AQSHA 2 (PENYAKIT DALAM PRIA)

Hari / Tanggal : Sabtu, 12 Oktober 2019

Dokter Jaga : dr. Hans/ dr. Muchsin
Dokter Muda : Asti/Lisa

K1B1 K1B2 K1B3 K1B4

DPJP : dr. Islamuddin, Sp.PD DPJP : dr. Desi Magfirah, Sp.PD DPJP : dr. DPJP: dr. Desi Maghfirah, Sp.PD
COW : dr. Indra COW : dr. Heyna COW : dr. COW: dr. Cut Heyna
DR : dr. Nelvi DR : dr. Reyza DR : dr. DR: dr. Reyza
Raber: Neurologi Raber: Div Geriatri Raber: Raber: Pulmo, GEH
Nama : Aris Mundhahar Nama : Usman HS Nama: Nasruddin Sofyan
TTL : 04/10/1996 TTL : 10/06/1955 TTL: 12-06-1974 (45 thn)
Alamat : Bireun Alamat : Aceh Besar Alamat: Nagan Raya
CM : 1-22-34-56 CM : 0-89-24-16 CM: 1223188
Hari Rawatan : 5 Hari rawatan : 5 Hari rawatan: 7

A/ A/ A/
1. Limfadenopati multiple ar colli 1. Penurunan kesadaran ec 1. Disfagia ec dd
bilateral ec dd 1. hipoglikemi berulang - TB laring
- Limfoma malgna 2. SDA - TB esophagus
- Limfadenitis TB 2. Hipoglikemia perbaikan - Ca esophagus
2. Abses perianal 3. Pneumonia (CAP) - akalasia
3. Dyspepsia type dismotility 4. CKD stage V ec HN - striktur esophagus
4. Tension type headache 5. PSMBA ec dd 2. TB paru kasus baru RO (+), dahak
Th/ 1. Uremic bleeding (-)
1. Bedrest 2. Stress ulcer 3. PPOK stabil
2. Diet MB II TKTP 3. Gastritif erosif 4. Kista ateroma
3. IVFD RL 20 gtt/i 6. Post stroke iskemik dengan
4. IV omeprazole 40 mg/12 jam hemiparese dextra Th/
5. Drip PCT 1 gr/12 jam 7. Hipertensi dengan HHD -Bedrest
6. Cefturoxime 1gr/8jam - Diet cair 1700 kkal
7. Ondancetron /8jam Th/ - IVFD Dex 5% 20 tpm
8. Amitriptilin 2x10 mg 1. Bed rest semi fowler - OAT 4FDC 1x3 tab
9. Citicolin 2x500 mg 2. O2 2 lpm nk - vit B6
Lab 10-10-2019 3. Diet ginjal 1700 kkal + 40 gr - domperidone 3x10 mg
Urinalisa protein -IVFD NaCl 0,9% 20 tpm
Makroskopik 4. IVFD Dex 10% tpm -Paracetamol 3x500 mg (k/p)
Warna: kuning 5. Transfuse PRC 1 kolf premed -Curcuma 1x360 mg
Kejernihan: keruh furosemide 1 amp - Mentol Spiritus cth 1 per 12 jam
Berat jenis: 1,016 6. Iv. Omeprazole 40 mg/ 12 jam
pH: 6,0 7. Iv ceftriaxone 2 gr/ 24 jam
Lekosit: +
8. Sucralfat syr 3xcI Lab 08-10-109
Protein: -
Glukosa: - PT/INR/APTT : 13,6/0,96/43,8
Keton: + Anti HCV : negative
Nitrit: negatif Lab 08-10-2019
HBsAg : Non reaktif
Urobilinogen: negatif Hb/Ht/e/l/t
6,6/21/2,6 /8,6/98 GDS : 79
Bilirubin:negatif
Darah: positif MCV/MCH/MCHC: 81/26/32
Mikroskopik Diftel: 0//0/0/84/8;/8 Lab 08-10-109
Leukosit: 6-8 Ur/cr: 58/76 PT/INR : 14,1/1
Eritrosit: 4-6 Na/K/Cl: 137/4,6/101 APTT : 43,4
Epitel: 3-5 Anti HCV : negative
HBsAg : Non reaktif
Lab 08-10-2019
Hb/Ht/e/l/t GDS : 129
11,4/35/4,1/8,1/330
MCV/MCH/MCHC: 85/28/33 Lab 07-10-2019
Diftel: 0/1/0/72/14/13 Hb/Ht/E/L/T:
GDS : 97 13,9/41/5,7/12,5/508
MCV/MCH/MCHC: 72/24/34
Diftel: 1/1/0/69/18/11
Ur/cr: 32/1,30
Na/K/Cl: 130/3,6/93

Lab 08-10-109
PT/APTT : 13,6/43,80
Anti HCV : Negatif
HBsAg : Non reaktif
GDS : 79
 K2B1 K2B2
DPJP : dr. Azzaki DPJP : dr. Diana, Sp.PD
Abubakar Sp.PD COW : dr. Nasriah
COW : dr. Ade baswin DR : dr. Akmal
DR : dr. rianda Raber : GH, HOM, Rhemato
Raber:
