Sie sind auf Seite 1von 7

AQSHA 3 (PENYAKIT DALAM WANITA)

Hari/Tanggal : Sabtu, 30 Juni 2019


Dokter Jaga : dr. Riza/ dr. Supri
Dokter Muda Jaga : Terah/Hiya

K1B1 K1B2 K1B3 K1B4


DPJP : dr. Mahriani SpPD DPJP : dr. Price Maya, Sp. PD DPJP: dr. Mahriani, SPPD DPJP : dr. M. Fuad, Sp.PD
COW : dr. Nadi COW : dr. Cut COW: dr. Nadi COW :
DR : dr. Reyza Dr : dr. Husna Dr : dr. Reyza DR : dr. Taufik
Raber : Raber : Obgyn Raber : EMD Raber :
Nama :Rukaiyah Insya Nama : Desi Susanti Nama: Sarinten M Harun Nama : Cut Rahimah
Umur 31/12/1945 (73thn) Umur : 36 th Umur: 24/1/1941 (78th) Umur : 69thn
CM : 1-21-25-64 CM : 1-21-29-26 CM: 0-99-50-57 CM :1118120
Alamat : Aceh Pidie Alamat : Aceh Besar Alamat: Mibo Alamat : BandaAceh
Hari rawatan : 4 Hari rawatan : 2 Hari rawatan: 4 Hari rawatan : 4

A/ A/ A/ A/
1. Penurunan kesadaran 1. Anemia sedang hipokrom mikrositer 1. Penurunan kesadaran ec dd/ - Anemia sedang hipokrom
(perbaikan) ec dd/ e.c. dd/ - HE mikrositer ec dd/
- SDA - Defisiensi besi - Sepsis 1. Defisiensibesi
- Uremic encefalopati - Penyakit kronik 2. PSMBA ec dd 2. Penyakitkronis
- Sepsis 2. Pneumonia (CAP) - Varises esophagus bleeding - Pro repair pen TKR
2. SDA ec dd/ 3. Post partum 2 hari (P4A0) - Varises fundus bleeding - Hipertensi stage 2
- Infeksi 4. Obs febris ec dd/ - Gastropati HT porta
- Metabolic acute - demam dengue 2. Sirosis hepatic std DC childpugh Th/
- CVD - Pneumonia B related hep. C - Bedrest
3. ISK - ISK 3. Hiponatremia berat - Diet MB 1700kkal/hari
4. Geriatric problem - Infeksi viral - IVFD Tutofusin 20gtt/i
(inanisi, insomnia, 5. Hipnatremia hipoosmolar Th/ - Paracetamol 3x500 mg
immobilisasi hipovolemik - Diet sonde 6x200cc - Transfusi PRC s/d Hb >10gr/dL
5. HHD + iskemik 4. Hipokalemia ringan - IV ceftotaxime 1gr/12 j - Valsartan 1x80 mg
inferolateral - IV furosemide 40mg/12j - Transfusi PRC s/d Hb 10 gr/dL
6. AKI stg 2 Th/ - Drip omz 80 mg dengan srynge
- Bedrest pump kecepatan 6,5 cc/j Lab 27/06/19
Th/ - Diet MB 1700 kkal/hari - IV vit k 1amp/8j Hb/Ht/E/L/Tr: 9,9/32/4,3/5,6/325
- IVFD NaCl 0,9% 30gtt/i - IVFD NaCl 0,9% 20 tpm -oseotide MCV/MCH/MCHC :
- Diet sonde TKTPm6x200cc - KSR 1x600 mg - flumicyl 3x200 752331
@200kkal - IV Ceftriaxone 2 gr/24 jam - lactulac 3x30 cc Diftel: 5/1/0/71/16/7
- O2 2-4l/i nasal kanul - drip albumin 15% 100cc/hr
- Iv. Ciprofloxacin Lab 29/6/19 - IVFD aminofusin hepar 1fls/hr Lab 26/06/19
200mg/12jam SGOT/SGPT : 163/45 - Lantus 10 unit (Exra) 16.00 wib Hb/Ht/E/L/Tr: 7,9/27/3,5/5,7/401
- IV Omeprazole MCV/MCH/MCHC :
40mg/24jam Lab 28/6/19 Lab 29/6/19 77/23/30
- Flumucyl tab 3x1 Hb/Ht/E/L/T Ca : 8,3 Diftel: 3/0/1/69/20/7
- Bicnat 3x500mg 8,6/25/4,2/9,2/134 Na/K/Cl : 139/42/110 Besi : 13
- Amlodipin 1x10mg MCV/MCH/MCHC : 61/21/34
- Naletal 1x40mg Diftel: 0/0/0/88/10/2 Lab 28/6/19 Lab 27/6/19
GDS: 102 SGOT/SGPT : 65/21 Urinalisa: Leukosit (+)
Lab 27/4/2019 UR/Cr: 32/0,49 Bil. Total/direk/indirek : Feses: dalam batas normal
Alb : 2,61 Na/K/Cl: 131/3,4/105 10,09/4,7/5,39
Ca/Na/K/Cl : 8,8/142/3,9/107 Alb : 1,80

