AQSHA 2 (PENYAKIT DALAM PRIA)

Hari / Tanggal : Senin, 23 September 2019

Dokter Jaga : dr. Rizqi/ dr. Akmal
Dokter Muda : Asti/Cut/Rahman

K1B1 K1B2 K1B3 K1B4

DPJP : dr. Price Maya, Sp. PD DPJP : dr. Abdullah, Sp.PD DPJP : dr.Fauzi Yusuf,Sp.PD KGEH DPJP: dr. Diana Erlita, Sp.PD
COW : dr. Karolina COW : dr. Radit COW : dr. Nazaruddin COW: dr. Derina
DR : dr. Nelvi
DR : dr. Nelvi Raber: EMD, RM, Geriatri DR : dr. Rianda DR: dr. Reyza
Raber: GH, Pulmo, Bedah vascular, Raber: Dept. Pulmo, Neuro Raber: EMD, Ortopedi
KKV
Nama: M. Gade Mahmud Nama : Razali M Yacob Nama: M. Dahlan Nama: Isa Ansari
TTL : 12/12/1962 TTL : 02/02/1954 (65th) TTL: 31/12/1967 TTL:01/01/1954(65th)
Alamat : Aceh Besar
Alamat : Banda Aceh CM : 0-97-34-86 Alamat: Aceh Jaya Alamat: Aceh Besar
CM : 0-78-28-23 Hari rawatan : 12 CM: 1219973 CM: 0-92-99-52
Hari rawatan : 11 Hari Rawatan: 18 Hari rawatan: 6
A/
1.Penurunan kesadaran (perbaikan) ec dd
A/ - ISPA
A/ A/
1. CKD stage V on HD regular - Sepsis 1. Prolong fever ec dd/ 1. Ulkus diabetic ar pedis
+Edema paru Akut - Imbalance elektrolit - TB paru sinistra
2. HT on therapy - Stroke - Pneumonia 2. AKI stage 2 dd diabetic
2. SDA dengan pencetus infeksi
3. HCAP ec dd - Malignancy nefropati
3. Pneumonia geriatric dd TB paru
- Bronkiektasi 4. DM tipe 2 NW 2. Pneumonia dd/ TB paru 3. DM tipe 2 NW
- TB paru dan infeksi 5. Geriatri problem 3. Dyspepsia type dismotility dd/ 4. Hipoalbuminemia
sekunder 6. ulcus decubitus grade 2 ar gluteus sinistra type mixed 5. Konstipasi (perbaikan)
4. Efusi Pleura bilateral 7. candidiasis oral 4. Anoreksia (perbaikan) 6. Dispepsia ec gastropati
8. ISK
5. Anemia sedang NN ec dd/ 9. Urosepsis
5. Cepalgia (perbaikan) diabetik
-perdarahan 10. HT on therapy 7. ISK Asimptomatik ec
-penyakit kronis 11. Hipoalbuminemia - Cystitis
12. HHS Th/ - Uretritis
1. Bed Rest 8. pneumonia ec dd
Th/
Th/ - Bedrest 2. Diet MII 1700 kkal/hari - HAP
- Bedrest - IVFD Nacl 0,9% 20tpm 3. IVFD Rl 20gtt/i - Infeksi sekunder
- O2 2 liter (k/p) - Diet sonde 6x 200 kkal/hari 4. IV Levofloxacin 750mg/hari
- Diet ginjal 1700 kkal/hari+ - IV Ceftriaxone 2 gr/ 24 jam 5. Lansoprazole 30 mg/ 12 jam
- IV Lansoprazole 30 mg/12jam
50gr protein 6. Eperison HCL 2x500 Th/
- Flumucyl 200 mg/ 8jam
- threeway - Citicolin 500mg/ 12 jam 7. Paracetamol 1gr/ 8 jam - Bedrest
- Furosemide drip 3 cc/jam - SC Lantus 0-0-0-14 Unit 8. Ondansetron 4gr/8j - Diet DM 1700 kkal/hari +
- Ceftriaxone 1gr/12jam - SC Apidra 3-3-3-3-3-3 unit 9. Neurodex 1tab/24jam ekstra putih telur
- IV Lansoprazole
- KSR 600mg/12 jam
10. Synbio 1tab/24jam - Iv ceftriaxone 750 mg/ 12 jam
- Clinimix 1 flas/24 jam (h7)
30mg/12jam - Burnazin zalf 11. Alprazolam 0,5mg/24j
- Sc novorapid 8-8-8 unit
- Drip NTG 1,5cc/jam - Nystatin drop 4gtt/6jam 12. Gabapentin 100mg/12j
- Sc lantus 0-0-0-12 unit
- Lenal ace 2x169mg - Amlodipin 10mg/24jam 13. Tramadol 50mg/12j
- Xarelto 15mg/24jam - Clindamisin 300mg/24jam
- Asam Folat 2x500 mg/12jam 14. Levofloxacin 750mg/24j - Futrolit/12 jam
- IV Paracetamol (K/P)
- Amlodipine 10 mg/24jam - Fluconazole 200 mg/24 jam 15. Combivent 1fls/12jam - Lactulosa 3xcI
- Drip novorapid 50 unit 3cc/jam 16. Nystatin 2cc/6jam - Domperidone 10mg/8jam
Lab 19/09/2019 17. Dexametason 5mg/ 6 jam - Sucralfat syr 3xCI
S.G.O.T : 165 Lab 21/09/2019 18. Citicolin 500 mg/12 jam - Fosen enema (extra)
Hb/Ht/E/L/T: 9,7/29/3,4/10,2/225
S.G.P.T 85 MCV/MCH/MCHC: 85/29/33
19. Clinimix 1 fls/hari - Transfusi PRC 1 klf
Albumim 3,07 Diftel: 0/1/0/73/22/4
Ur/cr : 31/0,7 Lab 22/09/2019 Lab 20/09/2019
