Denah Ruang Rawat

AQSHA 2 (Penyakit Dalam Pria)

Hari/Tanggal : Selasa 11 September 2018
Dokter Jaga : dr. Indra/ dr. Muna
Dokter Muda : Yulia /Ikrima

K1B1 K1B2 K1B3 K1B4

DPJP : dr. M. Riswan Sp.PD, KHOM DPJP : dr. M. Darma Muda Sp.PD DPJP : dr. M. Riswan Sp.PD, KHOM DPJP : dr. M. Riswan Sp.PD, KHOM
COW :dr. Yuni COW :dr. Yuni COW :dr. Yuni COW :dr. Yuni
DR : dr. Dilla DR : dr. Dilla DR : dr. Dilla DR : dr. Dilla
DM : Alfi DM : Alfi DM : Alfi DM : Alfi
Nama: Muamar M Nama : Ibrahim A Nama : Ibrahim Yusuf Nama: Mulyadinsyah
TTL : 12/9/1979 TTL : 18/12/1988 TTL : 01/07/1968 TTL: 8/5/1967
Alamat: Sigli Alamat: Aceh Jaya Alamat: Aceh Besar Alamat: Banda Aceh
Pekerjaan: Polisi CM: 1121939 CM: 1144459 Pekerjaan: Wiraswasta
CM: 1183931 Pekerjaan: Mahasiswa Pekerjaan: swasta CM: 1110187
Hari rawatan: 5 Hari rawatan :1 Hari rawatan : 1 Hari rawatan: 5

As/ A/ A/ A/
1. cholesistitis dengan colesistitis (sup) 1. HCAP Pneumonia 1. Hipertensi emergency 1.CKD stage V ec dd/
2. Nefrolitiasis Sinistra 2. CKD Stage V on HD regular 2. CKD stage V on HD Reguler 1.HN
3. Asites ec dd 3. Pneumonia 2.PNC
- Hipoalbuminemia 4. Iskemik Lateral On HD regular dengan edema paru
Th/ - Related hep B akut (perbaikan)
- bedrest - SBP Th/ 2.Hipertensi stage II
- diet M II rendah lemak 1700 kkal/ hari 4. Diare akut ec dd - Bedrest 3.HCAP
- IV cefoperazone sulbactame 1 gr/12 - Intoleransi makanan - Diet ginjal 1700 kkal/hr + 60 gr 4. ISK
jam (H4) - Disentri basiler protein/hari 5. Flebitis
- IV omeprazole 40 mg/ 12 jam - Rota virus - O2 2-4 liter tpm
- urdafalk 3 x 500 mg - IFVD Nacl 0,9% 20 gtt Th/
- kaltopren sup (k/p) Th/ - Iv ceftriaxone 2gr/24jam - Bedrest semiflowler
- drip tramadol 1 amp+ NaCl 0,9% 20 - Bedrest - Lenal ace 2x1 - O2 2-4 l/i
gtt  Continue - Diet ginjal 1700 kkal/hari + 60 - As folat 2x400mg - Diet ginjal 1700kkal/hari + 60gr
- Sucralfat syr 3 x CII gram protein/ hari - Amlodipine 1x10mg protein/hari
- Threeway - Valsartan 1x160mg - threeway
Lab/06/09/2018 - IV Ceftriaxone 2gr/24 jam - Balance cairan - lenal ace 2x1
HB/Ht/E/L/Tr - IV Omeprazole 40mg/12 jam - HD ( rabu-sabtu) - asam folat 2x1
12,9/37/4,5/12,6/238 - PCT 3x 500mg - Transfuse PRC 2 kolf on HD - amlodipin 1x10
MCV/MCH/MCHC - As. Folat 2x 400mg - Azytromicin 1x500mg - valsartan 1x160mg
82/29/35 - Lenal Ace 2x169 mg - Paracetamol 500mg (extra) - Bisoprolol 1x5mg
Diftell: 1/0/0/78/13/8 - Attapulgit 1 tab tiap bab cair max - Omeprazole 40mg/iv - hytrin 1x2mg
BT/CT: 2/7 12 tab/hari - Drip pct 1gr/8jam - hemodialisa (senin-kamis)
GDS: 123 - HD senin-kamis - ISDN 3x5mg - Clindamicyn 3 x 300 mg
Ur/Cr: 19/0,75 - Flumucyl 3x1 - Furosemid tab 40-40-0
Na/K/Cl: 146/3,5/107 Lab 10/09/2018
Lab 06/09/2018 Hb/Ht/E/L/Tr Urinalisi 07/09/2018
Hb/Ht/E/L/Tr 7,0/21/2,5/14,2/121 Ph: 8,0
10,1/30/3,4/187/9,5 MCV/MCH/MCHC Protein +2
MCV/MCH/MCHC 84/28/34 Glukosa +1
88/30/34 Diftell: 0/0/0/90/3/7
Diftell: 0/0/0/83/9/8 Lab 06/09/2018
Na/K/Cl: 145/3,3/100 Hb/Ht/E/L/Tr
Alb : 3,22 9,6/29/3,3/13,3/261
GDS : 170 MCV/MCH/MCHC
Ur/Cr : 74/8,00 85/29/34
Diftell: 13/1/1/66/15/4
GDS: 168
Ur/Cr: 89/13,09
Na/K/Cl: 150/4,2/108

Urinalisis: (07/09/2018)
Warna/ jernih: Kuning, Keruh
BJ/pH: 1,015/8,0
Leu/Prot/Glu/Darah: +/+2/+1/ +
Ket/Nit/Uro/Bil: - / - / - / -
Sedimen urin
Leu/erit/epi: 20-25/ 8-10/ 6-8
 K2B1
DPJP :dr. M.Riswan
Sp.PD,KHOM
COW :dr. Andi
DR : dr. Wahyu
DM : Willa
Nama : Kamaruzzaman
MY
TTL : 9/12/ 1971
Alamat: Aceh Besar
Pekerjaan: Petani
CM : 1134974
Hari rawatan : 5
A/
1. Pansitopenia ec dd/
1.Sirosis Hepatis
2.Anemia Aplastik
3.Leukimia akut
4. MDS
2. PSMBA ec dd/
