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AQSHA 2 (PENYAKIT DALAM PRIA)

Hari / Tanggal : Minggu 30/06/2019


Dokter Jaga : dr. Afrizal / dr.Akmal
DokterMuda : Mirza/Rusdi

K1B1 K1B2 K1B3 K1B4


DPJP : dr. T. Mamfaluti,Sp.PD DPJP: dr. AzhariGani SPPD DPJP : dr. Chacha, SpPD DPJP : dr. AzhariGani SPPD
COW : dr. TM Reza Tandi COW: dr. Rahmi COW : dr. Febri COW :dr.Rahmi
DR : dr. Okdimur Dr: dr. Wahyu DR : dr. Akmal DR : dr.Wahyu
Raber : Rber GEH Raber : GH Raber :
Nama: Tgk. M.Adam Arahman Nama :M. Ali Ismail Nama: Amiruddin Maksah Nama: Zulkifli m. Saleh
TTL : 01/05/1938 (81 Thn) TTL : 01-09-1964 (54thn) TTL : 01-07-1968 (50 thn) TTL : 17-08-1970
Alamat : Pidie Jaya Alamat : Bireuen Alamat : Nagan Alamat : Bireun
CM :1-21-22-19 CM :1209779 CM :1-21-24-62 CM :1-21-27-26
Hari Rawatan : 7 Hari Rawatan : 3 Hari Rawatan : 6 Hari Rawatan:3

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

Urinalisa Lab 18-6-2019


Protein +1 Lab 21-6-2019 Procalcitonin : 0,32
Leukosit6-8 Hb/Ht/E/L/T:
Granular cast + 6,3/18/2,4/34,4/201 Lab 10-6-2019
Hyalin cast+ MCV/MCH/MCHC:74/26/36 Urinalisis:
Diftell: 0/0/0/93/4/3 Keton +
PT/APTT : 15,20/37,70 Epitel : 2-3
Ur/Cr : 362/13,88
Na/K/Cl : 123/6,7/93 Albumin : 2,88
Anti HCV negatif GDS : 164
HbSAg negatif Ur/Cr: 17/0,55
Na/K/Cl: 134/3,8/99
K3B1 K3B2 K3B3 K3B4 K3B5
KOSONG per 02:00 KOSONG per 02:00 DPJP : dr. Chacha, DPJP: dr. Krisna DPJP : dr. Chacha, Sp.PD
Sp.PD Sp.PD COW : dr. Febri
COW : dr. Febri COW : dr. T. M. Reza DR : dr. Akmal
DR : dr. Akmal DR : dr. Okdimur Raber :
Raber : Raber: Urologi
Nama: Muhammad Nama: A. Jalil Yusuf Nama: Idris Puteh
Marjani TTL : 31/12/1952 TTL: 01-07-1937 (81 thn)
TTL: 01/07/1959 Alamat : Aceh Besar Alamat: Aceh Pidie
Alamat : Aceh Utara CM : 1002318 CM: 1-21-10-87
CM : 1212938 Hari rawatan : 2 Hari Rawatan: 18
Hari rawatan : 2
A/ A/
A/ 1. AKI stage III post 1. Penurunan kesadaran ec dd/
1. Pansitopenia ec dd renal dd akut on CAD - Urosepsis
1. Anemia Aplastik 2. Anemia Berat NN ec - SDA
2. MDS 3. dd CAD - Disequilibrium Synd
Mielofibrosis 3. Vesikolitiatis 2. Sepsis ec dd/
2. PSMBA (perbaikan 4. Severe Low Back Pain - Urosepsis
dd 1. Varises 5. Hepatitis B Kronis - HAP
esofagus bleeding. 2. 3. Pneumonia (HAP) dd/
Varises fundus Th/ Infeksi paru spesifik
bleeding 3. Ulkus - Bed rest 4. CKD stage V ec PNC
Gaster - Diet Ginjal 5. Nefrolithiasis bilateral
3. DM tipe 2 1700kkal/hari 6. Hipertensi on therapy
normoweight - IVFD Nacl 0,9 10 tpm 7. PPOK stabil
4. Hipertensi terkontrol (habis ganti threeway) 8. Geriatric Problem
5. Asites ec dd /1. - Flumucyl tab 3x200mg 9. ISK
Sirosis hepatic. 2. - Laxodin syr 3x CI 10. Hipoalbuminemia
CHF. 3. - Transfusi PRC s/d HB > 11. Hiperosilofilia
Hipoalbuminia 9 gr/dl
Th/
Th/ - Bed rest
- IVFD Nacl 0,9 20gtt - O2 2-4 lpm (NK)
- IV omeprazole - Diet Ginjal 6x200cc / hr
40mg/24j - IVFD NaCl 0,9% 30 tpm
- Sukralfat syrup 3x1 (mikro) s/s Dex 5%
- Dulcolax syr 3xCl - IVFD Eas Sfrimer 1fls post
- Transfusi PRC sp HB HD
> 10g/dl - IV Lansoprazole 30 mg/24
- Balance Cairan jam
- Amlodipine 1x5 mg
- Asam folat 2x400 mcg
- Lenal ace 2x169 mg
- Bicnat 3x500 mg
- Haloperidol 1 x 0,5 mg (sore)
- Drip Fluconazole 500mg/24j
- Drip albumin 25%/24jam
- Nystatin drops 4x2cc
- HD (Selasa Kamis Sabtu)
- Balance cairan
- Bos Primer (post hd)
- Gabapentin 1x100mg
- Cefepime 1gr/8j