Lab 25/4/2019 Lab 26/6/19


Hb/Ht/E/L/Tr: Hb/Ht/E/L/T
11,8/33/3,8/17,2/497 12.2/32/3.6/17.4/86
MCV/MCH/MCHC : Diftel: 0/1/0/88/5/6
85/31/36 PT/APTT: 23.80/ 41.80
Diftel: 1/1/0/85/5/8 Anti HCV/HBSAG: +/-
Ur/cr : 100/2,18 GDS: 248
GDS : 108 UR/Cr: 62/1.32
Na/K/Cl : 134/5,4/107 Na/K/Cl: 120/4.1/95

Lab 26/06/19
Urinalisis
Leukosit / Protein : + / +1
Glukosa / Keton : - /-
Nitrit ; -
Urobilinogen / Darah :- / +
Sedimen
leukosit: 8-10 LPB
Eritrosit :90-100
Epitel :4-6
Sel Ragi : +
K2B1 K2B2 K2B3 K2B4 K2B5
DPJP: dr. M Darma SPPD DPJP : dr. Abdullah, DPJP : dr. Masralena, Sp. DPJP : dr. M Darma, DPJP : dr. Masra lena,
COW: dr. Aziz Sp.PD PD Sp.PD Sp.PD
Dr. : dr. Riza COW : dr. Nadi COW : dr. Aziz COW : dr. Aziz COW : dr. Aziz
Dr : dr. Reyza DR :dr. Riza DR : dr. Riza DR : dr. Riza
Raber : Raber : Raber : Raber :
Nama:Mardhiah Daud Nama : Ruhamah Abdullah Nama : Siti Jariah Nama :Nuraini Ali usman Nama :Andiah M Yusuf
Umur: 01/07/1964(54 th) Umur : 58 th Umur : 16/01/1953 (66 th) Umur :73 Umur : 18-7-1964 (65thn)
CM: 1-00-04-50 CM : 1-21-29-27 CM : 1-21-27-20 CM :1212211 CM : 12124533
Alamat: Aceh Besar Alamat : Sabang Alamat :Aceh Utara Alamat :aceh besar Alamat :bireun
Hari rawatan: 4 Hari rawatan : 2 Hari rawatan : 2 Harirawatan: 9 Hari Rawatan: 6