1. varises esofagus
bleeding
2. varises fundus bleeding
3. consumption
koagulopati
4. gastropati hipertensi
portal
3.hipoalbuminemia (2,4)
4. Sirosis hepatis
5. HE grade 1 ec dd
- perdarahan
-Imbalance elektrolit
-dehidrasi
Th/
- bedrest
-diet MII 1700kkal/hari +
ekstra putih telur 3
-IVFD NaCl 0,9%
20gtt/menit
-IV omeprazole
40mg/12jam
-sucralfat syr 3xcII
-transfusi PRC sd
hb>10g/dl
-tansfusi TC 10kolf
-spironolacton 2x100mg
-Drip pct 1gr/8j extra
-Transfusi TC 10 kolf jika
sudah ada stok kosong
Premed dexa
-comafusin hepar 1fl/hr
Lab (10-9-2018)
Hb/Ht/Er/L/Tr
7,7/24/2,7/1,5/19
MCV/MCH/MCHC
87/28/33
Diftell : 1/0/0/74/12/13
Alb : 3,28
Ca: 7,7
Na/K/Cl : 142/4,8/104
Lab (8-9-2018)
Hb/Ht/Er/L/Tr
6,6/20/2,3/1,1/16
MCV/MCH/MCHC
86/29/34/16,4/9,0
Diftell : 4/0/0/66/18/12
Lab (7-9-2018)
MDT
eritrosit : NN
Leukosit : leukopenia
Trombosit : menurun
Aptt /pt: 38,9/ 1,16
Hbsag (-)
Anti HCV (-)
K2B2 K2B3 K2B4 K2B5
DPJP :dr. M.Riswan DPJP : dr. M. Riswan Sp.PD, KHOM DPJP : dr. M. Riswan DPJP : dr. M. Riswan
Sp.PD,KHOM COW :dr. Andi Sp.PD, KHOM Sp.PD, KHOM
COW :dr. Andi DR : dr. Wahyu COW :dr. Andi COW :dr. Andi
DR : dr. Wahyu DM : Willa DR : dr. Wahyu DR : dr. Wahyu
DM : Willa DM : Willa DM : Willa
Nama : Muchtar Yahya Nama : Sukamto Sukarjo Nama : M. Ali Ismail
TTL : 10/12/1958 TTL: 1/7/1974 TTL: 1/7/1940
Alamat: Bireun Alamat: Aceh Tengah Alamat: Pidie Jaya
Pekerjaan: pedagang Pekerjaan: Petani Pekerjaan: Petani
CM : 1183697 CM : 1183597 CM : 1183687
Hari rawatan : 1 Hari rawatan : 7 Hari rawatan : 3
A/ A/ A/
1. CKD stage V ec dd 1. PSMBA ec. Dd/ 1. Penurunan kesadaran ec
- Hipertensi nefropati 1.heparin reduced dd:
- PNC 2. stress ulcer 1. SDA
3. ulkus gaster
2. CHF FC NYHA II ec DCM 2. Sepsis
4. ulkus duodenum
3. Dm tipe 2 normoweight 2. Anemia berat NN ec PGK 3. Imbalance elektrolit
4. Pneumonia dd tb paru dengan 3. CKD stage V ec dd/ 2. Sepsis ec dd
infeksi sekunder - HN 1. Pneumonia
5. VR Moderate - PNC 2. Urosepsis
6. TR moderate 4. HAP dd TB paru dengan 3. Pneumonia Geriatri
7. Efusi pleura dextra ec CHF infeksi sekunder 4. Geriatric Problem
8. AF RVR 5. Hipertensi stage II on (infeksi, instabilitas jatuh,
9. Dispepsia dd therapy immobilisasi)
6. ISK asimtomatik
- Ulcus gaster
- Ulcus duodenum th/
Th/
- Gastritis erosif - Bedrest
- Bedrest
- NGT, kateter
-Diet Ginjal sonde 6x200cc
Th/ - O2 2-4 L/mnt
via NGT 1200kkal/hari
- bedrest - Diet sonde 6x200cc
+Protein 60gr/hari
- -O2 2-4 L/I nasal kanul - IVFD RL 20 gtt/i
- NGT dekompresi  bila
- NGT kateter hitam, puasa 6 jam hingga - Drip pct 1gr (k/p)
- -Diet sonde ginjal 6x200 cc + 50 gr NGT bersih - Iv omeprazole 40 mg / 12 j
protein - IVFD NACl 0,9 % 10 gtt/ i - Iv meropenem 1gr/8j
- Bisoprolol 2x5mg - IV. Ceftriaxone 2 gr/12j - Flumucyl 3x1
- ISDN 3x5mg (H7) - n. ventolin / 8 j
- Lenal ace 2x169 mg - Drip omeprazole 80 mg - atalpulgit 2 tab kp
dalam 48 cc nacl 0,9%
- CPG 1x75 mg - Lenal ace 2x169 mg - transfuse prc s/d hn >
- Valsartan 1x160mg - As. Folat 2x400 mg 10gr/dl
- Hyroz 1x2mg - Amlodipin 1x10mg tab - iv cefepim 1 gr/8jam
- IV Omeprazole 40mg/12jam - Valsartan 1x80mg
- Sumiarc 1x2 mg - Hemodialisa ( selasa-kamis-
- Digoxin 1x0,25mg sabtu) free heparin lab (9/9/2018)
- Transfuse PRC sd Hb >10
- Sucralfat syr 3xci hb/ht/e/l/trom
gr/dl
- HD (senin –kamis) - Balance cairan seimbang 7,6/25/3,0/4,7/60
- Drip human albumin 25% - Spoling ngt dgn NACL MCV/MCH/MCHC
150cc sampai ngt 82/25/31
Lab 09/09/2018 bersih/8jam diftel 2/0/0/34/41/23
Albumin : 2,38 - Mulai diet sonde ginjal na/k/cl
Ca : 7,5 6x200cc via ngt tutup 153/4,5/106
selama 4 jam .
