Beruflich Dokumente
Kultur Dokumente
A/ A/ A/ A/
1. Penurunan kesadaran ec dd/ 1. Hepatomegali ec dd 1.Sepsis ec dd 1. Pansitopenia ec dd/
- SDA - HLL - HAP - anemia aplastik
- Sepsis - Metastase Proses - sellulitis pedis s - leukemia akut
- Uremic enselopati - Abses Hepar - panophtalmitis - MDS
2. TB paru on terapi OAT 1. Pneumonia CAP 2. Rheumatic Heart Disease dd
3. AKI stg (?) dd acute on CKD Th/ 2. Post inflamatory cardiomyopathi
4. HHD - Bedrest hyperpigmentation 3. Hepatosplenomegaliec dd 1.
5. Geriatri problem ( infeksi, - Diet Hati II 1700kkal 3. AKI ST II Acute on ckd EC DD/1. Liver, 2. Malignancy
inanisi, instability, demensia ) - Threeeway Gns 2. PNC
6. Post TURP - IVFD aminofusin 1 fls/hari 4. Hiponatremi hipoosmolar Th/
- IV omeprazole 40mg/12jam 5. Dd/-Selulitis cruris sinistra - Bedrest
- Curcuma 3x21 -DVT - Diet MB 1700 kkal/hr
Th/ - Sucralfat Syr 3xCI -plebitis - IVFD RL 20 gtt/i
- Tirah Baring - Tramadol 2x0mg 6. perforasi okuli (s) - Iv. Furosemid 20 mg/12
- Diet sonde 6x200cc 7. massa intra oculer susp melanoma jam
- O2 2-4 l /i via nasal canul mali gnan - Spironolacton 100mg/24
- IVFD NaC 0,9% 10 gtt / i jam
- IV. Ceftriaxone 2gr/24 jam Lab 28/6/2019 Th/ - Curcuma 3x1
- Amlodipin 10grx1 SGOT/SGPT - Bedrest - Transfusi s/d HB
- Valsartan 80mg x1 150/167 - Diet sonde 6x200 cc 1700kkal/hari >10g/dl
- EAS FPRIMMER 1x24j - IVFD NaCl 0,9 % 20tpm
- Curcuma 2s1 Lab 23/6/19 - IV Ceftriaxone 2gr/24jam
- Peridoxin 1x2 Hb/Ht/E/L/T - IV Omeprazole 40mg/12jam Lab 28/6/19
- IV meropenem 1gr /12j 12,5/36/4,30/8,20/255 - IV metoclopramide 1 amp/12jam HB/HT/E/L/T : 4,3/12/1,6/3,0/81
- OAT 4FDC 1x3 tab GDS : 120 - Nebul combivent 1 resp/12jam MCV/MCH/MCHC: 77/27/35
- Flumucyl 3xCI Diftel 0/0/1/48/45/6
Lab 27-06-2019 -Clindamycin 3x300mg
Bil total 1,19 - Kompres NaCl 0,9%/12jam Lab 27/6/19
Bil Direct 0,52 -iv meropenem 1gr/8 jam (h3) HB/HT/E/L/T : 4,2/11/1,4/2,4/86
Bil Indirect 0,67 -IV vit K 1amp/8jam MCV/MCH/MCHC/RDW :
SGOT/SGPT 40/45 78/30/38
Alb 2,84 Lab 28/6/2019 Diftel 0/0/0/64/31/5
PT/APTT : 22.90/38.20 Ur/Cr: 43/0,70
Lab 27-06-2019 Na/K/Cl : 135/3,2/102
Hb/Ht/E/L/T
8,6/25/3,7/13,2/174 Lab 25/6/19
MCV/MCH/MCHC HB/HT/E/L/T : 11,4/36/3,9/16,1/69
69/24/34 MCV/MCH/MCHC/RDW : 92/30/32
Diftell : 2/0/0/52/33/13 Diftel 1/0/0/69/27/3
GDS : 125 Ur/Cr: 112/2,35
Ur/Cr : 174/2,12 Alb 3,03
Na/K/Cl: 147/3,3/115 Na/K/Cl : 125/4,7/102
AGD 25/06/19
pH 7,456
Pco2 34,20
P02 23
Hco3 24,3
Total co2 25,3
Sat o2 43,9
K2B1 K2B2 K2B3 K2B4 K2B5
DPJP : dr. Chacha, SpPD DPJP: dr. Kurnia F. Jamil, DPJP : DPJP: dr.Islamuddin, KOSONG PER 02:00
COW : dr. Febri Sp.PD dr.Islamuddin,Sp.PD Sp. PD
DR : dr. Akmal COW : dr. rahmi COW : dr. Febri COW : dr. Febri
Raber : DR : dr. wahyu DR : dr. Akmal DR : dr. Akmal
Raber: GH,
Nama : M Armasnyah Siregar Nama : Aljabar Tgk Basyah Nama: Faiden Amin Nama: Sarmin D.