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/ A/ Dyspepsia type like ulcer


1.PSMBA ec dd/ 1. Sirosis hepatis 1.Kolestasis intra dan ekstra dd/- mixed
1.Gastritis erosif std hepatik ec massa caput -dismotilitas
2. Ulcus gaster diskompensata pankreas - Hipertensi stage II
3.Ulcus duodenum dengan 2. Obs Jaundice ec dd Ca
2. Fatty liver degenerasi Caput pankreas
3.Hipertensi malignan 3. Anemia Sedang ec dd
2. DM tipe 2 NW penyakit kronis Th/
Th/ Th/ 4. Hipoalbuminemia - Bedrest
- IVFD NaCl 0,9% 20tpm - Iv. Omeprazole 5. Asites ec hipoalbumin - IVFD RL 20 gtt/i
- Bedrest 40 mg/12 jam - Domperidon 3x10mg
- Diet MII 1700kkal/hari - Lactulac syr 3xCI Th/ - Omeprazole 40mg/12
- IV Omeprazole 40 mg/ 12 - Sc levemir 0-0-0- - Bedrest jam
jam 20 - Diet hati 1700 kkal/ hari , - Antasidasyr 3xC1
- Sucralfat syr 3Xci - Sc novorapid 10- extra putih telur - Amlodipine 1x10mg
10-16 - IVFD Nacl 0,9% 30 gtt/i - Gabapentin 1x300mg
Lab 25-06-2019 - Spironolacton - Dekstrose 10 % 1 fls / 24 - Clinimix + Clinoloid
Hb/Ht/E/L/T 2x1 jam 1fls /hari
18,2/51/6,1/5,6/246 - Aminofusin 1 - IV Omeprazole 40mg/12j - Tutofusin drip 20gtt/i
MCV/MCH/MCHC fls/12 jam - IVFD Aminofusin Hepar 1
85/30/35 fls / 24 jam
Diftell : 2/1/0/57/24/16 - Furosemid 20 mg / 24 jam Lab 27/06/2019
HBSAG Anti HCV negatif - Curcuma 3x1 HB/HT/E/L/T :
Alb 5,54 - Tramadol 50mg 2x1 11,8/32/4/7,3/389
Gds 111 - Ketorolac syr 3xcl mCV/MCH/MCHC : 80/30/37
Na/K/Cl : 133/3,8/106 Diftel : 3/1/0/52/34/10
Ur/Cr : 33/1,32 PT/kontrol:14.1/13,1
Lab 26/06/2019 APTT/kontrol 32,5/36,5
Alb 2,63 UR/CR 12/1,3
Na/K/Cl 135/4,2/109 Na/K/Cl : 136/4/111
Lab 22/06/2019 Hbsag hcv negatif
HB/HT/E/L/T :
9,8/26/3,1/7,2/200
mCV/MCH/MCHC :
82/32/38
Diftel : 2/1/0/73/15/9
GDS : 123
UR/CR 24/0,55
Na/K/Cl : 136/3,8/110
SGOT/SGPT : 146/82
Alb : 2,66
K5B1 K5B2 K5B3 K5B4
K5B5
DPJP : dr. Islamuddin, DPJP: dr. Kurnia F. Jamil, DPJP :dr. T Mamfaluti DPJP : dr. Kurnia, sp.PD DPJP: dr. Azhari
Sp.PD Sp.PD SPPD COW : dr. Rahmi