Ca: 7,7
- Sucralfat syr 3x30cc viat
ngt/ 8jam Ur/Cr : 53/0,66
Lab 08/09/2018 - IV Dexametason extra
hb/ht/e/l/trom lab (7/9/2018)
9,1/27/3,0/11,3/204 Lab 7/9/2018 hb/ht/e/l/trom
MCV/MCH/MCHC PT/APTT 8,6/28/3,4/7,9/102
90/30/33 1,00/40,1 MCV/MCH/MCHC
diftel 2/0/0/66/23/9 Hb/ht/e/t/l 81/25/31
Ur/Cr : 115/6,98 5,616/2,0/173/14,9 diftel 2/0/0/51/28/19
As. Urat : 6,0 MCV/MCH/MCHC na/k/cl 156/4,7/109
LED : 21 81/28/35
ur/cr
209/18,88
na/k/cl
140/4,5/107
Lab 05/09/2018
Hb/Ht/Er/L/Tr
5,5/15/1,9/15,6/152
MCV/MCH/MCHC/LED
77/29/37/100
Diftell : 2/0/0/86/5/7
Alb/Ca/Ur/Cr/As.urat
3,04/8,6/255/23,16/11,8
Na/K/Cl : 132/4,6/101
Urinalisis 05.09.2018
Warna/ jernih: Kuning,
Keruh
BJ/pH: 1,015/7
Leu/Prot/Glu/Darah: +/+1
/+3 / -
Ket/Nit/Uro/Bil: - / - / - / -
Sedimen: Leu/erit/epi: 10-
15/6-8/ 4-6
 K3B1 K3B2 K3B3 K3B4 K3B5
PJP : dr.M. Diah, Sp.PD-KKV DPJP : dr.M. Diah, Sp.PD- DPJP : dr.M. Diah, Sp.PD- DPJP : dr.M. Diah, Sp.PD- DPJP : dr.M. Diah, Sp.PD-
COW : dr. andi KKV KKV KKV KKV
DR : dr. irwandi COW : dr. Andi COW : dr. Andi COW : dr. Andi COW : dr. Andi
DM : Syelza DR : dr. Irwandi DR : dr. Irwandi DR : dr. Irwandi DR : dr. Irwandi
DM : Syelza DM : Syelza DM : Syelza DM : Syelza

Nama: Bustami Jafaruddin Nama: Zakwan Nama : Rusli Yusuf Nama : Mahdi Mahmud Nama : tgk marsyuddin
TTL: 18/5/1987 TTL: 21/10/1994 TTL : 8/8/1946 TTL : 15/7/1960 TTL : 7/9/1960
Alamat: banda aceh Alamat: Nagan Raya Alamat: Banda Aceh Alamat: Pidie Alamat: aceh utara
Pekerjaan: wiraswasta Pekerjaan: Wiraswasta Pekerjaan: Pensiunan Pekerjaan: petani/pekebun Pekerjaan: petani
CM: 1096467 CM: 1184097 CM :0-87-74-44 CM : 1145348 CM : 0879570
Hari rawatan: 6 Hari rawatan: 2 Hari rawatan: 8 Hari rawatan: 17 Hari rawatan: 11

A/ A/ A/ A/ A/
1.CAPD terinfeksi dengan 1. Massa ar colli sinistra ec dd: 1. Hepatomegali dd hepatoma 1. selulitis a/r cruris sinistra
peritonitis local -. Ca. Nasofaring 2. Pneumonia CAP dd TB 1. PSMBA (perbaikan) ec
dd/ DVT
2. CKD stg V ec. PNC on HD -. Limfoma maligna paru dengan inf sekunder dd
3. PPOK stabil 2. DM tipe 2 normoweight
3. anemia sedang ec. Penyakit -. Abses colli sinistra 3. chest wall tumor 1. varises esofagus
4. Hiperkalemia
kronik 2. Anemia ringan hipokrom 5. Geriatri problem 4. total oklusi arteri tibialis bleeding
4. hipokalemia mikrositer ec dd: (inanisi,infeksi, instabilitas, posterior 2. varises fundus bleeding
5. gangguan pendengaran ec dd 1. Penyakit kronik jatuh) 5. artritis septik ar genu 3. Gastrepati hipertensi
1. Sudden deafness 2. Defisiensi Fe 6. DVT dd selulitis ar cruris porta
sinistra
2. SNAL dextra 2. sirosis hepatis stadium
6. Diare akut Th/ 7. Aki stage 1 prerenal dc related hep B childpugh
Th/
- Bedrest - Bedrest B
Th/
Th/ - Diet sonde 1700 kKal/hari - Diet DM 1700 kkal/hari 3.DM tipe II normoweight
- Bedrest
- bedrest -. IVFD NaCl 0,9% 20 gtt/i -O2 2-4L/i - IVFD Nacl 0,9% 20gtt/menit 4.hemorroid externa grade
- diet ginjal 1700 kkal /hari+ 42 - IV. ceftriaxon 2gr/24 jam -Diet hati II 1700kkal/hr + - Simarc 1x2mg (H13) III
gr protein - Paracetamol 3x500 mg extra putih telur - paracetamol 3x500mg 5.anemia sedang hipokrom
- threeway - IV ondansetron 1 amp (k/p) -IVFD aminofusin hepar 1 - clindamisin 3x300mg (H13) mikrositer ec dd
- PCT 3 x 500 mg -Transfusi prc 1 kolf fls/hr - Kompres luka dengan kasa 1. def fe
- KSR 2 x 600 mg -cetirizine 1x5mg -IV omeprazole 40mg/12j steril + NaCl 0,9% 4 x sehari 2. penyakit kronik.