Nama: Bustami Nama: Anwar juned
Dahruddin TTL: 15/01/1959
TTL: 12/10/1947 (71th) Alamat: Aceh Pidie
Alamat: Aceh Pidie CM: 1-05-96-02
CM: 1-22-38-60 Hari rawatan: 16
Hari rawatan: 2
A/
A/ 1. Sepsis (perbaikan) ec dd
1. Pneumonia CAP dd urosepsis
infeksi paru spesifik 2. CKD Stage V ec PNC
2. susp close fr. Femur 3. hipokalsemia
dextra 4. DVT
3. geriatric problem 5. Hiperurisemia
4. CHF Fc NYHA I-II ec 6. Abses genu et
CAD gastrocnemius sinistra
Th/ Th/
- tirah baring - bed rest
- diet MII 1500 kkal/hari - Diet ginjal 1700 kkal/hari
- IVFD NaCl 0,9% 20 tpm - Omeprazole 40mg/12 jam
- cateter urin - Nystatin drop 4x2 gtt
- iv. Omeprazole - Flumucyl 2x200 mg
40mg/12 jam - Lenal ace 2x169mg
- Iv. Ceftriaxone 1 gr/12 - Asam folat 2x400mg
jam - Paracetamol 500 mg/8jam
- paracetamol 3x500mg - Hemodialisa rabu - sabtu
- furosemide 2x40mg
Lab 10-10-2019
Hb/Ht/E/L/T
8,2/25/3,5/8,6/202
MCV/MCH/MCHC : 72/24/33
Diftel: 2/1/0/82/9/6
PT:pasien/control/INR :
15,80/13,8/1,12
APTT : 41,20/32,9
Lab 07-10-2019
Hb/Ht/E/L/T
6,6/21/3/6,1/193
MCV/MCH/MCHC : 69/22/32
Diftel:3/0/0/72/15/10
Ca: 7,3
Lab 03-10-2019
Hb/Ht/E/L/T
8,4/24/3,5/14,4/158
MCV/MCH/MCHC : 67/24/36
Diftel:1/0/0/94/3/2
Albumin: 2,4
Ca: 6,4
Ur/Cr: 167/5,2
Na/K/Cl: 141/4,6/108
Lab (01/10/19)
PT/Kontrol: 19,8/14,6
APTT/Kontrol: 45,9/33,9
D-dimer: 7648,16
Asam urat : 7,6
K2B3 K2B4 K2B5
DPJP : dr. Price Maya DPJP: dr. Desi Magfirah, DPJP : dr. M. Diah, Sp. PD
COW : dr. Fahril Sp.PD COW : dr. Arie
DR : dr. Hibban COW : dr. Cut Henna DR : dr. Reyza
Raber : GH,THT,Kardio DR : dr. Reyza Raber : Pulmo, EMD
Raber: KKV, GEH
Nama : Zulfikar zulkefli Nama : Saharman Hamka Nama: Syahidin Teuku
TTL : 10-02-1978 (41 thn) TTL : 07-03-1983 Muhammad
Alamat : banda aceh Alamat : Aceh Singkil TTL: 01/08/1950
CM : 1-22-12-38 CM : 1-22-26-86 Alamat: Banda Aceh
Hari rawatan : 26 Hari rawatan : 12 CM: 0-81-17-27
Hari Rawatan : 9
A/ A/
A/
1. CKD Stg V on HD 1. Sirosis hepatis stadium
1. TB paru
2. Susp Ca Laring dekoompensata related
2. DM tipe 2 normoweight
3. Hipertensi terkontrol hepatitis B child pugh B 3. Hipertensi stg I
4. Anemia sedang HM ec 2. Massa tumor di ampula 4. Geriatric problem
PGK recti dd malignancy (impairment of hearing)
3. Hipokalemia ringan
Th/ (perbaikan) Th/
- Bed Rest , threeway 4. Anemia sedang NN - Bed rest
- Diet ginjal 1700 kkal/hari + (perbaikan) - O2 2-4 liter/menit
60 gram protein/ kgbb/ hari 5. TR Mild MR Mild - Diet DM 1700kkal/hari
- hemodialisa senin dan kamis - IVFD NaCl 0,9% 20tpm
- IV Omeprazole 40 mg / 12 Th/ - IV Ceftriaxone 2gr/24jam
jam - Bedrest - Asetil sistein 3x200mg
- Diet M II 1700kkal/hari + - SC Novomix 16-0-16
- Valsartan 160 mg 1x1
- Micardis 1x80 mg
- Amlodipin 10 mg 1x1 ekstra ikan gabus
- Drip Paracetamol 1 gr/8 jam
- Asam folat 400 mg/ 12 jam - IVFD NaCl 0,9 % 20
- 4FDC 1x4
- Sucralfate 10 cc/ 8 jam gtt/mnt
- Curcuma 3x1
- Lactulose 3x1 - Lactulosa 3xCII - Peridoksin tab 2x1
- Furosemide 20 mg/ 8 jam - UDCA 3x1
- Concor 2,5 mg/24 jam - IV Ampicilin sulbaktam 1 Lab 10-10-2019
- Combivent 1 resp/8 jam gr/8 jam(H4) Bilirubin:total/direct/indirect:
