AQSHA 2 (PENYAKIT DALAM PRIA)

Hari / Tanggal : Senin 01/07/2019

Dokter Jaga : dr. uta / dr.aya
DokterMuda : Devi/Audi

K1B1 K1B2 K1B3 K1B4

DPJP : dr. T. Mamfaluti,Sp.PD DPJP: dr. Azhari Gani SPPD DPJP: dr. Azzaki abubakar Sp.PD DPJP : dr. AzhariGani SPPD
COW : dr. TM Reza Tandi COW: dr. Rahmi COW: COW :dr.Rahmi
DR : dr. Okdimur Dr: dr. Wahyu Dr: DR. Taufik DR : dr.Wahyu
Raber : Raber GEH Raber :
Nama: Tgk. M.Adam Arahman Nama :M. Ali Ismail Nama :Mukhtar affan Nama: Zulkifli m. Saleh
TTL : 01/05/1938 (81 Thn) TTL : 01-09-1964 (54thn) TTL : 31/12/1963 TTL : 17-08-1970
Alamat : Pidie Jaya Alamat : Bireuen Alamat : Bireun Alamat : Bireun
CM :1-21-22-19 CM :1209779 CM :1211826 CM :1-21-27-26
Hari Rawatan : 8 Hari Rawatan : 4 Hari Rawatan : 18 Hari Rawatan:3

A/ A/ A/ A/
1. Penurunan kesadaran ec dd/ 1. Hepatomegali ec dd 1. Penurunan kesadaran ec dd/ 1. Pansitopenia ec dd/
- SDA - HLL 1. Sepsis, 2. Stroke - anemia aplastik
- Sepsis - Metastase Proses 2. Sepsis ec dd: 1. Pneumonia, 2. - leukemia akut
- Uremic enselopati - Abses Hepar Urosepsis - MDS
2. TB paru on terapi OAT 3. Pneumonia, dd: tb parru dengan 2. Rheumatic Heart Disease dd
3. AKI stg (?) dd acute on CKD Th/ infeksi sekunder cardiomyopathi
4. HHD - Bedrest 4. ACHF Fc NHYA 2-3 ec dd/ 1. 3. Hepatosplenomegaliec dd 1.
5. Geriatri problem ( infeksi, - Diet Hati II 1700kkal Penyakit jantung anemia, 2.DCM CLiver, 2. Malignancy
inanisi, instability, demensia ) - Threeeway 5. hipoalumin
6. Post TURP - IVFD aminofusin 1 fls/hari 6. SAH +IVH ec stroke hemoragik Th/
- IV omeprazole 40mg/12jam 7. penyakit jantung anemia - Bedrest
- Curcuma 3x21 8. ISK - Diet MB 1700 kkal/hr
Th/ - Sucralfat Syr 3xCI - IVFD RL 20 gtt/i
- Tirah Baring - Tramadol 2x0mg - Iv. Furosemid 20 mg/12
- Diet sonde 6x200cc Th/ jam
- O2 2-4 l /i via nasal canul - Bedrest - Spironolacton
- IVFD NaC 0,9% 10 gtt / i - O2 2-4 /i 100mg/24 jam
- Amlodipin 10grx1 Lab 28/6/2019 - IVFD RL 10 tpm - Curcuma 3x1
- Valsartan 80mg x1 SGOT/SGPT - Diet sonde oral 6x200 mg cc/hari - Transfusi s/d HB
- Eas Fprimmer 1x24j 150/167 - Iv meropenem 3x1 gr >10g/dl
- Curcuma 2s1 - Hidonac 1200 mg /24 jam
- Peridoxin 1x2 Lab 23/6/19 - drip pct 1 gr
- OAT 4FDC 1x3 tab Hb/Ht/E/L/T - piracetam 3x1 gr Lab 28/6/19