Lab 16/09/2019 Na/K/Cl :149/4,1/117 Hb/Ht/E/L/T: 12/33/4,5/9/363 Hb/Ht/E/L/T: 8,9/26/3,3/23,1/393
MCV/MCH/MCHC: 74/27/36 MCV/MCH/MCHC: 78/27/35
Hb/Ht/E/L/T: 8,1/27/3,3/17,4/248 Diftel: 0/1/0/86/10/3 Diftel: 0/0/1087/6/6
MCV/MCH/MCHC:82/25/30 Lab 21/09/2019 Albumin : 3,3 Kolestreol total/HDL/LDL/TG:
Diftel:1/0/0/77/12/10 AGDA: Ca : 8,5 98/24/73/140
Ur/Cr:61/4,6 Ph: 7,493 Na/K/Cl :141/3,8/103 Ur/Cr : 49/2,17
pco2 :29,90 Na/K/Cl :138/4,9/110
Na/K/Cl :139/3,4/104
po2 : 64 Lab 17/09/2019
HCO3:23,2 Hb/Ht/E/L/T: 12,3/34/4,7/9,4/419 Lab 19/09/2019
Lab 15/09/2019 Total CO2:24,1 Urinalisa
MCV/MCH/MCHC:73/26/36
Ca : 8 BE:0,9 Warna : kuning
Saturasi O2:93,8 Diftel:2/1/0/84/9/4
Ur/Cr: 85/6,20 Berat jenis : 1,018
Na/K/Cl/Ca :132/3,3/94/8,3
Na/K/Cl : 138/4,8/102 Kejernihan : jernih
Lab 19/09/2019 AGDA
Ph : 5,0
Hb/Ht/E/L/T: 11/32/3,9/13,9/267 pH: 7,592 Lekukosit : +
Lab 12/09/2019 MCV/MCH/MCHC: 84/28/34 pCO2: 27,50 Protein : +1
Hb/ht/E/L/T: 8,0/25/3,1/9,3/292 Diftel: 0/1/071/22/6 pO2: 79
Ca : 8,3 Glukosa : +3
MCV/MCH/MCHC: 80/26/32 HCO3: 26,7 Keton : -
Na/K/Cl :148/4,1/111
Diftel: 5/2/0/53/30/10 Urinalisa (19/09/19) Total CO2: 27,6 Nitrit : -
HBsAg : non reaktif Kuning keruh Kelebihan basa (BE): 6,2 Urobilinogen : -
GDS : 108 Leukosit : (+) 15-20 Protein (+1) Saturasi O2: 97,3 Bilirubin : -
Ur/Cr: 43/6,40 Glukosa (+1) Keton (+) Darah : +
Eritrosit 40-50 Ca oksalat : (+) Lab 16/09/2019
Na/K/Cl : 158/5,0/94
Sel ragi (+) S.typhi O: 1/80 Lab 18/09/2019
S.paratyphi CO : 1/80 Hb/Ht/E/L/T: 9,2/26/3,3/24/385
Lab 17/09/2019 MCV/MCH/MCHC: 79/28/36
S.typhi H : 1/320
Bil. total/direk/indirek: 0,62/0,33/0,29 Diftel: 0/0/0/90/6/4
SGOT/SGPT: 19/11 S. paratyphi AH : 1/160
S.Paratyphi CH : 1/320 Albumin: 2,7
Urinalisa
Ur/Cr: 92/3,3
Kuning keruh Lekosit: positif
Protein : positif +1 Glukosa: positif +3 Lab 11/09/2019 Na/K/Cl: 128/6/101
Urobilinogen (+) Darah positif Hb/Ht/E/L/T: 13,0/39/4,7/11/176
Lekosit 30-40 Eritrosit 15-20 MCV/MCH/MCHC: 81/27/34
Epitel 3-5 Kristal fosfat : (+) Sel Diftel: 1/0/0/79/14/6
ragi: positif Ur/cr : 21/0,90
GDS : 103
Na/K/Cl: 133/4,8/98
Anti Dangue IgM : Negatif
Anti dangue IgG : Negatif
K2B1 K2B2 K2B3 K2B4 K2B5
DPJP: dr. Mahriani S,Sp.PD DPJP : dr. Diana Erlita, Sp. DPJP : dr. Price Maya. DPJP : dr. Price Maya, DPJP : dr. Fauzi Yusuf, Sp.PD
KR PD Sp.PD Sp.PD COW : dr.Nazaruddin
COW: dr. Nazaruddin COW : dr. Derina COW : dr. Radit COW : dr. Derina DR : dr. Rianda
DR: dr. Rianda DR : dr. Reyza DR : dr. Nelvi DR : dr. Reyza Raber : HOM,
Raber: GH Raber : KKV,GEH,Bedah Raber : Ortopedi, EMD Raber :
Plastik, bedah vaskular
Nama: Muhammad Khaidir Nama: Jaya Irianto Nama: Abdul hamid Nama: Hamdani AR Nama: Irwan Hasballah
TTL: 05/06/1994(25th) TTL: 25/12/1964 (54) TTL: 31/12/1958 TTL: 12/01/1965 TTL: 10/10/1993
Alamat: Pidie Jaya Alamat: Aceh Besar Alamat: Banda Aceh Alamat: Tapak tuan Alamat: Lhokseumawe
CM: 1-22-11-18 CM: 1-12-15-14 CM: 0-78-37-37 CM: 1-05-65-05 CM: 1-22-07-66
Hari rawatan: 9 Hari rawatan: 3 Hari Rawatan : 6 Hari Rawatan : 4 Hari Rawatan: 11

A/ A/ A/ A/ A/
1. CKD stage V dengan 1. Ulkus ar cruris dextra et 1. Ulkus dekubitus ar 1. CKD Stage V On HD 1. Diare kronik ec dd/
uremic syndrome sinistra pedis sinistra reguler -Ca. Recti
( perbaikan) dd PNC, HN 2. AKI stage 3 dd acute on 2. DM tipe 2 NW 2. Hernia umbilical 2. Anemia berat hipokrom
2. Anemia berat HM ec dd CKD 3. Anemia berat NN ec irreponible mikrositer ec perdarahan
Penyakit kronis 3. Dyspepsia type dd (perbaikan)