TTL : 16/8/1946 (72thn) TTL : 3112-1966 (52thn) TTL: 10/12/1970 (48 thn) TTL: 13-7-1961 (57 thn)
Alamat : Meuraxa Alamat : Aceh Utara Alamat: Bireuen Alamat: Simeulue
CM : 1-21-2558 CM :1212735 CM: 1-21-21-15 CM: 1-19-97-29
Hari Rawatan : 3 Hari Rawatan : 2 Hari Rawatan: 8 Hari Rawatan: 19
A/ A/ A/ A/
1.HE grade 1 dengan pencetus 1. CKD stage V on HD regular 1. Sepsis ec dd 1. Sepsis perbaikan ec dd/
infeksi ec PGD dengan udem paru akut - HAP - Abses ar colli
2. Sirosis Hepatis 2. Anemia sedang mikrositer - ISK dextra
3. Pneumonia geriatri normotik ec peny. Kronis 2. CKD stage V on PNC - HAP
4. AKI st III prerenal 4. Failure AV shunt 3. PSMBA (perbaikan) ec 2. Massa colli dextra ec
dd/hepatorenal syndrome dd/ dd/
5. PPOK eksaserbasi akut Th/ - Uremic bleeding - Limfoma Hodgkin
6.Inanisi - Bedrest - Gastritis erosive - Ca Nasofaring
7. Instabilitas dan jatuh - Diet Ginjal 1700kkal/hari + 4. Anemia berat hipokrom 3. Hipertensi stage I on
8. Immobilisasi 60gr protein/hr mikrositer ec dd/ 1. terapi
9. Hiponatremi Hiposmolar - Three way PGK 2. Defisiensi besi 4. Abses a/r colli
10. ISK - IV ceftriaxone 2gr/24j 5. Hipokalemia ringan 5. Hipoalbuminemia
11. Peny. Kronik - Drip NTG 10mg dalam Nacl 6. Hiponatremia euvolemic sedang
0,9 0cc dengan kecepatan 7. DM tipe 2 NW
Th/ 3cc/24j 8. Gastropeti diabetic Th/
- Bed rest - Drip Furosemide 20mg/jam 9. TB paru - Bed rest
- Diet Hati 1 dengan syringe pump 10. Trombositopenia - Diet sonde 1200 cc via
- O2 2-4LPM kecepatan 2cc/jam induced wafarin oral + extra putih telur
- Threeway, IVFD comafusin - Lenal ace 2x169mg - IVFD Clinimix1 fls/
hepar 1fls/hari - Asam folat 2x40mg Th/ 48j
- Nebule Combivent 1 - HD 1. Bed rest - IV Omeprazole 40
resp/8jam - Transfusi PRC s/d hb >70 2. Diet ginjal 6 x 200 cc mg/12 jam
- Spironolacton 1x100mg 3. Threeway - Erdostein 3x1
- Lactulac syr 3x45cc 4. IV meropenem 1 gr / 8 - Amlodipin 1x5mg
- IV. Omeprazole 40mg jam - Clinimix 1fls/48j
/24jam Lab 27/6/2019 5. IV omeprazole 40 mg / - Paracetamol 300mg
- Balance cairan 0 HB/HT/E/L/T 12 jam dan Tramadol 25mg