- Iv Vancomicyn 1x1gr 12,5/36/4,30/8,20/255 - IV omeprazole 40mg/12jam HB/HT/E/L/T : 4,3/12/1,6/3,0/81
- Aasam folat 2x400 mg GDS : 120 - Omeprazole 40 mg/12 jam MCV/MCH/MCHC: 77/27/35
- Lenal ace 2x1 tab - Curcuma 3x1 Diftel 0/0/1/48/45/6
- Iv Citikolin 2x500 mg - Flumucyl 3x20 mg
- Nebul ventolin 1 resp/8 jam Lab 27/6/19
Lab 29//6/19 - Flukonazol 20 mg/24 jam HB/HT/E/L/T : 4,2/11/1,4/2,4/86
Ur/Cr: 80/1,59 MCV/MCH/MCHC/RDW :
78/30/38
Lab 27-06-2019 Lab 28/6/2019 Diftel 0/0/0/64/31/5
Bil total 1,19 Na/K/C: 141/3,2/97 Ur/Cr: 43/0,70
Bil Direct 0,52 Na/K/Cl : 135/3,2/102
Bil Indirect 0,67 Lab 27/062019
SGOT/SGPT 40/45 PT/APTT : 16,2/32,8
Alb 2,84

Lab 27-06-2019 Lab 26/062019

Hb/Ht/E/L/T Hb/Ht/E/L/T
8,6/25/3,7/13,2/174 9,2/29/13,1/187/17,0/
MCV/MCH/MCHC MCV/MCH/MCHC:
69/24/34 92/30/32
Diftell : 2/0/0/52/33/13 Diftel : 1/0/0/82/10/7
GDS : 125
Ur/Cr : 174/2,12
Na/K/Cl: 147/3,3/115
 K2B1
DPJP : dr. Chacha, SpPD
COW : dr. Febri
DR : dr. Akmal
Raber :
Nama : M Armasnyah
Siregar
TTL : 16/8/1946 (72thn)
Alamat : Meuraxa
CM : 1-21-2558
Hari Rawatan : 4
A/
1.HE grade 1 dengan
pencetus infeksi
2. Sirosis Hepatis
3. Pneumonia geriatri
4. AKI st III prerenal
dd/hepatorenal syndrome
5. PPOK eksaserbasi akut
6.Inanisi
7. Instabilitas dan jatuh
8. Immobilisasi
9. Hiponatremi Hiposmolar
10. ISK
11. Peny. Kronik
Th/
- Bed rest
- Diet Hati 1
- O2 2-4LPM
- Threeway, IVFD
comafusin hepar 1fls/hari
- Nebule Combivent 1
resp/8jam
- Flixotide 1 resp/12 jam
- Spironolacton 1x100mg
- Lactulac syr 3x45cc
- IV. Omeprazole 40mg
/24jam
- Balance cairan 0
- Fossen Enema extra
- IV Cefepime 1gr/8jam skin
test
- Vit K 1amp/8j
Lab 29/062019
PT/APTT : 61,0/52,10
Anti HCV/HbsAg :
negatif/negatif
Bil Total/Dir/Ind :
0,77/0,53/0,24
SGOT/SGPT/Alb : 36/1/2,72
Lab 25-6-2019
Hb/Ht/E/L/T:
9,3/27/3,3/6,8/53
MCV/MCH/MCHC:81/28/35
Diftell: 0/1/0/52/39/8
GDS 150
Ur/cr 134/3,64
Na/K/Cl 130/4,7/108
Urinalisa
Protein +1
Leukosit6-8
Granular cast +
Hyalin cast+
K2B2 K2B3 K2B4 K2B5
DPJP: dr. Kurnia F. Jamil, DPJP:dr.Islamuddin,Sp.PD DPJP: dr.Islamuddin, DPJP: dr. Kurnia Sp.PD
Sp.PD COW : dr. Febri Sp. PD COW :
COW : dr. rahmi DR : dr. Akmal COW : dr. Febri DR :
DR : dr. wahyu Raber: GH, BTKV DR : dr. Akmal
Nama : Aljabar Tgk Basyah Nama: Faiden Amin Nama: Sarmin D. Nama: Ali Munir