- Drip fluconazole/ 24 jam - Omeprazole 20 mg/12 0,42/0,37/0,05
- Nystatin 4x1 drop jam SGOT/SGPT:41/21
- Meropenem 1 gr/12 jam (H2) - KSR 600 mg/24 jam
- Curcuma 1x1 Lab 09-10-2019
Lab 11-10-2019 - IV Aminofusin hepar 1 Procalsitonin : 0,11
Hb/Ht/E/L/T fls/24 jam
7,7/22/2,7/34,5/96 - Spironolakton Lab 08-10-2019
MCV/MCH/MCHC : 81/29/36 1000mg/8jam LED :
- Furosemid 40mg/8jam HbA1c : 7
Diftel:1/0/0/90/3/6
ALP : 114
- As.salisilat 3% +
Kolesterol total : 129
Lab 08-10-2019 desoksimetasone (sue)
HDL : 36
Hb/Ht/E/L/T LDL : 98
7,7/22/2,7/36,3/127 Lab 08/10/2019 Trig : 104
MCV/MCH/MCHC : 81/29/35 Hb/Ht/E/L/T : Ur/cr : 14/0,079
Diftel:0/0/0/92/35 9,1/25/2,5/11,5/95 As. Urat 4,3
MCV/MCH/MCHC :
Lab 05-10-2019 97/36/37 Lab 07-10-2019
Hb/Ht/E/L/T Diftel : 2/1/0/71/13/13 Urinalisa
7,1/21/2,5/28,4/146 MDT : anemia NN + Makroskopik
MCV/MCH/MCHC : 84/29/34 Trombositopenia Warna: kuning
Diftel:0/0/0/91/3/6 AFP : 2,92 Kejernihan: keruh
Biltot/direct/indirect : Berat jenis: 1,010
Lab 04-10-2019 25,4/15,5/9,9 pH: 5,5
Hb/Ht/E/L/T SGOT/SGPT : 85/44 Lekosit: negatif
Protein: +1
7,3/21/2,6/27,6/173
Glukosa: negatif
MCV/MCH/MCHC : 82/28/34 Lab 05/10/2019
Keton: negatif
Diftel:0/0/0/95/2/3 Hb/Ht/E/L/T :
Nitrit: negatif
Ur/Cr: 243/11,91 9,6/25/2,7/12,5/85 Urobilinogen: negatif
Na/K/Cl: 135/5,4/99 MCV/MCH/MCHC : Bilirubin:negatif
96/36/38 Darah: positif
Lab 26/09/2019 Diftel : 2/1/0/73/13/11 Mikroskopik
pH : 7,382 Na/K/Cl : 134/3,6/105 Leukosit: 2-3
pCO2 : 29,40 Ur/Cr : 22/0,70 Eritrosit: 6-8
pO2: 152 Albumin : 2,1 Epitel: 3-5
Bikarbonat : 17,6
total CO2 : 18,5 Lab (3/10/19) Lab 04/10/2019
BE : -5,9 ALP: 139 Hb/Ht/E/L/T :
saturasi O2 : 99,3 14,8/42/4,9/8,7/328
MCV/MCH/MCHC : 86/30/35
Diftel : 1/1/0/77/11/10
Na/K/Cl : 139/4,4/104
Ur/Cr : 24/1,2
GDS : 119
 K3B1 K3B2 K3B3 K3B4 K3B5
DPJP : dr. Islamuddin Sp. DPJP : dr. M.Diah, Sp.PD- DPJP : dr. Kurnia F Jamil, Sp. DPJP : dr. M. Riswan, DPJP : dr. Islamuddin, Sp.PD
PD KKV PD Sp.PD(K)HOM COW : dr. Indra
COW :dr. indra COW : dr. Arie COW : dr. Radit COW : dr.Alul DR : dr. Nelvi
DR :dr. Nelvi DR : dr. Reyza DR : dr. Nelvi DR : dr. Rianda Raber: GEH
Raber : Neurologi Raber : GH Raber : Pulmo, GEH, GH Raber : Neuro
Nama : M. Husen Latif Nama: Hamdani Abd Jalil Nama: Abdul Rauf Nama: Rusli Awaluddin Nama : Hasyem Gade
TTL : 02-05-1942 (77 thn) TTL: 15/09/1965 (65 thn) TTL: 01/07/1934 (85TH) TTL: 14/09/1945 (74 thn) TTL : 12/10/1961
Alamat: Aceh Jaya
Alamat : Langsa Alamat: Aceh Besar Alamat: Aceh Besar CM: 1-22-05-90 Alamat : Aceh Pidie
CM : 1-22-3-95 CM: 0-96-53-04 CM: 1-22-19-74 Hari Rawatan : 5 CM : 1-22-36-04
Hari rawatan : 2 Hari Rawatan : 5 Hari rawatan: 19 Hari rawatan : 4
A/
1. Penurunan kesadaran ec
A/ A/ A/ dd/ 1. Sepsis 2. Stroke 3.
A/
1. penurunan 1. CKD Stage V on HD 1. Disfagia ec massa tumor Imbalance elektrolit 1. Sirosis hepatis
kesadaran ec dd regular ec dd/ esofagus pars distal 2. Sepsis ec dd/1. stadium
- sepsis - HN 2. Polip multiple gaster et Pneumonia 2. Abeses ar dekompensata
femur post orif 3.