- Transfuse PRC 1 kolf /hari+ -tyamisin 29%+ mikonazole -IVFD NaCl 0,9% 20 gtt/i - arixtra 1 vial/24 j 6. hepatitis B kronik
premed cream (pagi) -Lactulac syr 3xCI 7. tb paru (tuntas berobat)
- cefepime 500 mg+gentamisin -Tyamisin 20% + -Nebule combivent 1 resp/8j Lab/ 02/09/2018 8.dermatitis seboroik
200mg dlm cairan ketocomazole cream (malam) -nebule flexotide 1 resp/12jam Hb/Ht/E/Tr/L: 9.HE grade I
dialisat/6jam -Pirotop cream (pagi dan -Flumucyl syr 3x200mg 10,4/30/3,3/410/7,1
- Transfusi PRC 1 kolf/hr s/d hn malam ) -IV cefepime 1gr/8j (H6) MCV/MCH/MCHC: Th/
> 10 mg/dl -Duragesic patch 25mcg/3hr 84/29/34 - Bedrest,
- Drip albumin 25 % 1 fl/hari Lab 08/09/2018 (H-5) Diftell:3/1/0/47/38/11 -O2 2-4 lm/hari (nasal
- Attapulgit 2 tab pertama. Hb/Ht/E/L/Tr -MST 2x10mg Albumin: 2,58 kanul)
Selanjutnya 1 tab tiap bab, 9,7/ 28/3,7/29,8 -sc lovenox 0,6 cc/24jam HbsAg : Negatif -diit hati 1700kkal/hari
maksimal 12 tab MCV/MCH/MCHC - simarc 1x2mg Ur/Cr: 15/0,58 -threeway
76/26/35 -dulcolax sup k/p Na/K/Cl :144/4,2/106 -iv furosemide 40mg/8jam
Lab 10/09/2018 Diftell: 0/0/1/90/4/5 -fossen enema (k/p) -iv cefotaxime 1gr/8jam
Hb/Ht/E/L/Tr GDS: 94 -sukralfat syr 3x30cc Lab/ 29/08/2018 (H9)
10,8/32/4,2/144/7,1 Ur/Cr: 18/0,36 Hb/Ht/E/Tr/L: -sc novorapid 8-8-8 unit
MCV/MCH/MCHC Na/K/Cl: 139/3,4/95 Lab 08/09/2018 9,4/27/3,3/477/6,0 (sebelum makan)
75/26/34 Hb/Ht/Er/L/Tr MCV/MCH/MCHC: -sc levemir 0-0-0-10 unit
Diftell: 1/0/1/90/2/6 10,6/31/3,6/17,8/118 83/29/35 -spironolakton 2x200mg
Ca: 7,4 MCV/MCH/MCHC Diftell:6/0/0/79/9/6 -anti hemoroid sup 2x/hari
Ur/Cr: 81/6,63 87/30/34 Albumin: 2,10 -graphalac syr 3x30cc
Na/K/Cl: 135/2,4/95 Diftell: 0/0/0/92/3/5 Hb-A1c: 9,60 -dermanide
GDS : 203 -inersm cream
Lab 06/09/2018 Ur/Cr : 203/1,60 -softuderm
Hb/Ht/E/L/Tr Cl : 99 Transfuse prc s/d
6,6/19/2,6/8,5/172 hb>10gr/dl
MCV/MCH/MCHC Lab 04/09/2018 -propanolol 2x20 mg
73/25/35 Urinalisis: -curcuma 3x1
Diftell: 0/0/0/91/3/6 Warna/ jernih: Kuning, Keruh -IVFD comafusin hepar 1
GDS: 172 BJ/pH: 1,015/6,5 fls/hari
Ur/Cr: 90/7,99 Leu/Prot/Glu/Darah: +/-/- / - -iv omeprazole 40mg/12 j
Na/K/Cl: 131/2,6/92 Ket/Nit/Uro/Bil: - / - / - / - -sukralfat syr 3xc1
Sedimen: Leu/erit/epi: 8-10/1- -paracetamol 3x500mg
2/ 3-5 -desonide
-nerson cream
Lab 03.09.2018 -transfusi prc s/d hb >
Hb/Ht/Er/L/Tr 10gr/dl
10,8/32/3,7/13,0/131 Lab 10.09.2018
MCV/MCH/MCHC Hb/Ht/Er/L/Tr
86/29/34 10,1/32/4,4/114/6,5
Diftell: 0/0/0/86/7/7 MCV/MCH/MCHC
SGOT/SGPT/Alb 75/23/32
55/35/2,86 Diftell: 7/0/0/62/20/11
GDS : 127 Alb : 3,06
Ur/Cr : 112/1,03 Ur/Cr : 34/1,09
Na/K/Cl : 139/5,5/97 Na/K/Cl : 143/3,6/94

Lab 07/09/2018
Hb/Ht/E/L/Tr
8,6/28/3,8/6,3/127
MCV/MCH/MCHC
73/23/31
Diftell: 6/0/0/65/18/11
 K4B1 K4B2 K4B3 K4B4 K4B5
DPJP :dr.M. Diah, Sp.PD- DPJP : dr. M. Darma Sp.PD DPJP : dr.M. Diah, Sp.PD- DPJP : dr.M. Diah, Sp.PD- DPJP : dr.M. Diah, Sp.PD-
KKV COW : dr. Andi KKV KKV KKV
COW : dr. Andi DR : dr. Boli COW : dr. Andi COW : dr.Andi COW : dr. Andi
DR : dr. Boli DM : Dessy DR : dr. Boli DR : dr. Boli DR : dr. Boli
DM : Dessy DM : Dessy DM : Dessy DM : Dessy
Nama: Ajir Kurniawan Nama: Budi Hariyanda Nama: Sufriadi Nama: Mustofa Nama : Nurdin
TTL : 6/7/1992 TTL : 14/7/1982 TTL : 10/10/1980 TTL : 2/6/1963 TTL : 1/7/1964
Alamat: simeuleu Alamat: Nagan raya Alamat: Banda Aceh Alamat: Lhoong Alamat : aceh besar