COW : dr. Febri COW : dr. rahmi COW : dr. T. M. Reza DR : dr. Wahyu Gani SPPD
DR : dr. Akmal DR : dr. wahyu DR : dr. Okdimur Raber : COW: dr. Rahmi
Raber: THT
Nama: Ibrahim Muhammad Nama: M Nurdin Rusli Nama: Suryanullah Zainuddin Nama: Husaini Nurdin Dr:Furqan
Nama: dr. Wahyu
Abdullah
TTL : 31/12/1957 (61 thn) TTL : 7/7/1986 (32 thn) TTL : 17/7/1985 TTL : 30/05/1963(56thn) TTL : 01/11/1991(27
Alamat : Bireun Alamat : Aceh Besar Alamat :Bireuen Alamat :Aceh Pidie thn)
CM : 1-17-05-97 CM : 1-21-29-7 CM : 1163405 CM : 1-21-05-52 Alamat : bireun
Hari Rawatan :5 Hari Rawatan :2 Hari rawatan : 6 Hari Rawatan :11 CM : 1-20-31-05
Hari Rawatan :6
A/ A/ A/ A/
1.PSMBA ec dd/ 1. Leukositosis ec dd - Struma nodusa toksik 1.
dd/ A/ pansitopenia ec dd/
-gastritis erosive - CML - DM tipe 2 -
Trombositosis esensial -anemia aplastic
-ulcus gaster - LLL - Hiponatremi -
Trombositosis relatif -leukemia
-ulcus duodenum - AML 2.
Varises vena safena -MDS
2.Anemia berate c dd/ 2. Hipernatremio Ringan Th/ magna sinistra et vena
-perdarahan 3. AKI stage 1 prerenal - Tirah baring tibialis anterior Th/
-peny.kronik 4. Kesadaran menurunan ec - Diet sonde 6x200 cc/hari 3. Hematuria ec dd/ -Bedrest
3.AKI Stage 3 dd Acute on dd - Iv ceftriaxone 2gr/24j - Isk -IVFD RL 20 gtt/i
CKD - Meningitis - IV Digoxin 0,25 mg/8jam - Bsk -iv.omeprazole 40mg/12
4.Hipertensi terkontrol - Stroke - Sc levemir 0-0-0-22 unit - Ca Buli jam
5.Post stroke (6tahun) - Metastase proses - Sc Apidra 3-3-3-3-3-3 4. Hiperkalemia ringan - Sucralfat Sir 3x CL
- Imbalance Elektrolit - Propanolol tab 2x40mg - IV ondansentron
Th/ - IVFD nacl 0,9 20tpm Th/ 4mg/8j
- Bed rest Th/ - Thyrozal tab 1x20mg - Bedrest -Paracetamol 500mg
- IVFD 0,9% NACL - Bedrest Lab 27-06-2019 - IVFD NaCl 0,9% 20tpm extra
- Lansoprazole30mg/12 - O2 2-4l/menit Free t4/TSHs : 19,38/0,018 - Diet MB 1700 kkal/hr -tranfusi PRC sampai
jam - Diet sonde 6x200cc - omeprazole 2x20mg HB > 10gr/dl
- Sucralfat syrup 3Xci - IVFD sol 2L1 gtt/i Lab 25-06-2019 - domperidone 3x10mg