- stroke - DM corpus dan antrum related hepatitis B
Urosepsis
-SDA 2. Anemia berat NN ec 3. PPOK stabil 3. PSMBA ec dd/ 1. dengan
2. sepsis ec dd PGK Pneumonia 2. Abses ar degenerative
- selulitis 3. Hipertensi stage I Th / pedis malignancy child
- urosepsis 4. Hiponatremia - Bed rest 4. Anemia berate c dd/ 1. pugh A
Perdarahan 2. Penyakit
3. selulitis ar ante - Diet M II 1700 kkal/hari kronik
2. Hepatitis B kronik
brachii dextra Th/ - Iv ceftriaxone 2 gr/24 5. OA genu bilateral 3. Post PSMBA ec
4. hypoalbuminemi - Bed rest jam 6. Post orif ar fwmur dextra dd/ 1. Varises
a berat - Diet ginjal 1700 - Ondansetron 1 amp/8 7. AKI stg II prerenal ec dd/ esophagus
1. Sepsis 2. Dehidrasi
5. post PSMBA ec kkal/hari + rendah jam bleeding bleeding
8. Alkalosis metabolic tidak
dd garam + protein 30 - Clinimix 1 fls/24 jam terkompensasi 2. Varises fundus
- ulcus gaster gr / hari) - Asetil sistein 3x200 mg bleeding bleeding
-ulcus - Threeway - Combivent 1 resp/8 jam Th/
duodenum - IV. Furosemide - Amoxicilin 2x1000 - Bed rest Th/
- Diet sonde 6x200 cc
- stress ulcer amp/8jam - Azitromycin 500mgx1 - O2 2-4 l 1. Bedrest
6. hypokalemia - Asam folat 2x400 mg - Sucralfat syr 3xCI - IVFD NaCl 0,9% 30 tpm 2. NGT
sedang - Lenal ace 2x169 mg - Bicnat 3x1 - Iv omeprazole 80 mg drip 3. Diet hati II 1700
7. hiponatremi - Flumucyl 3x200 mg - syringe pump kkal/hari
- Sucralfate syr 3xC1
hiposomolar - Valsartan 1x80 mg Lab 11/10/2019 - PCT 1 gr/8jam
4. IVFD comafusin
hipovolemik Hb/Ht/E/L/T : - Vascon 4gr titrasi hepar fls/ hari
8. pensitopenia Lab 08/10/2019 12/37/4,4/7/523 - Transamin 500 mg/8 jam 5. Lansoprazole 30
9. geriatric Hb/Ht/E/L/T : MCV/MCH/MCHC : 83/27/33 - Meropenem 500 mg/12 mg/12 jam
jam
problem 5,6/16/1,9/4,9/207 Diftel : 1/1/0/58/17/13 6. Spironolakton
- Citicolin 500/12jam
MCV/MCH/MCHC : 81/29/36 Ur/cr : 57/1,41 - Albumin 25% 100 cc 1x100 mg
Th/ Diftel : 0/0/0/84/6/10 Na/K/Cl : 137/5,2/102 - KSR 2x600 mg 7. Lactulosa syr
-bedrest, miring kanan/ kiri MDT : - Transfuse PRC 1 kolf per 3x30cc
per 2 jam Kesimpulan : anemia NN Lab 10/10/2019 hari sd Hb>10 gr/dl 8. Vit K 1amp/8jam
- O2 2-4 liter/ menit HbSag : non reaktif SGOT/SGPT : 16/13 Lab 08/10/2019
9. Iv vitamin k 1
-IVFD NaCl 0,9% 20 tpm GDS : 121 Asam urat : 5,3 Hb/Ht/E/L/T : 6,3/21/2,6/34,9/468 amp/8 jam
-Diet sonde 6x200 kkal/hr + UR/ CR 275/ 23,20 MCV/MCH/MCHC : 80/24/30 10. Cefotaxime 1 gr/ 8
--extra telor putih Na/K/Cl : 120/4,2/88 Lab 30/09/2019 Diftel : 1/0/1/85/7/6 jam
Ur/Cr : 149/2,34
-IVFD clinimx + clineloic I Ur/Cr : 43/1,59 11. Propranolol 10
fls/hari Lab 10/10/2019 mg/24 jam
-Meropenem 1 gr/ 8 jam AGDA Urinalisa
-Omeprazole 40 mg/12 jam pH:7,432 Makroskopik Lab 09/10/2019
-Albumin / 24 jam pCO2: 44,70 Warna: kuning Hb/Ht/E/L/T:
Kejernihan: keruh
-Citicholin 500 mg/12 jam pO2: 63 Berat jenis: 1,014 13/39/4,9/5/136
-Hydrovat 100o mg dalam HCO3: 30,1 pH: 5,0 MCV/MCH/MCHC: 80/26/33
NaCl 0,9% CO2: 31,5 Lekosit: + Diftel: 7/0/0/65/20/8
BE: 5,7 Darah: + Na/K/Cl:142/4,1/111
Mikroskopik
Lab 11-10-2019 SO2: 92,2 Ur/Cr: 23/0,9
Leukosit: 10-15
Hb/Ht/E/L/T: Eritrosit:6-8 HBsAg : reaktif
9,2/28/4,3/3,8/38 Lab 25/09/2019 : Epitel: 3-5 PT/APTT : 17/43,80
MCV/MCH/MCHC: PT/control/INR: Biltot/direct/indirect :
Lab 09/10/2019
65/21/33 12,7/14,6/0,88 AGDA 1,48/0,67/0,81
Diftel: 0/0/0/87/11/2 APTT : 30,6/33,4 pH : 7,502
pCO2 : 54,8
Albumin : 3,1
PT/APTT: 17,4/54,9 pO2 : 99 Protein total : 5,7