3. Hipertensi grade II (on dimotility dd type mixed - Perdarahan Th/ 2. Status koagulasi dengan
therapy) 4. Gout Arthritis kronik (perbaikan) - Bed rest manifestasi perdarahan
dengan multiple tofus - Penyakit kronis - O2 2-4 lpm (perbaikan)
Th/ 5. Anemia ringan NN ec 4. AKI stage I pre renal - Three way 3. Candidiasis oral
- Bedrest dd/ ec dd - Diet ginjal 1700 kkal/ ( perbaikan)
- Diet ginjal 1700 – penyakit kronis - Dehidrasi hari + 24 gram
kkal/hari + 50 gram – perdarahan - infeksi protein Th/
protein 6. Diare kronik ec dd: - Lenal ace 2x169 1. Bed rest
- threeway -clostridium difficle - Asam folat 2x400mg 2. Diet MB 1700
- IV lansoprazole -chrons desease Th/ - Alprazolam 0,25mg kkal/hari
30mg/12jam -IBD - Bed rest extra 3. IVFD futrolit 1 fls/ hari
- IV ondansetron - Diet DM 1700 kkal/hari - Kalitake 4. IV omeprazole 40
4mg/12jam - transfusi PRC 1 kolf - HD ( selasa dan mg/12 jam
- Lenal ace 2x169mg Th/ - IVFD Futrolit 1 fls/hari jumat) 5. IV transamin 500mg/8
- Asam folat 2x400mg - Bedrest - IV ceftriaxone 2gr/24jam jam
- Amlodipine 1x10mg - Diet ginjal 1700 kkal - IV lansoprazole 30mg/24j Lab 19-09-2019 6. Hemorrhoid sup 3x2
- Paracetamol 1 gr (extra) - IVFD Nacl 0,9% 20 tpm - Metronidazole 500mg/ 8j Hb/HT/E/L/T: 7. Atalpulgit 1 tab/x
- HD selasa jumat - O2 2-4 lpm nk - Lantus 0-0-0-10 10,9/31/3,3/7,6/185 mencret maks 12
- IV Omeprazole - Asetilsistein 3x200 mg MCV/MCH/MCHC : tab/hari
Lab 21/09/2019 40mg/12jam - Domperidone 3x10 mg 93/33/35 8. Drip metronidazole
Hb/Ht/E/T/L : 7,9/22/2,8/115/12,1 - Synbio 3x1 - Xarelto 15mg/24jam Diftel: 2/0/0/74/14/10 500mg/8jam
MCV/MCH/MCHC : 77/28/37 - Metoclopramide ½ - Futrolit 1 fls 24 jam Albumin : 3,5 9. Drip Fluconazole
Diftel : 1/1/0/80/8/10
Ca : 6,3
amp/8jam - Xarelto 15 mg / 24 jam Ur/cr : 181/10,8 200mg/hari
Ur/cr : 175/17,00 - IV Ceftriaxone Na/K/Cl : 139/5,9/104 10. Nystatin 2cc/6j
Na/K/Cl : 137/3,3/104 2gr/24jam Lab 21-09-2019 11. Paracetamol
- Lenal ace 169mg/12jam HB/HT/E/L/T: 500mg/8jam
Lab 19/09/2019 - Asam folat 8,3/26/3,3/6,6/361
Urinalisa 400mg/12jam MCV/MCH/MCHC : Lab 20-09-2019
Warna : kuning - Bicnat 500mg/8jam 80/26/32 HB/HT/E/L/T:
Kejernihan : jernih - Fluimucyl 200mg/8jam Diftel: 2/1/0/88/72/0 10,3/32/4,5/15,8/694
Berat jenis : 1,012 - Allupurinol Ca : 7,6 MCV/MCH/MCHC :72/23/32
Ph: 6,0 300mg/24jam Ur/cr : 16/1,00 Diftel:2/0/0/79/12/7
Leukosit : + - Clindamisin Na/K/Cl : 139/4,3110 Na/K/Cl:142/3,6/107
Protein : +3 300mg/8jam
Glukosa : +1 - Attapulgit 1 tab/BAB Lab 20-09-2019 Lab 19-09-2019
Keton : - - Ondansetron 8 mg/8 HB/HT/E/L/T: HB/HT/E/L/T:
Nitrit : - jam 6,9/23/2,9/6,7/386 8,1/27/3,8/11,1/635
Urobilinogen : - MCV/MCH/MCHC : MCV/MCH/MCHC : 70/21/31
Bilirubin :- Lab(20-09-19) 80/24/30
Darah : + HB/HT/E/L/T: 9,8/30/3,3/314/14,2
Diftel: 103/0/0/64/17/9 Lab 15-09-2019
MCV/MCH/MCHC : 90/30/33
Diftel:6/1/0/58/27/8 MDT : Normokrom HB/HT/E/L/T:
Lab 16/09/2019 pt: pasien/control/inr: Anisositosis dengan 8,4/27/3,8/20,8/569
Hb/Ht/E/L/T: 14,00/13,9/0,99 eusiofilia MCV/MCH/MCHC : 70/22/31
MCV/MCH/MCHC: APTT: pasien/control Kolesterol
35,80/34,3
Diftel: Total/HDL/LDL/TG : Lab 13-09-2019
Anti HCV: neg
PT pasien/control/INR: HbSAg: non reaktif 82/49/488/50 Anti HCV : negative
15,70/13,3/1,11 Ur/Cr: 51/2,50 HBsAG : non reaktif
APTT pasien/control: Na/K/Cl: 142/4,6/111 Lab 17-09-2019
32,50/33,9 HB/HT/E/L/T: Lab 13-09-2019
Lab(18-09-19)
Ur/Cr : 51/6,5 5/16/1,9/14,8/418 HB/HT/E/L/T:
Ur/Cr: MCV/MCH/MCHC : 9,5/30/4,3/21,1/610
Na/K/Cl: Urinalisa(16-09-19) 83/26/31 MCV/MCH/MCHC : 69/22/32
Warna : kuning jernih Diftel: 3/0/0/78/9/10 Diftel: 3/1/0/81/8/7