A/ A/ A/ A/ A/
1. Penurunan Kesadaran ec. 1. Hipertensi emergency dd 1. Ascites e.c.d.d. 1. Massa right lower 1. Pneumonia(perbaikan)
Dd urgensi - Malignansi quadran ec dd/ 2. Geriatri problem
- SDA 2. CKD Stage 5 e.c.d.d. - Meigh Syndrome -ca colon (inanisi, infeksi,
- Sepsis - HN - Sirosis hepatis -ca renal imobilisasi, instabilitas
- Stroke - PGOI - TB peritoneal -ca ovarium dan jatuh, impairment of
2. Sepsis ec dd/ 3. Susp. Carotid artery 2. Massa intra abdomen ec 2. anemia ringan hpokrim vision)
- Pneumonia disease ec hypertiroid dd/ mikrositer ec dd/ 3. Hipokalemia
2. Urosepsis 4. HHD - Ca colon - peny kronis 4. Hipoalbuminemia
3. SDA ec dd/ 5. Pneumonia (CAP) - Ca ovarium - defisiensi besi
- Infeksi - Ca endometrium 3. Hipoalbuminemia Th/
-Dehidrasi Th/ - Ca omentum sedang - Bed rest
- - Bedrest - Colonqua sarkoma 4. Hiponatremia - Diet lunak 1700 kkal /hari
3. Aki stg II pre renal - Diet ginjal 1700kkal + hipoosmolar hipovolemik - IVFD NaCl 0,9% 20 tpm
4. Anemia sedang 0,6 gr protein/hari Th/ 5. Geriatri problem - IV omeprazole 40 mg/12
5. HHD - Threeway - Bedrest (inanisi, instabilitas dan jam
- IV Perdipine 10 mg dlm - Threeway jatuh,immobilisasi) - iv metokloprmidide amp
Th/ 50 cc NaCl 0,9% 0,5 - IV furosemide 20 mg/8 jam (k/p)
- Bedrest micro/KgBB/I  3,25 - Spironolakton 1x100 mg Th/ - fluimucil 3x200 mg
- O2 2-4 lpm (NK) cc/jam - bedrest - Paracetamol 3x500 mg
- IVFD NaCl 0,9% 20 gtt/i - Amlodipin 1x10 mg Lab 27/06/2019 - diet MB TKTP 1700 - ksr 3x600 mg
- Levofloxacin 1x500 mg - Lenal ace 2x169 mg Hb/Ht/E/L/Tr: kkal/hr - spironolakton 2x25 mg
- IV Ceftazidin 1 gr/8 jam - Tab bicat 2x1 9,8/29/3,4/7,6/199 - IVFD NaCl 0,9% - valsartan 1x80 mg
- IV paracetamol 1 gr/8 jam - IV. Ceftriaxone 2 gr/24 MCV/MCH/MCHC : 30gtt/i - IV Ceftriaxone 1 gr/12 jam
- HCT 25 mg 1x1 jam 85/29/34 - Paracetamol - Attapulgite 1x1
- Adalat oros 30 mg 1x1 Diftel: 1/1/0/66/25/7 3x500mg - Ondancentron 4mg/8jam
Lab 28/06/2019 HbsAg/Anti HCV : -/- - Levofloxacin 1x500 - Sinbio 3x1
Lab 27/6/2019 Hb/Ht/E/L/Tr: Ca/Na/K/Cl : mg - KCL 25 meq dlm 500cc
Hb/Ht/E/L/Tr: 9,2/26/3,2/9,3/429 8,4/145/4,2/111 - IV. Ondancentron 4 NaCl 0,9% 24 jam
9.7/29/3.9/17.6/315 MCV/MCH/MCHC : GDS : 114 mg/8jam
MCV/MCH/MCHC : 81/29/36 Ur/Cr : 23/1,11 Lab 29/06/2019
76/25/33 Diftel: 1/0/0/82/13/4 Lab 23/06/2019 Hb/Ht/E/L/Tr:
GDS:124 HbsAg/Anti HCV : -/- Hb/Ht/E/L/Tr: 10,6/31/3,6/3,0/186
Ur/Cr: 78/2.94 Ca/Na/K/Cl : 10,4/30/3,9/8/326 MCV/MCH/MCHC :
Na/K/Cl: 141/4.8/111 8,7/147/4,4/116 MCV/MCH/MCHC : 85/29/34
GDS : 123 77/26/34 Diftel: 0/0/0/60/28/12
Ur/Cr : 189/8,76 Diftel: 0/1/0/83/12/4 Albumin: 2,47
Na/K/Cl : 145/ 2,3/ 106
Lab 22/06/2019
Hb/Ht/E/L/Tr:
Lab 25/06/2019
8,7/26/3,4/8,5/402
Hb/Ht/E/L/Tr:
MCV/MCH/MCHC :
9110,9/32/3,7/6,2/45194
76/26/34
MCV/MCH/MCHC :
Diftel: 0/0/0/82/12/6
85/29/34
Albumin: 2,54
Diftel: 33/0/1/68/18/10
Ur/Cr: 35/1,12
Albumin: 2,76
Na/K/Cl : 125/3,9/99
GDS : 124
Lab 23/06/2019 Ur/Cr: 15/0,45
Hb/Ht/E/L/Tr: Na/K/Cl : 138/ 2,6/ 107
0,4/30/3,9/8,0/326
MCV/MCH/MCHC : Lab 26/06/19
77/26/34 Urinalisis
Diftel: 0/1/0/83/12/4 Leukosit / Protein : -/ -
Glukosa / Keton : - /-
Nitrit ; -
Urobilinogen / Darah :- / -
Sedimen
leukosit: 1-2
Eritrosit :0-1
Epitel :2-3
K3B1 K3B2 K3B3 K3B4 K3B5
DPJP : dr. Diana Erlita, DPJP : dr. Diana,Sp.PD DPJP : dr. Price Maya, DPJP : dr. Mahriani, Sp.PD
Sp.PD COW : dr. Cut Sp.PD COW : dr. Nadi
COW : dr. Cut DR : dr. Husna COW : dr. Cut Dr : dr. Reyza
DR : dr. Husna Raber: GEH DR : dr. Husna Raber :
Raber : Raber : Geriatri, alergi,
neurologi, RM
Nama : Roswati Nama : Yusriah abd manaf Nama : Salbiah Basyah M Nama : Marsa Putri
Umur:49 tahun Umur: 47th Umur : 60thn Umur : 03/11/1993 (25 th)
CM: 1-20-23-89 CM: 1212242 CM :0493226 CM : 1-16-03-06
Alamat: Aceh Besar Alamat : Pidie Jaya Alamat : Banda Raya Alamat : Aceh Besar
Hari rawatan : 7 Hari rawatan : 8 Hari rawatan: 11 Hari rawatan : 3
A/
1.Penurunan kesadaran e.c A/ A/ A/
dd/ 1. Stroke, 2. sepsis - Massa intra abdomen ec - Sepsis e.c. pneumonia 1. Ascites gr. 3 e.c.d.d.
2.sepsis e.c dd/ 1. pneumoni, meigh syndrom + ISK - Hipoalbuminemia
2. urosepsis - Post parasintesis a.i. - Pneumonia dd infeksi - TB peritoneum