HCO3 : 43,3
Albumin : 2,1 Lab 24/09/2019 Total CO2: 45
Globulin : 3,1
GDS : 95 Hb/Ht/E/L/T : BE : 19,2 SGOT/SGPT : 175/41
Sat O2 : 96,1
Ur/cr: 104/1,30 12,4/37/4,3/6,9/383
Na/K/Cl: 129/2,9/107 MCV/MCH/MCHC : 86/29/33 Albumin : 2,3
Ca : 12,8
Diftel : 14/1/0/53/23/9 PT/INR : 13,2/0,93
APTT : 32,7
GDS 114 D-dimer : 730,66
Ur/cr : 34/1,70
Na/K/Cl : 143/4,8/106 Lab 08/10/2019
Hb/Ht/E/L/T : 5,6/18/2,3/32,1/500
MCV/MCH/MCHC : 77/24/32
Diftel : 1/0/0/85/7/7
GDS : 86
Na/K/Cl : 142/3/96
Ur/Cr : 168/2,4
 K4B1 K4B2 K4B3 K4B4 K4B5
DPJP: dr. Desi Maghfirah, DPJP : dr. Islamuddin, DPJP : dr. Diana Erlita, Sp.PD DPJP: dr. Desi Maghfirah, DPJP : dr. Kurnia F.J., Sp.PD
Sp.PD Sp.PD COW : dr. Nasriah Sp.PD COW : dr. Radit
COW: dr. Cut Heyna COW : dr. Indra DR: dr. Akmal COW: dr. Cut Heyna DR : dr. Nelvi
DR: dr. Reyza DR: dr. Nelvi Raber: GEH,GH DR: dr. Reyza Raber : HOM, GH,Neuro
Raber: GEH Raber: Kardio IPD, GH Raber: kardiologi IPD (divisi Pain)

Nama: Abu bakar Nama: Tgk. Abdurrahman Nama: M Gade Mahmud Nama: Hasballah Daud Nama: Sutan Engka
TTL : 01-07-1955 (64 thn) TTL: 01-07-1959 TTL : 12/12/1962 (56 thn) TTL : 20-06-1943 (76 thn) TTL : 04/05/1993 (26 thn)
Alamat : Aceh besar Alamat: Aceh Jaya Alamat : Banda Aceh Alamat : Aceh besar Alamat : Aceh Singkil
CM : 1-11-21-34 CM: 1-22-32-76 CM : 0-78-28-23 CM : 0-62-74-51 CM : 1-21-86-57
Hari Rawatan : 5 Hari Rawatan: 6 Hari Rawatan : 17 Hari Rawatan :5 Hari Rawatan : 16

A/
A/ A/ A/ A/
1. seminoma testis stadium
1. Hepatoma dengan cancer 1. CHF FC NYHA III ec 1. Sepsis (perbaikan) ec dd 1. Hipoglikemia
IIc
pain related hepatitis B dd 1. HHD - Urosepsis (perbaikan) ec low 2. cancer pain
2. Hipertensi stage I 2. AKI stage III ec dd - Pneumonia intake 3. anemia sedang NN ec dd/
3. DM tipe 2 Normoweight Cardio renal 2. CKD stage V on HD reguler 2. PPOK eksaserbasi –peny kronis
4. Anemia berat NN ec dd/ syndrome dengan uremic ensefalopati akut –perdarahan
- Penyakit kronik 3. HHD (perbaikan) 3. Hipertensi stage I 4.Hidronefrosis bilateral post
- Perdarahan 4. Anemia ringan ec dd 3. Pneumonia 4. CHF Fc NYHA III ec nefrotomi
- Penyakit kronik 4. Hioalbuminemia (2,4) dd/ 1. HHD 2. CAD 3. 5. hyperkalemia
Th/ - Perdarahan Anemia sedang DCM
- Bedrest 5. Efusi pleura bilateral 6. Hipokalsemia 5. AKI stage 2 dd Th/
- Diet hati II 6. Hypoalbuminemia 7. HHD nefropati diabetic -Bedrest
1700kkalk/hari 7. ISK 6. DM tipe 2 NW -Diet MII 1700 kkal/hari
- IVFD aminofusin hepar 1 Th/ -IVFD NaCl 0,9 % 20 tpm
fls/hari Th/ -Bedrest Th/ -duragesic patch 25mg/3 hari
-tramadol drip 1 amp/8 jam
- IV lansoprazole - Bedrest -Diet ginjal 1700 kkal/hari -Bedrest
-Lactulac syr 3 x cI
30mg/12jam - Posisi semifowler -Lenal Ace 2x169mg -Diet lunak rendah garam
-Kaltrofen sup k/p
- Tramadol 3x1 - O2 3-4L/i -Asam folat 2x400mg -IVFD NaCl 0,9% 20
-Gabapentin 3x300 mg
- Lactulose syr 3xCI - Threeway -Curcuma 3x1 gtt/menit -Neurodex 2x1
- Domperidone - Diet jantung 1700 -Gentamicin zlf 2x1 -Nebul ventolin 1 resp/8jam - IV cefoperazone sulbaktam 1
10mg/8jam kkal/hari, rendah -Gabapentin 1x100 mg - IV furosemide 20 mg/8jam gr/12 jam
- Amplodipine garam -Lansoprazole 30mg - Amlodipin 1x5 mg - ca glikonas / 8 jam
10mg/24jam - Bicnat 3x1 -Amlodipin 1x5 mg - valsartan 1x80 mg -kalitake 3 x 1
- Aminofusin hepar 1 - Clopidogrel 1x75 mg -Albumin 25 % 100 cc/24 jam - ISDN 5mg/24jam - transfuse 1 kolf/ hari target