Pekerjaan: pelajar Pekerjaan: wiraswasta Pekerjaan: Wiraswasta Pekerjaan: Petani Pekerjaan : Petani
CM: 1184099 CM: 1183929 CM: 0988329 CM: 1054434 CM : 1183923
Hari rawatan: 3 Hari rawatan: 5 Hari rawatan: 12 Hari rawatan : 4 Hari rawatan : 5

A/ A/ A/ A/ A/
1. Dd/ 1. SLE dengan 1. AKI stg 3 ec intoksikasi 1.Hepatik ensefalopati grade I 1. CHF Fc nyha II-III ec dd 1. penurunan kesadaran ec
manifestasi kulit asam jengkolat ec dd - HHD dd/1. SOL
2. Eritema nodosum 2. Hipoalbumiin (3,0) -imbalance elektrolit - CAD 2. imbalance elektrolit
leprosum -konstipasi - DCM 3. sepsis
3. Sklerosis sistemik 2. Sirosis Hepatis std 2. DM type 2 NW 2. PSMBA ec dd
2.Suspect morbus hansen Th/ decompensate related Hep.B 3. Anemia berat hipokrom -. ulcus gaster
-Bedrest kronik Child Pugh C mikrostier ec dd -. Ulcus duodenum
th / -diet ginjal MB 1900 kkal + 3. Hiponatremi hipoosmolar 1. peny. Kronik -. Stress Ulcer
1. bed rest protein 50 g/hari 4. Hipoalbuminemia 2. def fe 3. hemiparese dextra ec dd -
2. diet mb 1700 kkal/hari - IVFD Nacl 0,9 % 1500 5. Varises esophagus grade III 4. AKI stage 1 pre renal SOL
3. IVFD Nacl 0,9 % 20 gtt/i cc/hari 6.Anemia normokrom 4. massa a.r inguinal sinistra
4. metilprednisolon 3x16mg -balance cairan normositer ec dd penyakit ec.dd/
5.nistatin drop 4x2cc -iv furosemide 1 amp/8jam kronis Th/ 1. Lifoma
6.threeway -Bicnat tab 3x1 -bedrest 2. Limfadenitis
7.mecobalamin 2x50mg Th/ - diet jantung 1700 kkal rendah 5. anemia sedang NN
8.na diklofenat 2x1 Lab 09/09/2018 -Bedrest garam 6. susp. ISK
9.fitban 2x1 Ur/Cr : 129/10,52 -Diet hati1900 kkal/hr - O2 2-4 L /i
10.Tryamizin + merson 4 x -IVFD Comafusin hepar 1 -treeway Th
applie ditempat yang merah Lab 06/09/2018 fls/hari - IV furosemide 1amp/ 8 j -bedrest
HB/HT/E/L/Tr -iv cefotaxime 1gr/8jam (h9) - sc novorapid 6-6-6 ui -O2 2-4 l/i
lab ( 8/9/2018) 13,4/ 36/5,2/16,3/215 -graphalac syr 3x CII sc levemir 12 unit (22.00) -IVFD nacl 0,9 % 20 gtt/i
hb/ ht/e/trom/l MCV/MCH/MCHC -Propanolol 2x10mg -tf prc s/d hb >10 gr/dl -drip levofloxacin 750
13,3/41/5,0/494/15,1 69/26/37 -spironolacton 3x200mg -graphalac syr 3xcI mg/24 jam H4
MCV/MCH/MCHC Diftell: 0/0/1/83/8/8 -ksr 1x600mg -Tanapes 1x5mg tab - IV Omeprazole 40 mg /12
83/27/32 BT/CT: 2/7 -fosen enema extra (k/p) jam
diftel 0/0/0/80/15/5 HBsAg: negative -Gabapentin 3x 100 mg Lab 8/09/2018 - IV citicoline 500 mg/12
gds 127 Anti HCV: negative -transfusi prc s/d hb >9 gr/dl HB/Ht/E/L/Tr jam
ur/cr 30/0,67 Albumin: 3,01 4,3/16/2,6/4,7/201 -sucralfat syr 3xcII
na/k/cl GDS: 102 lab ( 9/9/2018) MCV/MCH/MCHC -transfusi PRC sd Hb >
148/5,2/104 Ur/Cr: 134/10,97 hb/ ht/e/trom/l 61/17/27 10gr/dl
Na/K/Cl: 139/4,2/102 7,6/21/2,2/1,4/18 Diftell: 8/0/1/50/28/13 -IV paracetamol 1gr/8jam
MCV/MCH/MCHC GDS: 150 Lab/08/09/2018
1. C 94/34/37 Ur/Cr: 68/1,85 Urinalisa
a diftel 0/1/0/64/20/15 Berat jenis : 1,015
ur/cr 24/0,62 pH: 6,5
g
na/k/cl Protein +1
a
s 131/3,7/97 Sedimen urin
e Leukosit 8-10
r Lab 06/09/18 Eritrosit 1-2
Na/K/Cl : 127/3,5/93 Epitel 6-8
(
2. 1 Urinalisis 05.09.2018 Lab/06/09/2018
Warna/ jernih: Kuning, Keruh Hb/Ht/E/LeuTr
BJ/pH: 1,015/8,0 8,2/26/3,4/11,5/494
Leu/Prot/Glu/Darah: +/+2/+1 / MCV/MCH/MCHC
+ 76/24/32
Ket/Nit/Uro/Bil: - / - / + / - Diftell: 0/0/0/82/8/10
Sedimen: Leu/erit/epi: 20-30/6- Albumin: 2,65
8/4-6 GDS: 141
Bakteri : positif Ur/Cr: 63/0,61
Na/K/Cl: 143/4,4/102