- Fossen Enema extra 7.2/21/2,6/12,9/304 6. Sucralfat syr 3 x C I dalam pulvis 2x1
- IV Cefepime 1gr/8jam skin MCV/MCH/MCHC 7. IV metoclopramid 1 - Levofloxacin
test 83/28/34 amp/8jam 750mg/24jam (h8)
- Vit K 1amp/8j Diftel : 6/1/0/71/16/6 8. Transfusi prc sampai hb - Cefipime 1gr/12j (h3)
- Transfusi FPP 600cc GDS/Ur/Cr : 88/8,13 > 10 gr / dl
Na/K/Cl : 143/3,5/110 9. Rifampisin 1x600mg Lab 27-6-2019
Lab 29/062019 10. Isoniazid 1x300mg PT/kontrol 14/13
PT/APTT : 61,0/52,10 AGDA : 11. Etambutol 1000mg/48j Aptt/kontrol 52,6/33,2
Anti HCV/HbsAg : PH/pCO2/pO2/HCO3/TCO2/BE 12. Pirazinamid 1x1600mg Alb 2,83
negatif/negatif /Saturasi O2 13. Gabapentin 1x100mg
Bil Total/Dir/Ind : 7,516/27,70/158/22,6/23,5/1,4/9 14. Mecobalamin 2x1 Lab 22-6-2019
0,77/0,53/0,24 98,5 15. Piridoksin 2x1 tab Hb/Ht/E/L/T:
SGOT/SGPT/Alb : 36/1/2,72 16. Curcuma 2x1 tab 10,6/31/3,8/16,8/356
17. HD senin/rabu/jumat MCV/MCH: 83/28
Lab 25-6-2019 Diftell: 0/0/0/84/6/10
Hb/Ht/E/L/T: Lab 25-6-2019
9,3/27/3,3/6,8/53 Hb/Ht/E/L/T: Lab 19-6-2019
MCV/MCH/MCHC:81/28/35 8,2/23/3,1/21,2/64 Hb/Ht/E/L/T:
Diftell: 0/1/0/52/39/8 MCV/MCH/MCHC:76/27/36 11,5/34/4,2/15,3/387
GDS 150 Diftell: 1/0/0/89/6/4 MCV/MCH: 83/28
Ur/cr 134/3,64 Bil direct 0,46 Diftell: 1/0/0/77/9/13
Na/K/Cl 130/4,7/108 SGOT.SGPT 26/8 Alb : 2,8
Lab 27-6-2019
Hb/Ht/E/L/T
9,1/27/3,2/13,3/207
MCV/MCH/MCHC
84/28/34
Diftell : 30/1/0/33/22/14
Albumin : 2,17
Ur/Cr : 26/2,73
Na/K/Cl : 145/2,5/110
Urinalisa
Berat jenis 1,010
Lekosit positif 20-25
Protein +1
Ph5
Epitel 8-10
K4B1 K4B2 K4B3 K4B4 K4B5
DPJP : dr. Khrisna, Sp.PD DPJP: dr. Kurnia F. Jamil, DPJP : dr. Kurnia F. Jamil, DPJP : dr.T.Mamfaluti,Sp.PD DPJP KARDIO
COW : dr. Reza Tandi Sp.PD Sp. PD COW : dr.Reza
DR : dr. Okdimur COW : dr. rahmi COW :dr. Rahmi DR : dr. Okdimur
Raber : GEH DR : dr. wahyu DR :dr. Wahyu Raber : GEH
Raber : GEH
Nama: Abdul Razak Nama: Syarifuddin K Banta Nama: Kemala Laot Nama: Sudirman T Baharuddin
TTL : 2/1/1951 (68th) TTL : 17/06/1956 TTL : 05-07-1946 (72thn) TTL : 31/12/1956
Alamat:Pidie Jaya Alamat: aceh barat Alamat: Aceh Barat Alamat :A.Besar
CM : 1-21-2451 CM : 1212846 CM : 1-21-22-60 CM : 1012552