fls/24jam - Furosemide 40mg/6 -Sucralfat syr 3xC1 - paracetamol 3x500 mg Hb > 10
- Omeprazole 20mg/12jam jam -Meropenem 500 mg/12 jam - lactulose syr 3xc1
- Dulcolac sup extra - Lactulac syr 3xcII -IV Albumin 25% 100 cc/12 jam Lab 10-10-2019
- Aspilet 80mg/12jam -Asetylcystein 200mg/12jam Lab 10-10-2019 Ur/Cr : 115/9,60
Lab 10-10-2019 - Fosen enema extra - vit k 1 amp/8jam Urinalisa
AFP : 2033,00 - Valsartan 80 mg/24 Makroskopik Lab 9-10-2019
Warna: kuning Hb/Ht/E/L/T:
jam Lab 10-10-2019
Lab 09-10-2019 Kejernihan: keruh 6,5/20/2,5/104/241
Hb/Ht/E/L/T:
Urinalisa Berat jenis: 1,013 MCV/MCH/MCHC: 79/26/33
Lab 10-10-2019 8,6/27/3.2/15,7/228
Makroskopik pH: 5,0 Diftel : 1/0/0/88/6/5
Urinalisa MCV/MCH/MCHC: 86/27/31
Warna: kuning Lekosit: + Ur/cr : 116/9,7
Makroskopik Diftel: 2/1/0/80/9/8
Kejernihan: jernih Mikroskopik Na/K/Cl : 135/6,0/114
Warna: kuning Albumin : 2,2
Berat jenis: 1,018 Kejernihan: keruh Leukosit: 6-8
pH: 5,5
Ur/cr : 52/5,1 Eritrosit: 1-2 Lab 08-10-2019
Berat jenis: 1,009 Na/K/Cl : 135/4,0/102 Hb/Ht/E/L/T:
keton : + pH: 5,0 Epitel: 3-5
8,2/25/3,1/10,5/266
Urobilinogen : + Darah : +
Lab 05-10-2019 MCV/MCH/MCHC: 79/26/33
Mikroskopik Urobilinogen : - Lab 08-10-2019 Diftel 5/1/0/81/7/6
Leukosit:1-2 Mikroskopik
Hb/Ht/E/L/T: Hb/Ht/E/L/T: PT APTT: 17,5/ 44,9
Eritrosit: 0-1 Leukosit:6-8 9,8/30/3,5/13,8/209 13,5/41/5,1/10,6/317
Epitel: 2-3 Eritrosit: 100-130 MCV/MCH/MCHC: 84/28/33 MCV/MCH/MCHC: Lab 07-10-2019
Epitel: 3-5 Diftel: 3/1/0/83/5/8 81/27/33 Ur/cr: 106/8,40
Lab 08-10-2019 Granular cast : + Albumin : 2,5 Diftel: 8/1/0/68/17/6
Hb/Ht/E/L/T: Sel ragi :+ Lab 04-10-2019
Ur/Cr : 52/2,7
7,5/22/2,5/8,4/188 Bakteri : + Urinalisis (2/10/19) Hb/Ht/E/L/T:
MCV/MCH/MCHC: 88/30/34
Na/K/Cl:144/3,8/106
Warna : kuning 10,7/33/4,2/11,3/287
Diftel : 2/1/0/72/14/11 GDS : 109 MCV/MCH/MCHC: 79/26/33
Lab 9-10-2019 Kejernihan : keruh AGDA
AntiHCV : negative Diftel: 4/0/2/82/7/5
Koleterol:tatal/HDL/LDL/tr Darah:+ pH : 7,386
HBsAg : reaktif Ur/Cr : 87/66,6
igliserida : 144/40/87/73 Leukosit : 2-3 pCO2 : 42,8
Bilirubin
Eritrosit : 4--6 pO2 : 340 Lab 01-10-2019
total/direct/indirect :
1,26/0,,49/0,77 Lab 7-10-2019 Epitel : 3-5 HCO3 : 25,9
Hb/Ht/E/L/T: 11,4/34/4,4/9/316
MCV/MCH/MCHC: 78/26/33
SGOT/SGPT : 139/95 Hb/Ht/E/L/T: Total CO2: 27,2 Diftel: 3/0/0/81/10/6
Albumin : 2,90 9,5/27/3,2/7,8/148 Lab 30-09-19 BE : 1,2 Ur/Cr : 71/4,6
GDS :141 MCV/MCH/MCHC: Hb/Ht/E/L/T: Sat O2 : 99,8 Lab 30-09-2019
Ur/cr : 69/1,30 86/30/35 9,1/25/3,1/23,6/171 Warna kuning
Na/K/Cl : 143/4,2/113 Diftel: 4/0/0/71/19/6 MCV/MCH/MCHC: 81/29/36 Kekeruhan jernih
HbsAg: nonreaktif Diftel: 1/1/0/93/2/3 Berat jenis 1,010
Ph 5.0
Albumin: 3,20 Na/K/Cl : 134/5/102
Leukosit -
GDS: 170 Ca : 8 Protein -
Ur/cr: 182/3,60 Ur/Cr : 223/8,4 Glukosa –
Na/K/Cl: 142/3,8/113 Albumin : 2,4 Keton -
Nitrit -
Urobilinogen –
Bilirubin -

Lab 29/09/2019
Hb/Ht/E/L/T: 8,6/26/3,2/9,4/303
MCV/MCH/MCHC:79/27/34
Diftel: 3/0/0/82/9/6
 K5B1 K5B2 K5B3 K5B4 K5B5
DPJP : dr.Abdullah, Sp.PD DPJP : dr. M. Riswan, DPJP : dr. Islamuddin, DPJP : dr Azzaki, Sp.PD- DPJP : dr Azzaki, Sp.PD-KGEH
COW : dr. Intan Sp.PD(K)HOM Sp.PD KGEH COW : dr. Ade Baswin
DR : dr. Okdimur COW : dr.Alul COW : dr. Indra COW : dr. Ade Baswin DR : dr. Rianda
Raber : HOM DR : dr. Rianda DR : dr. Nelvi DR : dr. Rianda Raber: IPD kardio, gigi dan
Raber : Raber: Raber : mulut
Nama : Nazaruddin M Nama : M. Yazid Nama: Ismail M. Yusuf Nama: Mukhtar H.Amad Nama : M. Dian