3. post PSMBA e.c dd/ Ascites paru sp - Limfoma maligna
1.uremic bleeding, 2. ulcus - Dyspepsia type like - Meigh Syndrome
gaster Th/ ulcer dd/ 2. Anemia aplastic
4. anemia ringan NN e.c -Bedrest 1. Type mimanafxed
PGK dd/ perdarahan - Diet MB 1500 kkal/ hari 2. Type dismotiliti Th/
5. AKI atage 3 prerenal dd/ - IV ceftriaxone 1gr/12j - Hipoalbumin sedang - Furosemide 1x40 mg
diabetik nefropati - IV furosemid 1 amp/12j - Geriatri - Spironolacton 2x100 mg
6. trombositopenia e.c dd/ 1. - IV omeprazole 1 vial/12j problem(inanisi,
Konsumtion coagulopati - drip tramadol 1 amp infeksi, instabilitas Lab 27/06/2019
7. charcot foot pedis dextra dalam 500 cc NaCl 0,9% dan jatuh) Hb/Ht/E/L/T
8. DM type II obese 20 tpm - OA genu grade III-IV 8,3/25/2,9/2,9/33
9. CHF NYHA II-III ec dd 1. -fosen enema (extra) bilateral MCV/MCH/MCHC
HHD, 2. IHD -lactulac syr 3xIC 86/29/33
10. HT Emergency Th/ Diftel: 0/0/1/60/28/11
11. Infark di batang otak Lab 27/6/2019 - Bedrest
12. Hipernatremia Hb/Ht/E/L/T : - Inj. omepreaole Lab 27/06/2019
hyperosmolar hipervolemik 11,2/35/4,0/9,2/619 40mg/12j Hb/Ht/E/L/T
MCV/MCH/MCHC : - Inj ondansetron 4mg/8j 5,9/18/2/2,6/35
Th/ 87/28/32 - Paracetamol 3x500mg MCV/MCH/MCHC
-Bedrest Difftell : 1/0//0/78/12/9 k/p 88/30/34
-NGT kateter Ca : 7,7 - Sucralfa tsyr 3 x CI Diftel: 0/0/0/56/34/10
- Diet sonde ginjal 1700 Na/K/Cl : 143/3,8/100 - Nystatin 3 x 1 cc HbsAg/Anti HCV: -/-
kkl/hari - Cetrizine 1x10mg Ur/Cr: 9/0,18
- O2 2-4 L nasal kanul Lab 25/6/2019 - Iv ceftriaxone 2gr/24j Ca/Na/K/Cl: 7,6/139/3,5/111
-IVFD NACL 0,9 % 20 gtt/i Ca125 : 195,07 - Fosen enema GDS : 101
-iv meropenem gr/8 ajam SGOT/SGPT : 23/25 - Attapulgit 1 tab/BAB
Iv omeprazole 40 mg/12 jam - Sinbio 3x1
- sc lantus 0-0-0-10 iu Lab 22/06/2019 - Albumin 25%
- sc apidra 3-3-3-3-3-3 Hb/Ht/E/L/T 100cc/hari
- mikardis 11x80 mg 11,5/35/4,1/11,7/867 - Mecobalamin
-sucralfat syr 3X CI MCV/MCH/MCHC 500mg/12jam
-herbesser CD IX200 mg 85/28/33 - Gabapentin 2x300mg
- nebul ventolin 11 resp /12j Diftel: 1/0/1/77/13/8 - Fitbon 1 tab 1x1
- fluimucil syrup 3x C2 GDS: 155 - Ventoline 1 resp/hari
- citikolin 2X500 Ur/Cr: 26/0,78 - Flexotide 1 resp/hari
- Clopidogrel 1x75mg Na/K/Cl: 133/3,6/106
- Drip perdipin 1 amp Lab 27/06/2019
- Clopidogrel 75mg 1x1 Lab 27/06/2019 Free T4 14,80
- Spironolakton 25 mg 1x1 Hb/Ht/E/L/T TSHs 1,489
- IV. Furosemid 20 mg/6jam 11.2/35/4,0/9.2/619 Bil. Total : 0,25
Lab 27/06/19 MCV/MCH/MCHC Direct/indirect : 0,11/0,14
Ca : 7.3 87/28/32 Albumin : 2,47
Ur/Cr : 168/2.26 Diftel: 1/0/0/78/12/9 Kolestrol
Na/K/Cl : 158/3.3/125 Na/K/Cl/Ca: total/LDL/Trigliserida :
Lab 26/06/19 143/3.8/100/7.7 164/112/235
Urinalisis : Leukosit / Protein Ca/Mg : 7,4/1,9
: +/ +1 Glukosa / Keton : - Asam urat : 5,6
/+,Nitrit ; -,Urobilinogen /
Darah :- / +.Sedimen Lab 25/06/2019
:leukosit: 20-25,Eritrosit :10- Hb/Ht/E/L/T
15,Epitel :4-6,Sel Ragi : + 11,3/35/4,2/10,6/230
Lab 23/06/2019 MCV/MCH/MCHC
Hb/Ht/E/L/T 85/27/32
11,9/35/4,1/10,4/46 Diftel: 1/0/0/78/11/10
MCV/MCH/MCHC Na/K/Cl: 139/3,3/113
85/29/34 Lab 19/06/2019
Diftel: 0/1/0/86/9/4 Hb/Ht/E/L/T
GDS : 373 12,2/37/4,4/13,9/272
Alb: 2,7 Alb: 2,7
PT/kontrol/INR: 13,5/13,4/1 Ur/Cr: 22/0,41
APTT/kontrol: 25,9/33,7
AGDA : Ph: 7,501,pCO2 : Lab 21/06/2019
25,7,pO2 : 245,HCO3 : 20,3 Urinalisa
total CO2 : 21,1 Protein : +1
BE: -1,2 Nitrit :Positif
Saturasi O2 : 99,1 Bakteri :Positif
K4B1 K4B2 K4B3 K4B4 K4B5
DPJP : dr. Mahriani,Sp.PD DPJP : dr. Diana Erlita, DPJP : dr. Masralena DPJP : dr. Darma,Sp.PD DPJP : dr. Price
COW : dr. Nadi Sp.PD ,Sp.PD COW : dr. Aziz Maya,Sp.PD
DR : dr. Reyza COW : dr. Cut COW : dr. Aziz DR : dr. Riza COW : dr. Cut
Raber : Dr : dr. Husna DR : dr. Riza Raber: DR : dr. Husna
Raber : Raber: Raber :
Nama: Shandy Gita H Nama : Wira Astuti Nama: Halimah Marahumah Nama: Rosmaniah Usman Nama: Nurjannah Hasyem
Umur: 10/11/1991 (27 th) Umur : 25 th Umur: 31/12/1956 Umur: 32thn Umur: 71 th
CM: 1-08-11-15 CM : 1-21-24-72 CM:1-21-28-47 CM: 1-21-24-67 CM: 1-20-76-46
Alamat: Aceh Tamiang Alamat : Aceh Tamiang Alamat: Lhokseumawe Alamat: Aceh Utara Alamat: Aceh Pidie
Hari Rawatan: 4 Hari rawatan : 6 Hari rawatan: 2 Hari rawatan: 6 Hari Rawatan: 2