Lab 05-09-2018
Albumin : 2,68

Lab 04-09-2018
Na/K/Cl :127/3,1/92
Lab 29/8/2018
Hb/Ht/E/Tr/L
10,3/26/3,3/38/10,7
MCV/MCH/MCHC
80/32/40
Diftell: 0/1/0/87/4/8
Ur/Cr : 21/0,38
Na/K/Cl : 109/3,2/74
GDS : 152
Alb : 2,4
Globulin : 3,72
PT/APTT : 1,47/2,25
Anti HCV : Negatif
HBsAg : positif
SGOT/SGPT : 57/35
Protein total : 6,12
 K5B1 K5B2 K5B3 K5B4 K5B5
DPJP : Dr.dr. Kurnia F. Jamil, DPJP : Dr.dr. Kurnia F. Jamil, DPJP : Dr.dr. Kurnia F Jamil, DPJP : Dr.dr. Kurnia F Jamil, DPJP : Dr.dr. Kurnia F
M.kes, Sp.PD-KPTI M.kes, Sp.PD-KPTI M.kes, Sp.PD-KPTI M.kes, Sp.PD-KPTI Jamil, M.kes, Sp.PD-KPTI
COW: dr. Ridhawahyuni COW: dr. Ridhawahyuni COW: dr. Ridhawahyuni COW: dr. Ridhawahyuni COW: dr. Ridhawahyuni
Dr : dr. Riza Dr : dr. Riza Dr : dr. Riza Dr : dr. Riza Dr : dr. Riza
DM : Fanina DM : Fanina DM : Fanina DM : Fanina DM : Fanina
Nama : Sulaiman M.Yahya Nama : M. Edi Nama : Sultan Ridwan Nama : Iswani bin Ismail Nama : Arjuna Nyak Umar
TTL : 12/3/1961 TTL: 1/7/1976 TTL; 8/9/1960 TTL; 12/2/1977 TTL:12/12/1970
Alamat: Aceh Barat Alamat : Aceh Utara Alamat : Aceh Tengah Alamat : Nagan Raya Alamat : Aceh Barat
Pekerjaan: PNS CM : 1183220 CM : 1083507 CM : 1183727 CM : 1182948
CM : 1047658 Hari rawatan : 13 Hari rawatan: 3 Hari rawatan : 7 Hari rawatan : 15
Hari rawatan : 8
A/ A/ A/ A/
A/ 1. Cancer pain 1. CKD stage v ec dd 1.Massa intraabdomen ec dd/ 1. CKD stage V on HD
1. CKD stage V on HD reguler 2. Sirosis hepatis dengan - urat nefropati - limfoma maligna dengan uremic syndrome
ec hipertensi Hepatoma -PNC - Ca colon dan edema paru (perbaikan)
2. dd/ 3.PSMBA ec dd 2. Anemia sedang NN ec dd - Ca rectum ec dd/
- Liver sirosis -Varises esofagus -. penyakit kronik 2.Limfadenopati ec dd/ - PNC
- TB peritoneal -varises fundus -. perdarahan - Limfoma maligna - HN
3. Hepatitis C viral -gastropati hipertnsi portal 3. gout artritis - Limfadenitis 2.Hipoalbuminemia
4. Hipertensi stage 2 4.Efusi pleura dextra 4. hiperkalemia (6,1) - Metastase proses 3.Hipertensi stage II
5.AF NVR perbaikan ec dd 3.konstipasi 4. Urtikaria dd/ uremic frost
-hepatic syndrom th/ 4.kolelitiasis dengan 5. Pneumonia
Th/ -pleura pneumonia - bed rest kolesistitis 6. hiperurisemia
- bedrest -Pleuritis TB - treeway 7. Hipokalsemia
-Diet ginjal 1500 kkal+30gr 5.Hepatitis B kronik - diet ginjal 1700 kkal/hr + Th/
protein+ diet rendah 6.Anemia sedang normokrom 30 gram protein -Tirah baring Th/
garam/hari normositer ec dd/ - lenal ace 2x169 mg -Diet MB 1900 kkal -Bedrest
- O2 2-3 lpm -pendarahan - as. Folat 2x400 mcg -IVFD RL 20 gtt/menit - diet ginjal 1700 kkal + 40
- Threeway -Penyakit kronik - iv ceftriaxone 1 g/ 12 j -Paracetamol 3x500mg gr protein/hr
-lenal ace 2x169 mg - bicnat 2x1 -Omeprazole 2x20mg - threeway
-As.folat 2x400mg Th/ - pct 3x500 mg -Domperidone 3x10mg - lenal ace 2x169 mg
-Herbesser CD 1x200mg -Bedrest -tramadol drip/8jam - asam folat 2x400mg
- digogsin 1x 0,125 mg -diet hati II 1700 kkal/hari lab (8/9/2018) - fosen enema (extra) - HD reguler
- codein 2x1 -threeway hb/ht/e/l/t - graphalac syr 3xCII - bisoprolol 1x5 mg
-curcuma 2x1 -IVFD aminofusin hepar 8,2/ 26/ 3,0/44,6/470 -codein 2x10mg - drip albumin 20% 100cc/hr
1fls/hari 10 gtt/menit mcv/mch/mchc -levofloxacin 1x500mg - valsartan 1x160 mg
Lab 06/09/2018 -IV omeprazol 40mg/12jam 86/28/32 - cetrizine 1x10mg