TTL : 3112-1966 (52thn) TTL: 10/12/1970 (48 thn) TTL: 13-7-1961 (57 thn) TTL: 01/01/1973
Alamat : Aceh Utara Alamat: Bireuen Alamat: Simeulue Alamat: Indrapuri
CM :1212735 CM: 1-21-21-15 CM: 1-19-97-29 CM: 1212991
Hari Rawatan : 3 Hari Rawatan: 9 Hari Rawatan: 20 Hari Rawatan: 2
A/ A/ A/ A/
1. CKD stage V on HD regular 1. Sepsis ec dd 1. Sepsis perbaikan ec Selulitis ar cruris sinistra
ec PGD dengan udem paru akut - HAP dd/
2. Anemia sedang mikrositer - ISK - Abses ar colli Th/
normotik ec peny. Kronis 2. CKD stage V on PNC dextra - Bed rest
3. Pneumonia 3. PSMBA (perbaikan) ec - HAP - Diet mb 1700 kkal/hari
4. Failure AV shunt dd/ 2. Massa colli dextra ec - IVFD NaCl 0,95 20 tpm
- Uremic bleeding dd/ - Icefepine 1 gr/12 jam iv
Th/ - Gastritis erosive - Limfoma - Clindamisin 330 gr/12 jam
- Bedrest 4. Anemia berat hipokrom Hodgkin - Paracetamol 3x500 pulvis
- Diet Ginjal 1700kkal/hari + mikrositer ec dd/ 1. - Ca Nasofaring - Rawat luka
60gr protein/hr PGK 2. Defisiensi besi 3. Hipertensi stage I on
- O2 2-4L/menit 5. Hipokalemia ringan terapi Lab 29-6-2019
- Three way 6. Hiponatremia 4. Abses a/r colli HB/HT/E/L/T
- IV ceftriaxone 2gr/24j euvolemic 5. Hipoalbuminemia 14,4/39/4,7/240/12,7
- Drip NTG 10mg dalam Nacl 7. DM tipe 2 NW sedang MCV/MCH/MCHC
0,9 0cc dengan kecepatan 8. Gastropeti diabetic 82/30/37
3cc/24j 9. TB paru Th/ Diftel : 1/11/0/87/6/5
- Drip Furosemide 20mg/jam 10. Trombositopenia - Bed rest GDS/Ur/Cr :114/24/0,52
dengan syringe pump induced wafarin - Diet sonde 1200 cc via Na/K/Cl : 136/3,8/103
kecepatan 2cc/jam oral + extra putih telur
- Lenal ace 2x169mg Th/ - IVFD Clinimix1 fls/
- Asam folat 2x40mg 1. Bed rest 48j
- HD 2. Diet ginjal 6 x 200 cc - IV Omeprazole 40
- Asetil sistein 3x200 mg 3. Threeway mg/12 jam
- Transfusi PRC s/d hb >70 4. IV meropenem 1 gr / 8 - Erdostein 3x1
jam - Amlodipin 1x5mg
5. IV omeprazole 40 mg / - Clinimix 1fls/48j
Lab 27/6/2019 12 jam - Paracetamol 300mg
HB/HT/E/L/T 6. Sucralfat syr 3 x C I dan Tramadol 25mg
7.2/21/2,6/12,9/304 7. IV metoclopramid 1 dalam pulvis 2x1
MCV/MCH/MCHC amp/8jam - Levofloxacin
83/28/34 8. Transfusi prc sampai hb 750mg/24jam (h8)
Diftel : 6/1/0/71/16/6 > 10 gr / dl - Cefipime 1gr/12j (h3)
GDS/Ur/Cr : 88/8,13 9. Rifampisin 1x600mg
Na/K/Cl : 143/3,5/110 10. Isoniazid 1x300mg Lab 29-6-2019