A/ A/ A/ A/ A/
1. SLE derajat berat dengan 1. Dispepsia tipe like ulcer 1. Penurunan kesadaran 1. Susp SLE dd APS 1.Obs febris ec dd/
melibatkan kulit dd/ ec.d.d. 2. Hipokalemia berat - Demam dengue
- tipe mixed - Sepsis 3. Hipoalbuminemia berat - Demam chikungnya
Th/ - Tipe dismotility - Uremic ensefalopati - Tonsilofaringitis akut
-Bedrest 2. RUQ pain e.c.d.d. - Stroke Th/ 2. Geriatri problem
- IVFD NaCl 9.0% 20ppm - Dispepsia 2. Sepsis e.c.d.d. -Bedrest - instabilitas dan jatuh
- IV Metil prednisolone - ISK - Urosepsis -IVFD NaCl 0,9% 20tpm - Impairment of vision
250mg/12j (H2) - Pneumonia (HAP) - Diet MB 1700kkal/hari - inanisi
- IV Omeprazole 40mg/12j Th/ 3. ISK - Inj. Omeprazole 3. Post ORIF a/I fr. Neck
- Ostriol 2x1 - Diet MII 1700 kkal.hari 4. AKI stage 3 dd. Acute on 40mg/12jam femur sinistra
- Ca. Laktat 2x1 - IVFD NaCl 0,9% 20 gtt/i CKD - Paracetamol 3x500mg 4. Hiponatremia hipoosmolar
- As. Folat 2x1 - IV omeprazole 40 mg/12 5. Hipertensi on therapy - Drip Albumin 25% hipovolemik (128)
-Nistatin drop 3xCI jam (HHD) 100cc/24jam
- Domperidone 3x10 mg 6. Asidosis metabolic - KSR 2x600mg Th/
Lab 25/6/2019 - Paracetamol 3x500 mg kompensasi Drip KCL dalam 500cc - Bedrest
Hb/Ht/E/L/T: - Sukralfat syr 3xCII NaCl 0,9% / hari - Diet Sonde 6x200 cc/hari
7,6/22/3,0/1,2/67 - Kaltropen sup k/p Th/ - IVFD NaCl 0,9% 20 gtt/i
MCV/MCH/MCHC: 76/26/34 - Lactulac syr 3xCI - Bed rest Lab (25/6/19) - Paracetamol 3x500mg
Diftel: 0/0/0/79/10/11 - Alprazolam 0,25 mg (k/p) - NGT, kateter Hb/Ht/E/L/T : - Citicolin 1 gr/12 jam
SGOT/SGPT : 33/116 - Diet sonde 6x200 cc/hari 7,8/23/2,6/5,7/191 - Ranitidin 1 amp/12 jam
Albumin : 2,67 Lab (27/6/19) - Threeway MCV/MCH/MCHC : - Ceftraixone 1 gr/12 jam
HDL/LDL/Trigli : 46/70/124 Free T4/TSHs : 11,14/2,478 - IV Omeprazole 87/30/34
Ur/Cr : 55/0,81 40mg/12jam Diftell : 3/1/0/67/25/4 Lab (28/6/19)
Na/K/Cl :141/48/111 Lab (26/6/19) - IV meropenem 1 gr/8 jam Albumin : 2,38 Hb/Ht/E/L/T:
Urinalisa - Drip paracetamol 1 gr (k/p) Ca : 7,0 12,8/37/5,2/3,4/117
Lab (28/6/19) Keton (+) - Paracetamol 3x500mg Na/K/Cl : 144/2,7/109 MCV/MCH/MCHC: 71/25/34
Urinalisa - IV furosemide 40mg/8jam Diftel: 1/1/0/64/23/11
Keton : 5 Lab (25/6/19) Lab (27/6/19) GDS : 97
Darah : 50 Hb/Ht/E/L/T: Lab (28/6/19) RF : negative Ur/Cr : 32/0,42
11,8/34/4.3/9,1/294 Anti HCV : negative Ca/Na/K/Cl : Na/K/Cl : 128/3,8/93
MCV/MCH/MCHC: HBsAg : Negatif 6,6/142/1,7/106
79/27/35
Diftel: 1/0/1/55/38/8,8 Lab (28/6/19) Lab (25/6/19)
HbsAg/Anti HCV : -/- pH/pCO2/pO2 : Leukosit (-)
Bil. Total/direk/indirek : 7,277/28.80/57 Protein (-)
0,56/0,16/0,4 Bikarbonat : 13,6 Darah (-)
SGOT/SGPT : 20/19 Total CO2 : 14,5
GDS : 102 BE : -11,3 Lab (25/6/19)
Ur/Cr : 8/0,64 Saturasi O2 : 85,2 Hb/Ht/E/L/T :
Na/K/Cl : 140/3,8/115 10/29/3,3/12,3/185
Lab (28/6/19) MCV/MCH : 85/30/35
Hb/Ht/E/L/T: Diftell : 0/0/0/90/8/2
10,2/29/3,4/29/67 CRP kualitatif : +
MCV/MCH/MCHC: GDS : 96
87/30/35 Ur/cr : 19/0,41
Diftel: 0/0/0/88/7/5 Na/K/Cl : 135/-/105
GDS : 70
Ur/Cr : 225/8,64 Lab 26-6-2019
Na/K/Cl : 144/4,9/113 Albumin : 1,52