Leukosit : (+) 6-8
GDS: 113 Ur/Cr : 12/0,6
Lab 16-09-2019 Ur/cr: 48/1,3 PT/APTT : 0,93/5,37
Asam urat : 13,8 Na/K/Cl :139/4/111 GDS : 96
Lab 15-09-2019 NA/K/Cl : 140/3,7/107
HB/HT/E/L/T: 9,1/29/3,3/13,4/462
MCV/MCH/MCHC : 89/29/33
Diftel: 6/1/1/56/27/9
 Albumin : 2,70
Ur/Cr : 44/2,30
Na/K/Cl : 134/5,1/100

K3B1 K3B2 K3B3 K3B4 K3B5

DPJP : dr. Price DPJP : dr. Price Maya DPJP : dr.Price DPJP: dr. Abdullah, Sp.PD DPJP : dr. Diana Erlita, Sp.PD
Maya,Sp.PD COW : dr. Reza Hans Maya,Sp.PD COW: dr. Radit COW : dr. Reza Hans
COW :dr. Reza Hans DR : dr. Reyza COW : dr. Reza Hans DR: dr. Nelvi DR : dr. Reyza
DR :dr. Reyza Raber : GH DR : dr. Reyza Raber: Raber : GH
Raber : GH Raber: GEH
Nama : M. Yahya Ibrahim Nama : zulfikar zulkefli Nama : Marhaban Sabi Nama : Nurdin AB Nama : Abdullah Bintang
TTL : 01-07-1940(79) TTL : 10-02-1978(41) TTL : 101/05/1930 TTL : 12/10/1964 TTL : 01/07/1951(68th)
Alamat : Aceh Besar Alamat : banda aceh Alamat : Aceh Besar Alamat : Banda Aceh Alamat : Aceh Besar
CM : 1-22-13-59 CM : 1-22-12-38 CM : 1-22-09-21 CM : 0-98-36-14 CM : 1-12-57-68
Hari rawatan : 5 Hari rawatan : 6 Hari rawatan : 10 Hari rawatan : 4 Hari rawatan : 3
A/ A/ A/ A/ A/
1. Penurunan kesadaran ec 1. CKD Stg V on HD 1. Hepatoma 1.CKD Stage V dengan 4. CKD Stg V ec dd/
dd/ dengan uremic
- Imbalance elektrolit
2. Anemia sedang NN ec dd edema paru akut – HN
sindromec dd/ - penyakit kronik 2. Hipertensi stage II – PGOI
- sepsis – HN
- Uremic enselopati - perdarahan 3. Dyspepsia dengan uremic
– PNC syndrom
- SDA
dengan uremic Th/ 5. Anemia berat NN
2. Sepsis ec dd/
syndrom - Bed Rest Th/ ec dd/
- Pneumonia
- Urosepsis
2. Hipertensi Stg II - Diet Hati 1700 kkal/hari - Bedrest – PGK
3. AKI stage II pre renal ec 3. Anemia sedang NN - IVFD aminofusin hepar 1 - Diet ginjal 6. Hipertensi Stg II
dehidrasi Th/ fls/hari 1700kkal/hari
4 Geriatric problem (Inanisi - Bed Rest -IV Omeprazole 40 mg/12 - O2 Simple mask Th/
ec low intake, Imobilisasi) - threeway jam - Three way - Bedrest
5. ISK Asimptomatik - Diet ginjal 1700 kkal/hari - Sistenol 3x1 - Paracetamol - Ca glukonas 1
6. Hipernatremia + 0.6 gram protein/ - Curcuma 3x1 1gr/8jam amp/12j
hiperosmolar hipovolemik kgbb/ hari - Drip NTG 5cc/jam - IV Ceftriaxone
- hemodialisa senin dan Lab 20/09/2019 - IV furosemide 40 2gr/24j (h4)
Th/ kamis Hb/Ht/E/L/T: mg /24 jam - IV Furosemid 20 mg
-bedrest - -levofloksasin 750 mg/
-Diet ginjal 1700kkal/hari 8,8/26/2,9/19,5/448 - Amlodipine 1x 10 / 12 jam
24 jam MCV/MCH/MCHC: mg - Calcitriol
- Threeway - Paracetamol 1 gram / 8
-IVFD 2:1 20gtt/i 89/31/34 - Bisoprolol 1x 5mg 0,25mg/12jam
jam Diftel: 2/0/1/75/12/10 - HCT 1x25 mg - Amlodipin
- IV meropenem
- IV Omeprazole 40 mg / Bilirubin - Domperidon 10mg 5mg/24jam
500mg/12jam
12 jam tot/direct/indirect: (extra) - Transfusi PRC sd
- IV omeprazole 40mg/24jam
- Fluimucyl 3x1 - Valsartan 160 mg 1x1 17,54/12,87/4,67 - Alprazolam 0,25/24 Hb>9,9
- Amlodipin 10 mg 1x1 SGOT/SGPT : 129/47 jam
Lab 21/09/2019 - Asam folat 400 mg/ 12 Ur/cr : 55/0,78 - flumucyl 3x1 Lab 21-9-2019
Ur/cr : 47/0,90 jam Na/K/Cl : 132/4,3/97 - Ceftriaxone 1 Na/k/cl : 142/5,6/114
- Sucralfate 10 cc/ 8 jam gram/12 jam
Lab 20/09/2019 - Nebul Ventolin 2,5/ 8 Lab 16/09/2019 - Combivent 1 resp Lab 20-9-2019
Hb/Ht/E/L/T: jam AFP: 3,87 ( extra) Hb/Ht/E/T/L:
12,2/40/6,6/6,9/156
- Ambroxol 3x1 5,7/17/2,1/6,1/192
MCV/MCH/MCHC: Lab 22/09/2019 Lab 14/09/2019 - Paracetamol 500 mg MCV/MCH/MCHC: 79/27/34
60/19/31 Hb/Ht/E/L/T:
Diftel: 6/0/1/65/21/7 Hb/Ht/E/L/T: 3x1 Diftel: 12/0/0/61/18/9