11. Etambutol 1000mg/48j PT/kontrol 13,9/13,7
AGDA : 12. Pirazinamid 1x1600mg Aptt/kontrol 41,8/34,2
PH/pCO2/pO2/HCO3/TCO2/B 13. Gabapentin 1x100mg
E/Saturasi O2 14. Mecobalamin 2x1 Lab 27-6-2019
7,516/27,70/158/22,6/23,5/1,4/9 15. Piridoksin 2x1 tab PT/kontrol 14/13
98,5 16. Curcuma 2x1 tab Aptt/kontrol 52,6/33,2
17. Balamce cairan Alb 2,83
18. HD senin/rabu/jumat
Lab 22-6-2019
Lab 25-6-2019 Hb/Ht/E/L/T:
Hb/Ht/E/L/T: 10,6/31/3,8/16,8/356
8,2/23/3,1/21,2/64 MCV/MCH: 83/28
MCV/MCH/MCHC:76/27/36 Diftell: 0/0/0/84/6/10
Diftell: 1/0/0/89/6/4
Bil direct 0,46 Lab 19-6-2019
SGOT.SGPT 26/8 Hb/Ht/E/L/T:
11,5/34/4,2/15,3/387
MCV/MCH: 83/28
Lab 21-6-2019 Diftell: 1/0/0/77/9/13
Hb/Ht/E/L/T: Alb : 2,8
6,3/18/2,4/34,4/201
MCV/MCH/MCHC:74/26/36 Lab 18-6-2019
Diftell: 0/0/0/93/4/3 Procalcitonin : 0,32
PT/APTT : 15,20/37,70
Ur/Cr : 362/13,88 Lab 10-6-2019
Na/K/Cl : 123/6,7/93 Urinalisis:
Anti HCV negatif Keton +
HbSAg negatif Epitel : 2-3
Albumin : 2,88
GDS : 164
Ur/Cr: 17/0,55
Na/K/Cl: 134/3,8/99
 K3B1 K3B2 K3B3 K3B4 K3B5
DPJP: dr. Islamuddin DPJP : dr. Azhari Ghani DPJP : dr. Chacha, DPJP: dr. Krisna DPJP : dr. Chacha, Sp.PD
Sp.PD Sp.PD Sp.PD Sp.PD COW : dr. Febri
COW: COW : COW : dr. Febri COW : dr. T. M. Reza DR : dr. Akmal
Dr: DR : dr. taufik DR : dr. Akmal DR : dr. Okdimur Raber :
Raber : Raber : Raber: Urologi
Nama :Ibrahim Hanafiah Nama: Irum Mahdi Nama: Muhammad Nama: A. Jalil Yusuf Nama: Idris Puteh
TTL : 05/07/1972 TTL: 09/08/1996 Marjani TTL : 31/12/1952 TTL: 01-07-1937 (81 thn)
Alamat : Pidie Alamat : Aceh Utara TTL: 01/07/1959 Alamat : Aceh Besar Alamat: Aceh Pidie
CM :1212976 CM : 1213012 Alamat : Aceh Utara CM : 1002318 CM: 1-21-10-87
Hari Rawatan : 2 Hari rawatan : 1 CM : 1212938 Hari rawatan : 3 Hari Rawatan: 18
Hari rawatan : 3
A/ A/ A/ A/
1. PSMBA ec dd: 1. Leukositosis dengan A/ 1. AKI stage III post 1. Penurunan kesadaran ec dd/
1. Gastritis erosif, 2. Ulkus bisitopenia ec dd: 1. AML, 1. Pansitopenia ec dd renal dd akut on CAD - Urosepsis
gaster, 3. Ulkus duodenum 2. MDS, 3. Anemia aplastik 1. Anemia Aplastik 2. Anemia Berat NN ec - SDA
2. Anemia berat hipokrom 2. MDS 3. dd CAD - Disequilibrium Synd
mkrositik Th/ Mielofibrosis 3. Vesikolitiatis 2. Sepsis ec dd/