Lab (28/6/19) Lab 27-6-19


Analisa gas darah Faktor Reumatoid: Negatif
pH : 7,277 Na/K/Cl/Ca:
pCO2 : 28,8 142/1.7/106/6.6
pO2 : 57
HCO3 : 13,6
Total CO2 : 14,5
BE : -11,3
Sat. O2 : 85,2
K5B1 K5B2 K5B3 K5B4 K5B5
DPJP : dr.Diana Erlita, DPJP : dr. Abdullah, Sp. DPJP : dr.Price Maya,
Sp.PD PD Sp.PD
COW : dr. Cut COW : dr. Nadi COW : dr. Cut
DR : dr Husna Dr : dr. Reyza DR : dr Husna
Raber: Raber : HOM Raber: Geriatri
Nama : Rubama M. Saman Nama : Rubiah Puziono Nama ::Fatimah Syam
Umur : 61thn Umur : 43 th Umur : 07/03/1952 (67th)
CM : 0697674 CM : 1-21-28-48 CM : 1-03-90-19
Alamat : aceh besar Alamat : Aceh Tengah Alamat : Aceh Besar
Hari rawatan : 6 Hari rawatan : 2 Hari rawatan : 4

A/ A/ A/
1. Anemia berat e.c dd/ 1. Ca Mammae post stage 1. Penurunan kesadaran
- Occult bleeding Kemoterapi 8 siklus dengan ec.dd
- Defisiensi besi regimen : 1. Sepsis
- Penyakit kronik - Doxorubicin 2. Stroke
2. PSMBA e.c dd/ - Pashtaxed 3. SDA
1. Ulcus gaster 2. Efusi pleura bilateral ec 2. Sepsis ec dd/
2. Ulcus duodenum, dd/ 3. ISK
3. Gastritis erosif, - Metastase proses 4. Pneumonia
- Ca paru 3. LBBB
Th/ - Pleuro pneumonia 4. Hipokalemia ringan
- Bed rest 3. dd/ 1. Limfedema 5. Geratri problem (inaisi,
- Diet MII 1700kkal/hari extremitas sup sinistra imobilisais, insabilitas dan
- IVFD RL 20 gtt/i 2. DVT jatuh)
- IV omeprazole 2x40 mg 4. DM type II
- domperidon 3x10 mg tab 5. Heigh risk trombosis Th//
- Sucralfat Syr 3xC1 5. Bedrest
- Lactulac Syr 1xC1 Th/ 6. Diet sonde 6x200
- Bedrest 7. IVFD NaCl 0.9% 20gtt
Lab 28/06/2019 - O2 3 lpm 8. IVFD Clinimix 1 fl/hari
Hb/Ht/E/L/T: - Diet MB 1700 kkal/hari 9. Domperidon 3x10
10,5/32/4,2/2,9/112 - IVFD NaCl 0,9% 10 gtt/i 10. KSR 1x600
MCV/MCH/MCHC : 77/25/33
Diftel: 8/0/0/50/34/8 Lab 26/06/2019
Lab 28/06/2019 Hb/Ht/E/L/Tr:
Lab 26/06/19 Hb/Ht/E/L/Tr: 11.4/32/3.5/4.9/207
Urinalisis 13,8/42/4,8/6,8/274 MCV/MCH/MCHC :
Leukosit / Protein : -/- MCV/MCH/MCHC : 89/32//36
Glukosa / Keton : - /- 88/29/33 Diftel: 3/1/0/66/21/9
Nitrit ; - Diftel: 2/1/0/61/26/10 GDS : 97
Urobilinogen / Darah :- /- Alb : 3,4 UR/CR : 32/0.92
Sedimen GDS : 207 Na/K/Cl : 138/3.6/107
leukosit: 1-2 Ur/Cr : 21/0,27
Eritrosit :0-1 Na/K/Cl : 144/3,8/103
Epitel :3-5