Thalib TTL : 07-06-1997 (22tahun) TTL: 01-09-1982 (37 th) TTL: 08-10-1966 TTL : 20/03/1953 66 tahun
TTL : 01-07-1973 (46 tahun) Alamat : Aceh tamiang Alamat: Aceh Besar Alamat: Pidie Jaya Alamat : Pidie
Alamat : Aceh besar CM : 1-19-10-69 CM: 1-22-32-85 CM: 1-22-36-08 CM : 1-22-34-44
CM :1-14-50-62 Hari rawatan : 3 Hari rawatan: 6 Hari rawatan: 4 Hari rawatan : 5
Hari rawatan : 18
A/ A/ A/ A/
A/ 1. Rhabdomiosarkoma 1. Obs febris ec dd/ 1. Penurunan kesadaran 1. Hepatoma dengan
1. adnocarsinoma gaster post kemoterapi siklus - Faringitis ec dd/ Cancer pain
post kemo siklus ke 6 I dengan regimen 2. Pneumonia(CAP) - Uremic enselopaty 2. Trombositosis reaktif
dengan cancer pain carboplatin, epiruticin, 3. Dyspepsia tipe like - Imbalance elektrolit dd/
NRS 5-6 vincrishtine ulcer 2. CKD stage V dengan -trombositosis
2. PSMBA ec dd/ 2. Efek panjang obat uremic syndrome ec essential
- Ca gaster grade II Th/ dd/ 1. PGOI 2. PNC 3. 3. Pneumonia ( CAP)
- Ulkus gsater 3. Anemia sedang - Tirah baring DN 4.efusi pleura dextra ec dd/
3. Anemia sedang NN ec - threeway 3. Anemia sedang ec - pleuropneumonia
perdarahan Th/ - Paracetamol 1gr (K/P) PGK - Pleuritis TB
4. Susp efusi pleura - Tirah baring - IV levofloxacin 750 4. Hipokalemia sedang
sinistra - Diet sonde oral 6x200 mg / 24 jam 5. DM tipe II NW Th/
- IVRL RL 20gtt/menit - resp/12 jam 6. ISK 1. Bedrest
Th/ - Transfuse PRC s/d Hb - IV omeprazole 40 7. Nefrolitiasis bilateral 2. Diet hati II 1700
- Bedrest >10 mg/12 jam multiple kkal/hari
- Diet sonde 6x200 - IV ambacin 1gr/12jam - Lactulac sr 3x Ci 8. Asidosis metabolik 3. IVFD cairan 2;1 20 tpm
kkal/hari - Fosen enema (K/P) 4. Aminofusin hepar 1
- IV lasix 40mg/24jam Lab 10-10-2019 - Kompolac syr 3x1 Th/ fls/hari ; 20 tpm
- Paracetamol 3x500 mg Hb/Ht/E/T/L: - Salisil talk 3x1 sue 1. Bedrest 5. Tramadol 2x50 mg
- Codein 3x10mg 8,8/26/3,2/460/14,5 2. Three way 6. Lactulac 3x30 cc
- Ambacin 1gr/24jam MCV/MCH/MCHC: 79/27/35 Lab 9-10-2019 3. Diet ginjal 1700 7. Iv omeprazole 40 mg/ 12
- Duragesic patch/3 hari Diftel: 0/0/0/94/5/1 Malaria : negative kkal/hari + 90 gr jm
- Prosogan drip amp 5 Procalsitonin: 0,90 protein /hari 8. Iv. Ceftriaxone 2gr
cc/jam Urinalisa 4. Asam folat 400 mgx2 9. Sucralfat syr xc1
- MST 2x15mg Urobilinogen : positif 5. Lenal ace 169/12jam 10. Fosen enema supp
- Clinimix + clinoleic 1 6. Kalitac 3x1
fls/hari Lab 7-10-2019 7. Ca glukonas (extra) Lab 10/10/2019
- Transamin Hb/Ht/E/T/L: 8. Insulin rapid dalam AFP : 4,87
500mg/8jam 12,6/35/4,1/330/19,1 dex 40% 50cc
- Trasetat 2x1 MCV/MCH/MCHC: 84/31/37 9. Combivent 1 Lab 09 /10/2019
Diftel: 0/1/0/71/23/5 resp/8jam Urinalisa
Lab 09/10/2019 GDS: 130 10. Cefrriaxone Makroskopik
Hb/Ht/E/T/L: Ur/cr: 25/1,10 2gr/24jam Warna: kuning
7,7/23/2,7/113/25,8 Na/K/Cl: 132/3,8/98 11. Meropenem Kejernihan: keruh
MCV/MCH/MCHC: 500mg/24jam Berat jenis: 1,020
86/29/34 pH: 5,5
Lekosit: -
Diftel: 0/0/0/98/2/0 Lab 10-10-2019
Protein: +1
PT/APTT: 1,02/1,14 Hb/Ht/E/T/L:
Glukosa: -
8,7/26/3,3/585/19,6 Keton: -
Lab 06/10/2019 MCV/MCH/MCHC: Nitrit: -
Hb/Ht/E/T/L: 80/27/33 Urobilinogen: -
9,8/29/3,4/221/65,8 Diftel: 0/0/0/87/3/10 Bilirubin:-
MCV/MCH/MCHC: Asam urat : 10,6 Darah: -
86/29/34 Na/K/Cl : 142/7,1/107 Mikroskopik
Diftel: 0/0/1/99/0/0 Ca: 10,5 Leukosit: 2-3
Ur/cr: 346/16,7 Eritrosit: 1-2
Epitel: 3-4

Lab 08 /10/2019
Hb/Ht/E/L/T:
12,3/37/4,2/14,2/541