7,2/19/2,4/12,6/155 9,6/27/3,1/16,7/319 Albumin : 3,5
Na/K/Cl:160/3,5/125 MCV/MCH/MCHC: 81/30/37
Ca: 8,4 MCV/MCH/MCHC: Lab 19/09/2019 Ca : 7,3
Diftel: 0/0/0/88/4/8 86/31/36 Hb/Ht/E/L/T: Ur/Cr : 201/14,2
Procalcitonin:3,09
Ur/cr : 242/16,9 Diftel: 2/1/0/76/13/8 8,4/24/2,8/6,8/97 Na/K/Cl : 141/6/115
Lab 19/09/2019
Na/K/Cl : 135/5,9/101 Anti HCV : negative MCV/MCH/MCHC: HbSag: non reaktif
Warna : kuning GDS : 128 HbsAg: non reaktif 85/30/35
Kejerninah : keruh Ca : 8,4 BILtotal/direct/indirect: Diftel: 6/1/0/70/14/9
Berat jenis : 1,021
Ph: 5,5 11,4/7,67/3,77 Ur/cr : 82/7,6
Leukosit : + S.G.O.T : 137 Na/K/Cl : 140/3,9/105
Bil : - S.G.P.T : 46 GDS : 100
Protein : +1 Albumin: 3,10 Albumin : 3,6
Glukos : -
Keton : - Gds: 92
Nitrit : - Ur/cr: 54/1,00
Urobilinogen : - Na/K/Cl : 140/4,7/105
Darah : +

Lab 18/09/2019
Hb/Ht/E/L/T:
12,3/40/6,7/10,4/140
MCV/MCH/MCHC: 61/19/31
Diftel: 3/0/0/82/10/5
Anti HCV : negatif
HbsAg : non reaktif
AGDA
pH: 7,468
pCO2: 39,80
pO2: 48
HCO3: 29,1
Total CO2: 30,3
Kelebihan basa (BE): 5,6
Saturasi O2: 85,5
Ur/cr : 172/1,90
Albumin: 3,10
Na/K/Cl : 168/3,9/131

K4B1 K4B2 K4B3 K4B4 K4B5

DPJP : dr.T.Mamfaluti, DPJP : DPJP : dr.M Darma MS, DPJP : dr. M. Diah, Sp.PD-KKV DPJP : dr. Diana Erlita,
Sp.PD COW : Sp.PD COW : dr. Andri Sp.PD
COW : dr. Hena DR: COW : dr. Afrizal DR : dr. Okdimur COW :dr. Derina
DR : dr. Teguh Raber: DR: dr. Taufiq Raber : EMD, Div. Kardio DR : dr. Reyza
Raber : EMD,KKV Raber: GH Raber : Div.Kardio
Nama: Adi Darman Nama: Dastus Anas Nama : Umar S. Nyak Leman Nama : Zainuddin A Wahab Nama : Muhd. Amin Geh
TTL : 16-09-1964 TTL : 01-07-19966 TTL : 03-06-1958 TTL : 06/07/1962 (57hn) TTL : 14/04/1945
Alamat : sabang Alamat : Aceh Barat Alamat : Aceh Barat Alamat : Aceh Utara Alamat : Kota Banda Aceh
CM : 1-18-94-30 Daya CM : 1-21-62-20 CM : 1-13-70-11 CM : 1-09-91-34
Hari Rawatan : 1 CM :1-22-16-39 Hari rawatan : 6 Hari rawatan : 8 Hari rawatan : 5
Hari Rawatan : 3
A/ A/ A/ A/
1. Abdominal pain ec CAPD A/ 1. Hepatic encelopati grade 1. STEMI septal 1. Pneumonia
failure 1. Intoksikasi 1 2. Sepsis ec geriatric
2. CKD stage v on HD pestisida 2. SBP pneumonia 2. Diare
regular dengan susp 3. Sirosis hepatis stadium 3. ISK akut(perbaikan)
3. Peditis ar antebracii tentamen DC berdegenerasi 4. DM tipe 2 NW ec dd/
dextra suicide maligna – intoleransi
4. Anemia sedang NN ec 2. AKI stage 4. Varices esofagus Th/ makanan
PGK prerenal 5. Multiple ulkus gaster ar -Bedrest – infeksi bakteri
3. Depresi berat antrum -Diet MII 1700 kkal/hari – infeksi virus
Th/ 4. Peningkatan 6. Massa di hepar lobus -IVFD NaCl 0.9% 10 gtt/i 3. Dyspepsia type
- Bedrest enzim dextra - IV Meropenem 1 gr/8 jam like ulcer dd
- O2 2-4 L transaminase 7. Hipoalbuminemia 2,1 - IV Omeprazole 40 mg/12 gastropati
- Diet Ginjal 1700 ec dd/ 8. Hiponatremia jam diabetik
kkal/hari - Hepatotoksin hipoosmolar hipovolemik - SC Lantus 14 SC 4. CAD
- Threeway liver injury - Drip paracetamol 1 gr/8 jam 5. Geriatri problem
- IV Ceftriaxone 2 - Viral akut Th/ - Aspilet 1x80 mg 6. OA Lumbal
gram/24 jam - Bedrest - Bisoprolol 5 mg/24 jam 7. DM Tipe II Obese
- IV omeprazole 4 Th/ - Diet sonde 6x200 kkal/hari - Nebule Ventolin 1 resp/8 grade 1
gram/ 12 jam - Bedrest - IV lansoprazole jam
- Lenal ace 2x 169 - Diet sonde 30mg/12jam - Ondansetron 4 gr/8 jam IV Th/
mg 6x200 - Curcuma 3x1 - Clopidogrel 75 mg/24 jam 1. Diet MII 1700
- Asam folat 2x400 kkal/hari - Propanolol 10mg/24jam PO kkal/hari
- Ca glukonas 1 - Ivfd NaCl - Lactulac 3xCI 2. Bed rest, guyur rl