- Transfusi prc sd - Paracetamol 3x500mg Hb/Ht/E/L/T - aspilet 1x80mg Lab 27-6-2019
HB>10gr/dl - Paracetamol 1gr (extra) 15,8/47/5,6/31,7/245 - Kalitake 3x1 sach Hb/Ht/L/T
- Meropenem 2gr/24j MCV/MCH/MCHC - Cytodrox 1x500mg 8,0/23/0,7/37
84/28/34 - Drip heparin 300 MCV/MCH/MCHC
Lab 29-6-2019 Diftell : 0/0/1/87/7/5 unit/24jam (h3) diberikan 83/29/35
Hb/L/T Lab 29-6-2019 GDS 448 selama 5-7 hari (saran dari Diftell
10.2/9,6/220 Hb/Ht/E/L/T : Ur/Cr 35/0,63 BTKV) 0/0/0/11/84/5
MCV/MCH 77/26 12.2/37/4.3/129,9/571 Na/K/Cl 125/5,6/103
Diftel 2/0/0/74/16/8 MCV/MCH/MCHC : Lab 27-06-2019
Ur/Cr: 22/2,8 86/28/33 T4 19,38 Lab 25-6-2019 Lab 25-6-2019
Diftel : 1/12/0/75/10/2 TSHs 0,018 Hb/Ht/L/T Hb/Ht/L/T
Lab 27-6-2019 Kalsium : 9.1 15,3/49/34,9/1535 6,9/20/2,1/53
Hb/L/T Na/K/Cl : 147/4.4/107 Albumin: 4,73 Diftell
7,5/7,9/141 Ur/Cr 69/1.23 Ur/cr: 23/0,99 0/0/0/3/92/5
MCV/MCH 77/27 Na/K/Cl PT/APTT
Diftel 2/0/0/77/14/7 136/5,9/110 14,50/32,60
MDT GDs: 173
Anemia hipokrom Ur/Cr
mikrositer dengan Lab 23-6-2019 44/1,15
trombositopenia Hb/Ht/L/T Na/K/Cl
Kolestoral total/LDL 15,2/48/6,3/34,8/1704 135/3,9/109
88/54 MCV/MCH/MCHC : 77/24/31
Trigliserid 103
Lab 20-6-2019
Lab 25-6-2019 Hb/Ht/L/T
PT/APTT 14/43/29200/1.220.000
14,40/29,30 MCV/MCH/MCHC : 80/25/31
HBsAG: Negatif
Anti HCV: Negatif URINALISA
GDs: 126 Leukosit/darah: +/+
Ur/Cr: 100/3,80 Eritrosit: 250-270
Na/K/Cl: 144/3,8/115
Lab 21-6-2019
PT/APTT: 16,70/50,80
K6B1 K6B2 K6B3 K6B4 K6B5
DPJP :dr. T Mamfaluti DPJP: dr. Hendra Z,Sp.PD DPJP: dr. Azhari Gani SPPD KOSONG PER 02:00 DPJP UROLOGI
SPPD COW : dr. T. M. Reza COW: dr. Rahmi
COW : dr. T. M. Reza DR : dr. Okdimur Dr: dr. Wahyu
DR : dr. Okdimur Raber: GEH

Nama: Kamaludin Idris Nama: Rahmad Saman Nama: M. Yati


TTL: 24/7/2001 (17Thn) TTL : 1/7/1983 (35th) TTL: 01-07-1951
Alamat: Gayo Lues Alamat : Gayo Lues Alamat: Aceh Selatan
CM: 1-21-24-64 CM : 0941205 CM: 1-21-22-28
Hari Rawatan: 6 Hari Rawatan :5 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