 3. Radialopati lumbalis 3. Anemia sedang HM ec dd
- Anemia aplastik 4. Ulcus decubitus grade III - peny kronik
5. Anemia hipokrom mikrositik ec
- MDS - defisiensi besi
dd
- Akut leukemia 4. Geriatri problem ( inanisi, infeksi,
- penyakit kronik
4. Geriatric problem instablittisas, imobilisasi)
- Acute bleeding
5. Hipertensi stge II on terapi 5. Hipertensi stage 1
- Defisiensi Fe
6. Hipoalbuminemia sedang
6. CKD stage V on HD regular
Th/ 7. Hiponatremia (perbaikan)
(Selasa-Jumat)
- Bed rest 7. MRSA
Th/
- Diet sonde via oral 8. Ansietas dan depresi
9. Hipertensi stage II (HHD) - Bedrest
- IVFD NaCl 0.9% 20gtt/i
- Diet DM 1700 kkal/hari + extra
- Flumucyl 3x200mg Th/ putih telur
- Valsartan 1x80mg - Bedrest - IVFD NaCl 0,9% 20 gtt
- Nebule ventoline 1 - Diet ginjal 1700 kkal/hari + - Clindamicin 3x300 mg
resp/8j protein 1 gram - Drip Albumin 25% 100cc/hari
- fosen enema k/p - Threeway - Paracetamol 3x500 mg
- paracetamol 1gr/8jam - O2 4L/menit - Lactolac Syr 3 x CI
- lactulus 3x1 - IV Vancomisin 1 gram tiap - KSR 2 x 600 mg
- drip novalgin habis HD\
- Drip Amikasin 500 mg dalam 500
- drip clinimix 1 fls/24 jam - Paracetamol 2x1 gram cc NaCl 0,9% 20 tpm
- meropenem 1 gr/8jam - Metilprednisolon 2x8mg - Novorapid 10-10-10
- combivent /12j - Rawat Luka - Levemir 0-0-0-12
- flixotide /12j - Amlodipin 10 mg
- Metil prednisolone 128mg/12jam Lab (18/07/19)
Hb/Ht/E/L/Tr: 8,3/24/3.0/11,1//287
- omeprazole 40 mg/12jam Lab (18/07/19)
MCV/MCH/MCHC: 80/28/35
Diftel: 3/1/-1/81/7/9 Albumin : 2,91
Lab (17/07/19) Albumin: 2,9
AGD Ca : 9 Lab (13/07/19)
pH : 7,501 Hb/Ht/E/L/Tr: 8,9/25/3.2/6.9//300
Na/K/Cl : 136/5,4/102
pCO2 : 27,50 MCV/MCH/MCHC: 78/28/36
1. Diftel: 1/0/0/74/15/10
pO2 : 106 . Albumin: 2,33
HCO3 : 21,7
Total CO2 : 22,5
Lab 11-07-2019:
BE : -0,8
SPO2 : 97,4 Protein
total/albumin/globulin:5,83/2,50/3,33
Lab (16/07/19)
Lab 10-07-2019:
Hb/Ht/E/L/Tr: 7,6/21/2,8/0,8/3
Albumin: 2,63
MCV/MCH/MCHC: 77/27/36
Diftel: 1/2/1/49/34/13 Lab (9/07/19)
Ur/cr : 56/0,57 Hb/Ht/E/L/Tr: 12.4/37/4.7/6.7//254
Alb : 2,33 MCV/MCH/MCHC: 79/27/34
Globulin : 2,40 Diftel: 2/1/0/70/14/13
Prot total : 4,73 Albumin 2.23
Na/K/Cl : 135/4,8/107 Ur/cr : 14/0.54
PT/APTT : 1,43 / 39,90 Na/k/cl : 132/3.1/100

Lab 15/7/19
ur/cr : 144/2,42 Lab (5/07/19)
Hb/Ht/E/L/Tr: 9.4/27/3,5/4,9/265
procalcitonin : 3.04
MCV/MCH/MCHC: 78/27/35
Diftel: 3/1/0/60/25/11
Lab (13/07/19) Albumin 2,13
Hb/Ht/E/L/Tr: 8.2/24/3,0/1,1/23 Protein Total : 6,16
MCV/MCH/MCHC: 79/27/35 Ca : 6,5
Diftel: 0/2/0/58/30/10 Na/k/cl : 132/3,5/101

Lab (10/07/19)
Hb/Ht/E/L/Tr: 8.6/25/3,1/0,9/26
MCV/MCH/MCHC: 78/27/35
Diftel: 0/1/1/71/20/7

Lab (08/07/19)
Hb/Ht/E/L/Tr: 10.1/29/3,7/1,7/7
MCV/MCH/MCHC: 78/27/35
Diftel: 0/2/0/52/44/2
GDS 197 mg/dl
Ur/cr: 32/0.39
Na/k/cl : 135/4.7/103