ampul extra 0,9% 30 gtt/ - Albumin 25% 1 fls/hari Lab 19-09-2019 300 cc lanjut
- Novorapid 10 iu menit - Compolax3xC1 Warna : kuning 3. IV Ceftriaxone 2
extra - Iv - Cefotaxime/12jam Kejernihan:keruh gr /24 jam
- Kalitake 1 sast/ 8 lansoprazole - Comafusin /24jam Berat jenis : 1,018 4. Attapulgit 1x1
jam 30 mg/ 12 pH :5,5 5. Clopidogrel 1x75
- Kaltropen supp jam Lab 23/09/2019 leukosit :positif mg
3x1 - Curcuma 3x1 PT/APTT : 28,7/51,3 protein:positif (+1) 6. Simvastatin 1 x
- Bicnat 3x1 Ca : 7,4 glukosa:positif (+3) 80 mg
Lab 20/09/2019 - Fluimucyl Na/K/Cl : 122/5,6/97 keton:positif 7. Sucralfat syr 3Xci
Hb/Ht/E/L/T: 3x1 nitrit: negatif 8. SC LANTUS 0-0-0-
7,3/21/2,5/23/423 - Sukralfat syr urobilinogen : negatif 10
MCV/MCH/MCHC: 84/29/35 3x CII Lab 21/09/2019 bilirubin : negatif 9. Fluimucyl
Diftel: 0/0/0/93/3/4 - Nystatin Hb/Ht/E/L/T: darah: positif 200mg/8jam
GDS : 133 drop 4x2cc 8,6/24/3/132/10,1 leukosit:4-6 10. Domperiddone
Ur/cr : 254/22,2 MCV/MCH/MCHC: 83/29/35 eritrosit: 8-10 100mg/8jam
Na/K/Cl : 136/6,3/102 Lab 21/09/2019 Diftel: 0/0/0/93/4/3 epitel:3-5 11. Lansoprazole
Hb/Ht/E/L/T: HbSAg : reaktif sel ragi : positif 30mg/24 jam
14,9/42/4,7/9,8/219 SGOT/SGPT : 166/21 12. Paracetamol
MCV/MCH/MCHC: Albumin : 2,1 Lab 18-09-2019 500gr/8jam
89/32/36 Ca : 7,3 Hb/Ht/E/L/T: 8,8/25/3/4,6/189
MCV/MCH/MCHC: 84/29/35
Diftel: 0/0/0/87/7/6 Ur/Cr : 200/1,5 Lab 19/09/2019
Diftel: 1/1/0/61/19/18
HbSAg : reaktif Na/K/Cl : 141/4,8/102 Albumin : 2,53 Hb/Ht/E/L/T:
Anti HCV : Negatif Ur/Cr : 45/0,91 15,1/43/5,2/10,4/634
Albumin : 3,40 Na/K/Cl : 139/3/104 MCV/MCH/MCHC: 83/29/35
Na/K/Cl : 118/6,2/93 Diftel: 3/1/0/60/25/11
Lab 17-09-2019
Ca/Mg : 8,8/2,1 GDS 180
Na/K/Cl : 140/3,2/107 Ur/cr: 31/1,20
Na/k/cl : 135/4,5/100
Lab 15-09-2019
Hb/Ht/E/L/T: 10,6/29/3,4/15,4/282
MCV/MCH/MCHC: 86/31/36
Diftel: 1/1/0/90/4
AGDA
pH ; 7,18
pCO2 :15,30
PO2 :151
HCO3 : 5,7
Total CO2 :6.2
BE : -19,8
Saturasi O2 : 98,8
Albumin : 3
Troponin I : 0,14
CKMB : 46
Ur/Cr :68/1,40
Na/K/Cl/Ca : 131/3,4/94/9,7
 K5B1 K5B2 K5B3 K5B4 K5B5
DPJP : dr.M.Darma MS DPJP : dr. Azzaki AB, DPJP : dr.Abdullah,SP.PD DPJP: dr. Price Maya, DPJP : dr. Azzaki
.Sp.PD Sp.PD COW :dr. Radit Sp.PD Abubakar,Sp.PD
COW : dr. Afrizal COW: dr.Kudrah DR : dr. Nelvi COW: dr.Radit COW :
DR : dr. Taufiq Dr: dr. Taufiq Raber: Neuro, HOM Dr: dr.Nelvi DR :
Raber: Raber: Raber: EMD, GH, Raber :
B.Urologi,KKV
Nama : Rusli Abdullah Nama : Muslem Abdullah Nama : M Jamil A Nama : Fadli Mahmud Nama : Muchammad Zainul
TTL :1/7/1946 TTL : 09-04-1978 (41th) TTL :02-07-1963(56 th) TTL : 22/06/1967 TTL : 1/07/1984
Alamat : Bireun Alamat : Aceh Besar Alamat :aceh Pidie Alamat :Aceh pidie Alamat :Aceh pidie
CM :1-06-28-78 CM : 1-21-96-22 CM :1-21-61-14 Hari rawatan : 6 CM : 1-22-10-98
Hari rawatan : 4 Hari rawatan : 3 Hari rawatan :16 Hari rawatan : 6
A/
A/ A/ A/ 1. PSMBA ec dd A/
1. Konstipasi ec dd/ 1. PSMBB ec dd/ 1. Penurunan kesadaran stress ulcer 1. Dispepsia type like
– Ca recti – Hemoroid interna (perbaikan) ec dd/ 2. Pneumonia (HAP) ulcer dd tipe
– IBD – Polip recti -Syok sepsis 3. Diabetik dismotiliti
2. DM tipe 2 NW – Ca colorectal -Urosepsis nefropathy ec dd/
- Over DM Th/
3. Hipertensi on therapy 2. Anemia ringan 2. NHL st. IV
- Uremic stage 1.Bed rest
prokemoterapi
4. ISK 2.diet MB 1700 kkal
Th/ Th/ 3. Syok sepsis ec dd/
5. CAD Three way
- Bedrest - Bedrest -HAP 6. CHF FC Nyha III-IV Ivfd nacl 0,9 % 20 gtt/i
- Diet MII 700 kkal/hari - Diet bubur kecap -Urosepsis
ec dd/ CAD, HHD IV Lansoprazol 30 mg/12 jam