Hb/Ht/E/L/Tr - lactulac syr 3xCI diftel 4/1/0/87/5/3 Lab 08/09/2018 - salisic talk I
9,3/28/3,1/11,0/159 -IV ceftriaxone 2 gr/24j (h10) anti hcv/ hbsag (negative) Hb/Ht/E/L/Tr - amlodipin 1x10 mg
MCV/MCH/MCHC -fosen enema (k/p) alb 2,69 8,0/25/2,8/150/19,2 - allopurinol 1 x 100 mg
90/30/34 -sistenol 3x500mg gds 87 MCV/MCH/MCHC -drip levofloxacin 500mg /48
Diftell: 3/0/0/87/4/6 -curcuma tab 3x1 ur/cr 159 89/29/32 j
Bil.total/direct/indirect -Transfusi prc 1 kolf sd hb > Diftell: 0/1/0/85/5/9 -kalitake 3x1 sach
0,65/0,58/0,77 10gr/dl INR/APTT : 0,89/1,23 - Transfusi PRC 1 kolf/hari
SGOT/SGPT: 24/27 -MST 3 x10mg Alb : 1,55 -Drip ca glukonas 1 amp/12
- Druragesic patch 12,5 mcg/3 Ca: 4,4 jam ( cek ulang ca serum)
hari Ur/Cr: 187/5,85
Lab/3/09/2018 - CPZ 2x12,5 mg Na/K/Cl: 136/4,4/110 Lab 07/09/2018
Hb/Ht/Er/L/Tr -sucralfat syr 3xc1 Hb/Ht/E/L/Tr
9,3/28/3,2/9,6/176 Lab 07/09/2018 7,3/22/2,8/17,3/227
MCV/MCH/MCHC Lab 06/09/2018 Hb/Ht/E/L/Tr MCV/MCH/MCHC
89/30/33 Hb/Ht/E/L/Tr 13,4/40/5,0/6,5/253 81/26/33
GDS : 155 9,2/28/3,5/8,6/488 MCV/MCH/MCHC Diftell: 4/1/0/69/17/9
PT/APTT: 1,22/1,12 MCV/MCH/MCHC 79/27/34 Albumin: 2,23
Protein total/alb/globulin 82/27/32 Diftell: 3/0/0/65/8/24 Ca: 5,6
7,24/3,58 Diftell: 5/0/0/67/18/10 Bil total/direct/indirect Na/K/Cl: 150/3,7/114
Na/K/Cl : 142/5,8/99 Ur/Cr: 27/0,69 0,67/0,37/0,30
Ur/Cr : 209/8,69 Na/K/Cl: 145/5,2/102 SGOT/SGPT: 21/13 Lab/ 31/08/2018
Asam urat :8,4
Lab 05.09.2018
Lab 05.09.2018 Hb/Ht/Er/L/Tr Urinalisis 29.8.2018
Hb/Ht/E/T/L 13,5/40/5,1/7,1/268 Warna/ jernih: Kuning,
8,4/26/3,1/465/10,2 MCV/MCH/MCHC Keruh
MCV/MCH/MCH/LED 79/27/34 BJ/pH: 1,015/7,5
82/27/33/77 GDS : 93 Leu/Prot/Glu/Darah: +/-/- / -
Diftell : 2/0/0/70/18/10 Na/K/Cl : 147/4,4/106 Ket/Nit/Uro/Bil: - / - / / -
PT/APTT : 1,16/2,7 Ur/Cr : 48/1,24 Sedimen:
Ca/Ur/Cr Leu/erit/epi: 10-15/1-2/20-30 2. M
8,8/39/0,68
Na/K/Cl : 136/4,8/108 Lab/ 28/08/2018
Hb/Ht/E/L/Tr
Lab 03.09.2018 9,1/27/3,4/11,4/252
AFP: 35126,46 MCV/MCH/MCHC
79/27/34
Diftell: 15/1/0/64/12/8
GDS: 94
AntiHCV/HbsAg: neg/neg
Ur/cr: 212/19,07
Na/K/Cl: 149/5,0/119
 K6B1 K6B2
DPJP : Dr.dr. Kurnia f jamil, DPJP : Dr.dr. Kurnia f jamil,
M.kes, Sp.PD-KPTI M.kes, Sp.PD-KPTI
COW: dr. Ridhawahyuni COW: dr. Ridhawahyuni
Dr : dr. Ishak Dr : dr. Ishak
DM : Thesa DM : Thesa
Nama : Khairuddin Nama : Zakaria Pirsouw
TTL : 01/12/1962 TTL : 21/4/1969
Alamat: Banda Aceh Alamat: Aceh Timur
CM: 0947660 CM: 11389943
Pekerjaan: swasta Pekerjaan: Wiraswasta
Hari rawatan :1 Hari rawatan : 14
A/ A/
1. gastritis antral berat
2. duodenitis
3.Esofagitis grade B
4. ISK komplikata
5.Nefrolithiasis bilateral
6. CKD stage III ec PGOI
7. spondilo arthrosis lumbalis
Th/
-bedrest
- diet ginjal 1700kkal/hr
- threeway
- IVFD RL 20 gtt/i
- drip ciprofloxacin
200mg/12j (H4)
-Buscopan IV 1 amp/8j (H9)
- lenal ace 2x169mg
- asam folat 2x400mg
- Paracetamol 4x500mg
- Sucralfat syr 4xcII
- Domperidone 3x10 mg
- lactoB 2x2sach
- TransfusiPRC s/d Hb 10
gr/dL
Lab/07/09/2018
Warna/ jernih: Kuning, Keruh
BJ/pH: 1,015/6,5
Leu/Prot/Glu/Darah: +/+1/- / +
Ket/Nit/Uro/Bil: - / - / / -
Sedimen:
Leu/erit/epi: 15-20/6-8/4-6
Lab/07/09/2018
Tinja rutin
Warna/bau: kuning /Khas
Eri/Leu: -/-
Parasit/telur cacing: -/-
Konsistensi : lunak
Lab/ 06/09/2018
Hb/Ht/E/L/Tr
9,6/29/3,8/12,6/240
MCV/MCH/MCHC
76/25/33
Diftell: 1/1/1/67/24/6
Lab 29/8/2018 Ur/Cr: 42/1,63
Hb/Ht/E/L/Tr Lab/31/08/2018