MCV/MCH/MCHC: 88/29/33
Diftel: 0/0/1/87/6/6
Anti HCV (-)
HBSAg non reaktiv
SGOT/SGPT 71/104
Gds 158
Ur/cr : 29/0,80
Na/K/Cl : 148/3,9/106
 K6B1 K6B2 K6B3 K6B4 K6B5
DPJP : dr. Azzaki Abu DPJP : DPJP : dr. Abdullah, Sp.PD DPJP: dr. T Mamfaluti, DPJP : dr. M.DIah, Sp.PD
Bakar, SpPD COW : COW : dr. intan Sp.PD COW : dr. Arie
COW : dr. Ade Baswin DR : DR : dr. okdimur COW : dr. Nazaruddin DR: dr. Reyza
DR : dr. Rianda Raber : Raber : GEH DR : dr. Akmal Raber:
Raber : GH Raber:Kardio IPD
Nama: M.Amin Nama: Junaidi M Juned Nama : T Adan Nama : A Rahman Thaib
TTL : 03/06/1982 (37 th) TTL : 04/07/1970 TTL : 20/07/1936 (83 thn) TTL : 01/05/1960 (59 thn)
Alamat : ABDYA Alamat : Aceh Pidie Alamat : Aceh Besar Alamat : Aceh Pidie
CM : 1-22-30-65 CM : 1-22-37-47 CM : 0-88-0-88 CM : 1-22-31-08
Hari rawatan : 9 Hari rawatan : 3 Hari rawatan : 3 Hari rawatan : 8

A/ A/ A/ A/
1.CKD stage V dngan uremic 1. Penurunan kesadaran ec 1. Anemia berat NN ec 1. Esophagitis grade A
syndrome (perbaikan) ec dd dd dd 2. Ulcus gaster
- HN - uremic ensefalopati - Perdarahan 3. CHF Fc NYHA II-III ec dd
- PGOI - stroke - Penyakit kronik - HHD
2. Anemia sedang HM ec dd - sepsis 2. Geriatri problem - IHD
-Penyakit kronis 2. CKD stage V ec dd 3. PPOK eksaserbasi
-Def. besi - urat nefropati akut Th/
3. Diare akut (teratasi) ec - HN 4. Post septoplasty atas Bedrest
dd - PNC indikasi epistaksis Diet MII 1700 kkal/hari
-viral infection 3. Hipertensi stage II anterior IVFD NaCl 0,9% 20gtt/menit
-bacterial infection 4. Pneumonia HAP 5. Iskemik lateral dan IV Omeprazole 40mg/12jam
4. Hiperkalemia sedang 5. Anemia ringan NN ec dd LAD IV furosemide 20mg/8 jam
- penyakit kronis IV ondansetron 4mg/8jam
Th/ - perdarahan Th/ Valsartan 1x160mg
-Bed rest 6. post stroke iskemik -Tirah baring Sucralfat syr 3Xcii
- Diet ginjal 1700 kkal/hari + 7. hypernatremia -Diet sonde oral Amoxicillin 1000mg/12jam
0,6-0,8 gr hipovolemik 6x200cc/hari Azitromisin 500mg/12jam
protein/kgBB/Hari -IVFD NaCl 0,9% 20gtt/i
- Three way Th/ -IV ceftriaxone 1gr/12jam Lab 08-10-2019
- IV ceftriaxone 2 gr/24 jam -Bed rest H2) Pt : 12,30
- lansoprazole 30mg/12 jam - O2 2-4 liter/menit -Nebule Ventolin 1 Apt : 32,20
- sucralfate syr 3xCI - Diet sonde ginjal via NGT resp/8jam
- domperidone 10mg/8 jam 6x200 kkal/hari -Flumicyl 3x200 Lab 07-10-2019
- lenal ace 169/12 jam - IVFD sol 2:1 10 tpm Hb/Ht/E/L/T:
- as. Folat 400mcg/12 jam - cefepim 1gr/24jam Lab 10-10-2019 10,3/31/3,8/8,5/473
- loperamid 2mg/mencret - Ca asetat 169mg/12jam Hb/Ht/E/L/T: MCV/MCH/MCHC: 82/27/33
- amlodipine 10mg/24jam - as. Folat 400mg/12 jam 2,7/9/1,2/7,2/168 Diftel: 5/0/0/62/21/12
- valsartan 160mg/24 jam MCV/MCH/MCHC:
Lab 07-10-2019 - alupurinol 100mg/24 jam 75/24/31 Lab 05-10-2019
Hb/Ht/E/L/T: - citicolin 500mg/24 jam Diftel: 0/0/0/89/4/7 Hb/Ht/E/L/T:
7,4/22/2,9/6.6/175 - drip perdipin mulai PT: pasien/control/INR : 7,8/26/2,9/12,4/532
MCV/MCH/MCHC: 0,5mg/jam 16,40/13,6/1,17 MCV/MCH/MCHC: 87/27/31
77/25/33 APTT:pasien/control : Diftel: 3/0/0/71/15/11
Diftel: 8/1/0/76/8/7 Lab 10/10/2019 23,89/32,7 Anti HCV : negative
Na/K/CL : 143/6,7/114 Hb/Ht/E/L/T: Albumin : 3,10 HBsAG : non reactif
10,6/31/3,9/11,5/283 GDS : 139 GDS : 81
MCV/MCH/MCHC: 82/28/34 Ur/cr : 81/1,30 Ur/cr: 24/1,5
Diftel: 2/0/0/81/8/9 Na/K/Cl : 144/5,0/117 Na/K/Cl: 142/4,4/107
Anti HCV : negative
HBsAg: non reaktif
Ur/cr: 192/7,30
Na/K/Cl: 154/3,7/115