- Nacl 0,9% 20 gtt - IVFD NaCl 0,9% 20tpm 4. AKI stage II prerenal
7. DM tipe 2 NW Domperidon 10 mg
- Glimepiride 1x2mg - paracetamol 1 gram iv 5. Jaundice ec dd/
8. Anemia sedang Sucralfat syr 3xCI
- Metformin 2x50 mg (extra) -cholelithiasis
ec acute bleeding
- Amlodipine 1 x10 mg ec PGK Lab(17-09-19)
Th/ 9. CKD Stage IV ec Hb/Ht/E/T/L: 14,8/45/5,4/313/9,3
Lab 21-9-2019 - Bedrest DN MCV/MCH/MCHC: 83/28/33
PT :pasien/kontrol/INR : - Diet hati 1700 kkal/hari Diftel: 2/1/0/63/27/7
10. Trombositopenia GDS : 104
15,30/14,3/1,09 - Aminofusin 1 fls/hari 11. Hipoalbumin Ur/cr : 19/0,83
APTT : pasien/kontrol : - Gabapentin 300mg/12jam Na/K/Cl :145/4/106
30,20/34,3 - Mecobalamin Th/
Albumin:3,50 500mg/12jam iv 1.Bed rest
GDS : 121 - Paracetamol drip (K/P) 2.diet DM 1700 kkal
- SC Lovenox 0,4/24 jam Three way
Lab 16-9-2019 -Kaltropen sup (extra) Ceftriaxone 2 gr/ 24 jam
Hb/Ht/E/T/L: Furosemide 2 amp/ 24 jam
13,40/4,6/224/6,8 Lab 21-9-2019 Calsitriol 0,25 mg 1x1
MCV/MCH/MCHC: 789/29/32 Hb/Ht/E/T/L: Fluimucyl 3x1
Albumin 25 %/ 24 jam
Diftel: 7/0/1/46/38/8 10,6/33/3,9/35,6/68
Lantus 0-0-0-10
Na/K/Cl : 143/4,2/107 MCV/MCH/MCHC:
Bicnat 3x1
Pt/apt : 2/7 83/27/32 Valsartan 1x80 mg
HbSag: non reaktif Diftel: 0/0/0/23/75/2 Kaltrofen sup (extra)
GDS 216 Albumin : 2,80 Drip Lansoprazole dalam 50
Ur/Cr : 35/1,06 Ca : 7,6 cc Nacl/ jam
Ur/cr : 55/0,50 Vit. K 1 amp/8 jam
Na/K/Cl : 146/4,1/118
Lab(21-09-19)
Hb/Ht/E/T/L: 7,1/21/2,5/309/12,1
Lab 18-9-2019 MCV/MCH/MCHC: 83/29/35
Hb/Ht/E/T/L: Diftel: 2/1/1/62/28/6
6,7/25/2,7/74/87,1 Pt/APtt : 14,7/ 37,5
Albumin : 2,30
MCV/MCH/MCHC: Ca : 7,6
92/25/27 Ur/cr : 160/4,30
Na/K/Cl : 139/4,2/111
Diftel: 0/0/0/12/87/1
Alb: 2,89 Urinalisa(20-09-19)
Ur/Cr : 59/0,63 Warna : kuning
Lekosit : positif
Protein : (+2)
Lab 16-09-2019 Glukosa (+3)
Ur/Cr : 108/1,0 Darah : (+)
Na/K/Cl :164/4,2/135 Leu: 200-300
Erit: 60-70
Epitel :3-5
Lab 14-09-2019
Hb/Ht/E/L/T: Urinalisa(18-09-19)
8.7/30/3.4/144.6/72 Warna : kuning keruh
Lekosit : positif
MCV/MCH/MCHC:
Protein : (+2)
87/26/30 Glukosa (+3)
Diftel:0/0/0/6/93/1 Darah : (+)
PT pasien ; 21.70 Leu: 300-500
Kontrol 13,7 Erit: 40-50
Epitel : 2-5
INR 1.58 Triple Fosfat : (+)
APTT 35.90
Kontrol 32.8 Lab 17-9-2019
Ca 8.4 Hb/Ht/E/T/L: 9,0/28/3,3/311/15,1
MCV/MCH/MCHC: 84/28/33
Na/K/Cl: 165/4.4/134

K6B1
DPJP : dr. M. Riswan, Sp.PD
COW : dr. Emier
DR : dr. Hibban
Raber :
Diftel: 3/1/0/64/23/9
K6B2 K6B3 K6B4 K6B5
DPJP : dr. Abdullah, DPJP : dr.Price Maya,Sp.PD DPJP: dr.Mahriani S, Sp.PD DPJP: dr. Abdullah, Sp.PD
Sp.PD COW : dr. derina COW : dr. Nazaruddin COW : dr. Radit
COW : dr. Radit DR : dr. Reyza DR : dr. Rianda DR : dr. Nelvi
DR: dr. Nelvi Raber: Alergi&Imunologi, Raber: neurologi Raber: GEH
Raber: GH, BTKV, Neuro, EMD
Nama : Nasrul Kadir Nama: Abu bakar bin Kasem Nama: Yunawar M.Yusuf Nama : Ibrahim Usman Nama : Arani M
TTL: 10/11//1969(49 th) TTL : 9-12-1975 (43th) TTL : 01/07/1985 (34th) TTL : 01/07/1962(57th) TTL : 01/07/1944
Alamat: Aceh Besar Alamat : Aceh utara Alamat : Bireun Alamat : Aceh Besar Alamat : Aceh Besar
CM : 1-21-72-74
CM: 1-17-46-80 CM : 1-22-09-18 CM : 1-22-15-18 CM : 1-22-13-92
Hari rawatan : 13
Hari rawatan: 4 Hari rawatan : 10 Hari rawatan : 3 Hari rawatan : 6
A/
A/ 1. CKD stage V on HD A/ A/ A/
1. NHL relaps siklus I reguler 1. Dd/ 1. Artitis septik dd 1. Susp. Massa intra abdomen
dengan regimen Cysplatin 2. Obs. Seizure ec dd - Adrenal insufisiensi gout artritis akut ec dd Ca Colon
2. Trombocytopenia - Metastase proses ke - eutiroid 2. Dyspepsia tipe dd 2. AKI stage 3 dd/ acute on