Tinja rutin : dalam batas


normal

Lab 24/06/2019
Hb/Ht/E/L/T: 3/10/1,5/6,/183
MCV/MCH/MCHC : 67/20/30
Diftel: 0/0/0/84/10/6
Ur/Cr : 28/0,56
Na/K/Cl : 135/3,5/111
Anti HCV : negatif
HbsAg : negatif
GDS : 144
K6B1 K6B2 K6B3 K6B4 K6B5
DPJP : dr. M. Darma, DPJP : dr. Abdullah Sp.PD DPJP : dr. Mahriani,Sp.PD DPJP : dr. M. Darma, DPJP : dr. Mahriani, Sp.PD
SpPD COW: dr. Nadi COW : dr. Nadi SpPD COW : dr.Nadi
COW : dr. Aziz DR : dr. Reyza DR : dr. Reyza COW : dr. Aziz DR : dr. Reyza
DR : dr. Riza Raber : Raber : B.Vaskular DR : dr. Riza Raber : Endokrin
Raber: Raber: GEH
Nama: Jasmani Abdullah Nama : Nuraini H Daud Nama : Rukiah Yahya Nama : Basyariah Ali Nama : Aminah Daman
Umur: 04/08/1959 (59 thn) Umur : 50 thn Umur : 1-7-1956 (62 thn) Umur : 1/7/1958 (60thn) Umur : 06-06-1960 (59h)
CM: 1-21-22-90 CM : 1-21-26-87 CM : 1-21-18-47 CM : 1-21-25-93 CM :1-21-26-88
Alamat: Aceh Besar Alamat : Aceh Utara Alamat : Bireuen Alamat : Aceh Utara Alamat : Langkat
Hari rawatan: 7 Hari rawatan : 4 Hari rawatan : 11 Hari rawatan : 4 Hari rawatan : 3