14,6/44/5,3/7,6/283 Hb/Ht/E/Tr/Leu
MCV/MCH/MCHC 8,5/26/3,6/370/10,1
83/28/33 MCV/MCH/MCHC: 74/24/32
Diftell: 16/1/1/46/28/8 Diftell: 2/1/0/61/25/11
CT/BT : 2/7 Ca/Na/K/Cl: 8,5/135/4,8/114
Anti HCV (-) Lab 28.08.2018
HbsAg (-) Hb/Ht/E/Tr/Leu
8,9/27/3,8/346/12,8
MCV/MCH/MCHC: 72/23/33
Diftell:1/0/0/64/23/12
GDS: 111
Ur/Cr: 85/1,62
Na/K/Cl: 137/4,6/104
PT/APTT: 1,06/0,98
HBsAg: negatif
Endoskopi 31.08.2018
Kesimpulan:
- esofagitis grade B
- Gastritis antral berat
- duodenitis
K6B3
DPJP : Dr.dr. Kurnia f jamil,
M.kes, Sp.PD-KPTI
COW: dr. Ridhawahyuni
Dr : dr. Ishak
DM : Thesa
Nama : M. Adam HZ
TTL : 1/7/1942
Alamat: Aceh Jaya
CM: 1183309
Pekerjaan: petani/pekebun
Hari rawatan : 11
A/
1. ISK komplikata
2. Gout artritis
3. AKI Stage 2 prerenal
dd/akut on CKD
4. gross hematuria ec dd/
(perbaikan)
- ruptur uretrae
- BSK
- ISK
5. Candidiasis oral
6. Diare akut
Th/
-bedrest
- diet sonde cair 6 x 200 ml
rendah purin + protein 40
g/hari
-IVFD Nacl 0,9% 10gtt/i
-IV ceftriaxone 3g/24j (H9)
-IV omeprazole 40mg/12j
- IV Paracetamol 1 gr/8 jam
-lenal ace 2x169mg/dl
-asam folat 2x400mg
- nystatin drop 4x 2 cc
-sucralfat syr 3x CI
-IV ondancentron 4 mg/8 jam
- flukonazol 1x100mg (p.oral)
- attalpulgit 1 tab tiap bab cair
- Transfusi PRC s/d Hb>10
g/dL
Lab/06/09/2018
Hb/Ht/E/L/Tr
8,8/28/2,9/27,1/398
MCV/MCH/MCHC
97/31/32
Diftell: 0/0/1/91/5/3
Albumin: 2,57
Ur/Cr: 169/2,51
Lab 03.09.2018
Hb/Ht/E/Tr/Leu
8,4/26/2,7/627/34,4
MCV/MCH/MCHC: 94/31/33
LED: 130
Diftell:1/0/0/92/5/2
Ur/Cr: 228/4,75
Urinalisis
BJ/pH: 1,010/6,5
Leu/Prot/Glu: + / +1 / -
Ket/Nit/Uro/Bil/Darah:
-/-/-/-/+
Sedimen urin
Leu/erit/epi: 20-25/ 10-15/ 6-8
Lab 01-09-2018
Alb : 2,60
Asam urat : 7,7
K6B4 K6B5
DPJP : Dr.dr. Kurnia f jamil, DPJP : Dr.dr. Kurnia f jamil,
M.kes, Sp.PD-KPTI M.kes, Sp.PD-KPTI
COW: dr. Ridhawahyuni COW: dr. Ridhawahyuni
Dr : dr. Ishak Dr : dr. Ishak
DM : Thesa DM : Thesa
Nama : Sunariyo Suir
TTL: 24/6/1973
Alamat: Banda Aceh
Pekerjaan: Karyawan swasta
CM : 1166466
Hari rawatan : 7
A/
1. Pneumonia
2. Ulkus decubitus grd IV a/r
oxygeal
3. sepsis
1. 4. Imobilisasi
2. 5. Malnutrisi
3. 6. Post Stroke Iskemik
4. 7. Anemia sedang Hipokrom
Mikrositer ec dd/
- - Def. Besi
- - Penya. Kronik
- 8.retinopati hipertensi stage 1
- 9. Hipoalbuminemia
- 10.katarak seuilis imatur ODS
Th/
- Bedrest
- Kasur decubitus jika tersedia
- Mobilisasi pasif, mika-
miki/2jam
- NGT-cateter urin, threeway
terpasang
- O2 2-4lpm nasal kanul
- Suction berkala
- Diet sonde cair 6x200 cc
1700 kkal/hr + ekstra putih
telur
- IVFD NaCl 0,9% 20 gtt/i
- IVFD Clinimix+ Clinolic 1
fls/hr 15 gtt/i
- Inj. Ceftazidine 1 gr/8 j (H6)
- Inj. Omeprazole 40 mg/12j
- N asetyl sistein tab 3x200 mg
- Rawat luka tiap hari
- Balance cairan seimbang/24j
- IV citicoline 500mg/12j
- Vit B complex 1x1
- As. Folat 1x1
- Transfusi PRC s/d Hb >10
g/dl
- Operasi tutup defek bila KU
membaik
- Chest fisioterapi
- Drip albumin 25 % 100 ml 1
fls/24 jam (H4)
- Cendo litres 4x1 gtt ODS
Lab 07.09.2018
Hb/Ht/E/Tr/Leu
11,9/36/4,7/6,8/373
MCV/MCH/MCHC: 77/25/33
Diftell:1/0/0/69/23/7
Ferritin: 772,67
Fe:20
SGOT/SGPT:18/14
Alb/Glo: 5,48/2,26
Ca/Mg: 8,8/2.8
GDS: 117
Ur/Cr: 25/0,30
Na/K/Cl: 141/4,4/102
Lab 04.09.2018
Hb/Ht/E/Tr/Leu
7,4/24/3,3/392/8,0
MCV/MCH/MCHC: 72/23/31
Diftell:0/0/1/77/16/6
PT/APTT: 0,98/1,09
GDS: 117
Ur/Cr: 25/0,30
Na/K/Cl: 141/4,4/102