intracranial
induced chemotherapy
- Uremic ensefalopati
2. Hiponatremia  Like ulcer CKD
3. Neutropenia induced 3. Tumor scalp ar hipoosmolar hipovolemik  Tipe mixed 3. Geriatri problem
chemotherapy occipital 3. dermatitis generalisata 3. Low back pain ec ( inanisi, instabilitas,
4. Hipertensi St II 4. bradikardia (perbaikan) dd spondylitis konstipasi)
Th/ lumbalis 4. Hiperkalemia
- Bedrest Th/ Th/ 4. Hipertensi 5. Hipertensi terkontrol
- Diet MII 1700kkal/hari -Bedrest -Bed rest terkontrol
-Diet Ginjal 1700 kkal/hari
- IVFD NaCl 0.9% 20 gtt -Diet MII 1700 KKAL/hari 5. OA Genu Dextra Th/
- Drip perdipin 1amp dalam
- SC Leucogen 1cc (extra) 500cc NaCl 0,9% -IVFD Nacl 0,9 % 20 tpm KL-1V -Bedrest
-Cetirizine 10mg/12jam - IV Ceftriaxone 1 gr/12 jam -Cetirizine 10 mg/24 jam -Diet ginjal 1700 kkal
-Paracetamol 1000 gr/12 j PO - IV Lansoprazol 30 mg/12 j -Salycil talc - IVFD NaCl 0,9% 20tpm
-Paracetamol 500 mg /8 jam -Desoksimethasone zalf Th/ - IV Omeprazole 40mg/12jam
Lab 21/09/2019 -Asam folat 2x1 (malam) - Bedrest - Amlodipin 10mg/24jam
Hb/Ht/E/L/T : -Lenal Ace 169 mg /12 jam - Lactulac 3Xcii
- Diet MB 1700kkal/hari
-Sukralfat 3xCI
10,3/27/3,3/0,2/24 Lab 20-09-2019 - IVFD NaCl 0,9% + - Ceftriaxone 2gr
Ondansetron 4 mg/12j
MCV/MCH/MCHC : 81/31/39 -Iv fenitoin 100 mg /8 jam Hb/Ht/E/L/T: Tramadol 1 amp -Buskopan (extra)
Diftel : 0/0/-1/32/64/5 -Curcuma 3x360 mg 13,6/40/4,6/10,1/182 20tpm -Gabapentin
- drip perdipin 1 amp dlm 50cc MCV/MCH/MCHC: - IV Omeprazole -Apidra dalam 10 cc Dex 5 %
Lab 20/09/2019 NaCl 0,9%, kec. 5cc/jam 86/30/34 40mg/12jam 10 unit
Hb/Ht/E/L/T : - Alprazolam 1x1 Diftel: 9/0/1/74/12/4 - IV Ondancetron -Ca glukonas 1 amp extra
12,5/32/4/0,9/7 - Valsartan 80mg/24 jam Na/K/Cl : 133/5,2/99 4mg/8jam
- paracetamol drip
MCV/MCH/MCHC : 81/32/39 - Sucralfat syr 3xCI Lab 22-09-2019
1gram/24jam
Diftel : 1/0/0/59/37/3 Lab 16-09-2019 - Gabapentin Ca : 7,4
Lab 21/09/2019 Albumin:2,60 300mg/12jam Ur/cr: 28/1
Hb/Ht/E/L/T: Ca:7,5 - Ceftriaxone Na/K/Cl: 145/2,9/112
16/09/2019 10/30/3,5/8,6/142 2gr/24jam
Hb/Ht/E/L/T MCV/MCH/MCHC: 84/2934 Lab 14-09-2019 Lab 19-09-2019
8,4/25/3,1/17,5/12 Diftel : 4/1/0/71/15/9 FT4: 18,18 Lab 20-09-2019 Albumin: 3,30
PT/ApTT : 12,4/ 46
MCV/MCH/MCHC TSHs: 1,797 Hb/Ht/E/L/T:
Albumin : 3
79/27/34 UR/CR : 87/12 10,5/31/3,8/23,4/269 Lab 19-09-2019
Diftel Na/k/Cl : 143/4,3/105 Lab 14-09-2019 MCV/MCH/MCHC: Urinalisis
00/0/0/46/28/26 Hb/Ht/E/L/T: 81/28/34 Warna : kuning
Lab 17/09/2019 11,9/33/4,0/7,8/148 Diftel: 0/0/0/87/7/6 Berat jenis : 1,010
14/09/2019 Hb/Ht/E/L/T: MCV/MCH/MCHC: Kejernihan : keruh
6,8/22/2,6/8,5/169 Ph : 5,0
Hb/Ht/E/L/T 582/30/36
MCV/MCH/MCHC: 82/26/32 Lekukosit : +
8,4/23/3,1/19,1/17 Diftel: 15/1/0/72/8/4 Protein : +1
Diftel : 4/0/0/74/13/9
MCV/MCH/MCHC HbsAg: nonreaktif
Ur/cr: 20/0,80 Glukosa : negatif
77/28/36 Ca:9 Na/K/Cl: 128/3,9/96 Keton : +
Diftel Ur/Cr; 105/15,85 GDS : 71 Nitrit : -
3/0/0/53/19/25 Na/K/Cl:137/3,8/114 Urobilinogen : -
Bilirubin : -
Lab 13/09/2019 Darah : +
11/09/2019
Kalsium (ca) : 10,1 Leukosit :15-20
Hb/Ht/E/L/T
NA/K/CL : 152/4,6/110 Eritrosit :300-400
4,6/13/1,6/22,8/19
Epitel :2-3
MCV/MCH/MCHC Lab 12/09/2019 Granular cast :+
79/28/36 Hb/Ht/E/L/T:
Hyalin cast : +
Diftel 8,5/25/3,2/9,2/179
0/0/1/44/18/37 MCV/MCH/MCHC: 79/27/34
Diftel : 2/0/0/81/9/8 Lab 19-09-2019
GDS : 86 Hb/Ht/E/L/T:
Ur/cr : 96/12,50 11,7/33/4,1/11,1/264
Na/K/Cl: 144/4,2/107 MCV/MCH/MCHC:80/28/35
Diftel: 4/1/0/78/8/9
Lab 07-9-2019 Ur/cr: 210/8,90
anti HCV negative
HBSAG non reaktif
Na/K/Cl: 131/6,3/97
GDS : 84