A/ A/ A/ A/ A/
1. CKD stage V dengan 1. Obs jaundice ec dd 1.Penurunan kesadaran 1. Hepatomegali ec dd/ 1. Massa mediastinum dd/
uremic syndrome - Hematoma (perbaikan) e.c dd - Hepatoma - Ca thyroid
(prebaikan) e.c.d.d. - Ca caput pancreas - Sepsis - Abses hepar - Lymphom maligna
- DN - Koledolitiasis - Uremic ensefalopati 2. Anemia sedang ec dd/ 2. Dispepsia tipe
- GNC 2. Hepatomegali ec dd/ 2.Sepsis e.c dd - Penyakit kronik dysmotility dd tipe mix
2. DM tipe II NW - HCC -urosepsis - Perdarahan 3. HAP
3. Anemia sedang ec PGK - Metastase proses -pneumonia 3. Asites ec dd/ 4. HT stg II
4. ISK 3. PSMBA ec dd/ 3.CKD stage V dengan - Hipoalbuminemia
5. Hiponatremia - Varises esofagus uremicsyndrome HD reguler - Sirosis hepar Th/
6. Hiperkalemia bleeding E.c dd - Meigh syndrome 1. Bedrest
- Varises fundus -PGOI 4. Nefrolitiasis sinistra 2. Diet MII 1700kkal/hari
Th/ bleeding -HN 3. IVFD NaCl 0,9% 20tpm
- Bedrest - Gastropati hipertensi 4.Anemia ringan HM ec Th/ 4. IV Prosogan 30mg/24jam
- O2 2-4 lpm portal penyakit kronik dd def. Fe - Bedrest 5. Inj Ceftriaxone 2gr/24jam
- Diet ginjal 1700 kkal/hari + 4. DM type II dengan 5. Nefrolitihiasis Sinistra - Diet MII 6. Valsartan 1x160mg
0,6 gr protein/kgBB/hari hipoglikemia - IVFD NaCl 0,9% 20tpm
- IVFD NaCl 3% 15 tpm 5. Hipokalemia ringan Th/ - Inj Omeprazole Lab 28/06/2019
- SC novorapid 8-8-8 - Bed rest 40mg/24jam Free T4/TSH : 18,47/2,65
- Lenal ace 2x169 mg Th/ - Diet sonde 6x200 cc/hari - IV Cefoperazone
- asam folat 2x400 mcg - Bedrest - O2 2-3lpm Sulbactam 1 gr/ 8 jam Lab 28/06/2019
- IV Ca Gluconas 1 amp - Diet Hati II 1500kkal - IVFD NaCl 0,9% 10 gtt/i - Parasetamol 3x500mg Free T4/TSH : 14,42/0,546
(extra) - Insersi NGT - IV Omeprazole 40 mg/12 j - MST 2x15mg
- Kalitake sachet 3x1 - IVFD Nacl 0.9% 20gtt - Asamfolat 2 x 400 mcg - IV Cefoperazone 1 gr/8 Lab 26/06/2019
- lasix 20 mg/8 jam iv - SUkralfat syr 3x1 - Bicnat 3 x 500 mg jam Hb/Ht/E/T/L:
- IV Omeprazole 40 mg/12 - IV OMZ 40g/24j - IV Meropeem 1 gr/8jam 13,3/40/4,8/16/304
jam - IVFD Aminofusin hepar (H10) Lab 27/6/2019 MCV/MCH/MCHC: 83/28/34
-. ondasentron 4 mg/8 jam 1fls/24j - HD : senin, rabu, jumat Hb/Ht/E/T/L: Diftel: 0/1/0/90/7/2
- iv ceftriaxone 2 gr/24 jam - Ksr 2x600mg 9/26/3.2/14.9/233 GDS : 142
- sc Lantus 0-0-0-10 - Lactulose 2x30 cc Lab 29/06/2019 MCV/MCH/MCHC: Ur/Cr : 70/0,96
- Inj ceftriaxone 2gr/24 jam Hb/Ht/E/L/T : 83/29/35 Na/K/Cl: 140/3,8/113
Lab 26/06/19 - Sucralfat syr 3xCI 6,9/22/2,8/11,9/202 Diftel: 1/0/1/72/15/11
Urinalisis - Sc Hazelin 0-0-0-12 Unit MCV/MCH/MCHC : Urinalisis : warna kuning Lab 27/6/19
Leukosit / Protein : +/ +1 78/25/32 jernih, berat jenis 1.010, pH Free T4: 14.42
Glukosa / Keton : - /+ Lab 28/6/2019 Difftell : 1/1//1/77/10/10 5, leukosit 1-2, eritrosit 0- TSHs: 0.546
Nitrit ; - PT/APTT : 13,90/33,10 Albumin : 2,28 1,epitel 2-3
Urobilinogen / Darah :- / + Ca : 8,6
Sedimen Lab 26/6/2019 Ur/Cr : 64/4,99 Lab 26/6/2019
leukosit: 50-60 Urinalisa Na/K/Cl : 141/3,9/103 Hb/Ht/E/T/L:
Eritrosit :8-10 Protein : - Lab 24/6/19 9,1/28/3,4/17,8/269
Epitel :4-6 Leukosit : - Hb/Ht/E/L/T : MCV/MCH/MCHC:
Granular Cast : + Darah : - 9,1/28/3,6/11,4/30 81/27/33
MCV/MCH : 76/25/33 Diftel: 1/1/0/71/14/12
Lab 24/06/19 Lab 26/6/2019 Difftell : 1/1//0/83/8/7 GDS : 108
Hb/Ht/E/L/T Hb/Ht/E/T/L: Ur/Cr : 230/7,33 Ur/Cr : 42/1,34
8,1/23/3/278/21,3 8/22/2,8/12,3/530 Na/K/Cl : 143/5,1/115 Na/K/Cl: 139/4,1/115
MCV/MCH/MCHC MCV/MCH/MCHC: Lab 20/06/19 SGOT/SGPT : 129/53
79/27/35 78/28/36 Beratjenis 1,005
Diftel: 1/1//0/85/8/5 Diftel: 2/1/0/76/18/3 pH 6,0
Ur/Cr: 197/12,89 GDS : 296 nitrit (-)
Na/K/Cl: 120/5,5/97 Ur/Cr : 86/1,17 protein (+)
HbA1C 14,9 Na/K/Cl: 140/3/116 keton (-)
HbsAg/Anti HCV : -/- glukosa (-)
Lab 20/06/19 Bil Tot/Bil D/ Bil Ind : urobilinogen (-)
Na/K/Cl: 116/5,7/94 26,48/16,48/10 epitel 4-6
GDS : 494 SGOT/SGPT : 165/95 warnakuning
Ca : 9,7 Protein tot/Alb/Glob : darah (+)
Anti HCV : negatif 6,96/2,92/4,04 leu 120-130
HbsAg : negatif eri 3-5
Lab 27/6/19 lekosit (+)
Urinalisa makroskopik dalam bilirubin (-)
batas normal Lab 19/6/19
Epitel: 3-5 Hb/Ht/E/L/T :
9,2/27/3,6/15,1/16
MCV/MCH : 76/26
Difftell : 0/0/0/94/3/3
Ur/Cr : 171/6,9
Na/K/Cl : 145/5,2/115
GDS L 33