Hari rawatan : 6 Hari rawatan : 3 Hari rawatan : 7 Hari Rawatan :8
A/ A/
A/ 1.PSMBA ec dd/ 1. Hematoskezia ec dd
1.Bisitopenia ec dd 1.Varises esofagus - Polip recti
1.AML bleeding - Hemoroid interna
2.Hepatitis viral 2.Varises fundus - Ca recti
2.Post PSMBA ec dd bleeding
1.Varises esofagus 2. Hipertensi on Terapi Th/
bleeding 3. .Sirosis hepatis std - Bed Rest
2.Varises fundus bleeding decompesata related hepatitis - Diet MB 1700kkal/hr
3.Massa intraabdomen B - IVFD NACL 0.9 30gtt
4. Cancer pain 4. Anemia Berat Hipokrom - IV omeprazole 40mg/12j
Mikrositer ec dd - IV asam traneksmat 150mg/8j
Th/ 1. Perdarahan - Attapulgit 1/mencret
- Tirah baring 2. Penyakit Kronis -Nystatin drop/6jam
- Diet hati II 1700 kkal/hari
- IVFD Aminofusin hepar 1 Th/ 27/6/19
fl/hari - Bedrest PT/kontrol 13,6/13
- IVFD Dextrose 5% 10tpm - NGT APTT/kontrol 38,5/33,2
- IV Omeprazole - IVFD NaCl 0,9% 20tpm
40mg/12jam - Omeprazole 40 mg/ 12 jam 24/6/19
- Domperidone 3x10mg - Sucralfat syr 3xci Hb/Ht/E/L/T
- Cucuma 3x1 tab - Propanolol 1x10mg 11,4/33/3,7/7,8/300
- Lactulac syr 3XCII - Domperidone 3x10mg MCV/MCH/MCHC
- Transfusi PRC sd Hb 89/30/34
>10gr/dl Lab 29-06-2019 Diftell : 5/1/0/62/24/8
- MST tab 2x10mg Hb/Ht/E/L/T HBSAG Anti HCV negatif
- Katrofen supp ekstra 6,4/21/2,8/2,6/50 GDS 78
- Cetirizine 1x10mg MCV/MCH/MCHC Alb 5,91
75/23/31 Ur/Cr : 14/0,78
Lab (26/06/19) Diftell : 9/0/0/61/20/10 Na/K/Cl: 137/3,4/109
Hb/Ht/E/L/T: PT/APTT : 18.30/38.40
6.2/18/1,8/11,6/40 Billirubin T/D/I :
MCV/MCH/MCHC: 1,12/0,36/0,76
102/35/34
PT/APTT: 16,70/43.30
MDT : Lab 25-06-2019
Kesimpulan : Anemia Hb/Ht/E/L/T
Normokrom dengan atypical 6,4/20/2,8/2,4/23
mononucklear sel +, + MCV/MCH/MCHC
trombositopenia 73/23/31
Saran L: Follow up MDT 1 Diftell : 3/0/0/63/22/12
lagi GDS : 102
Hbsag: positif
Lab (26/06/19) Ur/Cr : 36/0,75
Hb/Ht/E/L/T: Na/K/Cl: 135/3,4/111
6,2/18/1,8/11,6/40
MCV/MCH/MCHC
102/35/34
Diftell
1/0/0/30/28/41
MDT anemia normokrom dg
atypical mononuklear sel+
trombositopenia
PT/kontrol 16,7/13,1
APTT 43,30/32,2
Lab (25/06/19)
Hb/Ht/E/L/T:
5,6/16/2,1/19,0/203
MCV/MCH/MCHC
73/26/36
Diftell
2/1/0/80/10/7