- Berd rest 2. PSMBA (perbaikan 4. Severe Low Back Pain - Urosepsis
Th/ - Diet MII 1700 dd 1. Varises 5. Hepatitis B Kronis - HAP
- Bedrest kkal/hari esofagus bleeding. 3. Pneumonia (HAP) dd/
- Diet sonde oral 6x200 mg - IVFD NaCl 0,8% 2. Varises fundus Th/ Infeksi paru spesifik
cc/hari - Drip levofloxacin 500 bleeding 3. Ulkus - Bed rest 4. CKD stage V ec PNC
- IVFD NaCl 0,95 20 gtt/i mg/24 jam Gaster - Diet Ginjal 5. Nefrolithiasis bilateral
- IV omeprazole 40mg/12jam - Drip parasetamol 1 gr/ 3. DM tipe 2 1700kkal/hari 6. Hipertensi on therapy
- Sucralfat Syr 3xCI - IV omeprazole normoweight - IVFD Nacl 0,9 10 tpm 7. PPOK stabil
- Trnsfusi PRC sampai 40mg/24j 4. Hipertensi (habis ganti threeway) 8. Geriatric Problem
dengan hb>10 gr/dl - Drip Ondestron 4 mg/8 terkontrol - Flumucyl tab 3x200mg 9. ISK
jam 5. Asites ec dd /1. - Laxadin syr 3x CI 10. Hipoalbuminemia
Lab 29/6/2019 - Transfusi TC 10 kolf Sirosis hepatic. 2. - Curcuma 3x200 mg 11. Hipereosilofilia
CHF. 3. Mecobalamin 500 mg/12
Hb/Ht/E/L/T Hipoalbuminia jam Th/
6,1/21/3,3/337/8,7/ Lab 30-6-2019 - Transfusi PRC s/d HB - Bed rest
MCV/MCH/MCHC: Hb/Ht/E/L/T: Th/ > 9 gr/dl - O2 2-4 lpm (NK)
65/19/29 4,8/15/2,1/16/111,7 - IVFD Nacl 0,9 20gtt - Diet Ginjal 6x200cc / hr
Diftel : 2/1/0/6/7/20/10 MCV/MCH/MCHC - Diet 1700 kkal/hari - IVFD NaCl 0,9% 30 tpm
Na/K/C: 144/3,8/108 72/23/32 - IV omeprazole Lab 30-6-2019 (mikro) s/s Dex 5%
Diftell : 8/0/0/25/10/57 40mg/24j Hb/Ht/E/L/T - IVFD Eas Sfrimer 1fls post
PT pasien/kontrol: 21,6/13,4 - Sukralfat syrup 3x1 6,7/3/2,4/336/9,4 HD
APTT pasie/kontrol: - Dulcolax syr 3xCl MCV/MCH/MCHC - IV Lansoprazole 30 mg/24
50,4/34,3 - Transfusi PRC sp HB 85/28/33 jam
Na/K/Cl : 137/3,8/106 > 10g/dl Diftell : 6/1/0/70/13/10 - Amlodipine 1x5 mg
- Balance Cairan PT pasien/kontrol: - Asam folat 2x400 mcg
15,6/13,4 - Lenal ace 2x169 mg
APTT pasie/kontrol: - Bicnat 3x500 mg
Lab 27-6-2019 39,4/34,3 - Haloperidol 1 x 0,5 mg (sore)
Hb/Ht/E/L/T Ur/Cr : 89,14 - Drip Fluconazole 500mg/24j
7,9/26/3,8/100/2,4 Na/K/Cl : 144/4,5/118 - Drip albumin 25%/24jam
MCV/MCH/MCHC HbaAg: positif - Nystatin drops 4x2cc
68/21/31 - HD (Selasa Kamis Sabtu)
Diftell : 8/0/1/64/21/6 - Balance cairan
PT pasien/kontrol: - Bos Primer (post hd)
14,33/13,7 - Gabapentin 1x100mg
APTT pasie/kontrol: - KSR 1X600 mg
32,6/34,2 - Cefepime 1gr/8j
Ur/Cr : 24/0,83
Na/K/Cl : 114/4,2/110 Lab 27-6-2019
HbaAg: positif Hb/Ht/E/L/T
9,1/27/3,2/13,3/207
MCV/MCH/MCHC
84/28/34
Diftell : 30/1/0/33/22/14
Albumin : 2,17
Ur/Cr : 26/2,73
Na/K/Cl : 145/2,5/110
Urinalisa
Berat jenis 1,010
Lekosit positif 20-25
Protein +1
Ph5
Epitel 8-10
 K4B1 K4B2 K4B3 K4B4 K4B5
DPJP : dr. Khrisna, Sp.PD DPJP: dr. Kurnia F. DPJP : dr. Kurnia F. DPJP : DPJP KARDIOLOGI
COW : dr. Reza Tandi Jamil, Sp.PD Jamil, Sp. PD dr.T.Mamfaluti,Sp.PD
DR : dr. Okdimur COW : dr. rahmi COW :dr. Rahmi COW : dr.Reza
Raber : GEH DR : dr. Wahyu DR :dr. Wahyu DR : dr. Okdimur
Raber GEH Raber : GEH Raber : GEH

Nama: Abdul Razak
TTL : 2/1/1951 (68th)
Alamat:Pidie Jaya
CM : 1-21-2451
Hari rawatan : 7
Nama: Syarifuddin K Banta
TTL : 17/06/1956
Alamat: aceh barat
CM : 1212846
Hari rawatan : 4
Nama: Kemala Laot Nama: Sudirman T Baharuddin
TTL : 05-07-1946 (72thn) TTL : 31/12/1956
Alamat: Aceh Barat Alamat :A.Besar
CM : 1-21-22-60 CM : 1012552
Hari rawatan : 8 Hari Rawatan :9

A/ A/ A/ A/ Dyspepsia type like ulcer

1.PSMBA ec dd/ 1. Sirosis hepatis 1.Kolestasis intra dan ekstra dd/- mixed
1.Gastritis erosif std hepatik ec massa caput -dismotilitas
2. Ulcus gaster diskompensata pankreas - Hipertensi stage II
3.Ulcus duodenum dengan 2. Obs Jaundice ec dd Ca
2. Fatty liver degenerasi Caput pankreas
3.Hipertensi malignan 3. Anemia Sedang ec dd
2. DM tipe 2 NW penyakit kronis Th/
Th/ Th/ 4. Hipoalbuminemia - Bedrest
- IVFD NaCl 0,9% 20tpm - Deit hati 2 1700 5. Asites ec hipoalbumin - IVFD RL 20 gtt/i
- Bedrest kkal/hari - Domperidon 3x10mg
- Diet MII 1700kkal/hari - Iv. Omeprazole Th/ - Omeprazole
- IV Omeprazole 40 mg/ 12 40 mg/12 jam - Bedrest 40mg/12 jam
jam - Lactulac syr - Diet hati 1700 kkal/ hari , - Antasidasyr 3xC1
- Sucralfat syr 3Xci 3xCI extra putih telur - Amlodipine 1x10mg
- Katrofen K/P - Sc levemir 0-0- - IVFD Nacl 0,9% 30 gtt/i - Gabapentin 1x300mg
0-20 - Dekstrose 10 % 1 fls / 24 - Clinimix + Clinoloid
Lab 29-06-2019 - Sc novorapid 10- jam 1fls /hari
Hb/Ht/E/L/T 10-16 - IV Omeprazole 40mg/12j - Tutofusin drip 20gtt/i
14,5/41/4,8/199/4,9 - Spironolacton - IVFD Aminofusin Hepar 1 - Mecobalamin 3x1
MCV/MCH/MCHC 2x1 fls / 24 jam tab
85/30/36 - Furosemid 20 mg / 24 jam
Diftell : 620/48/31/13 Lab 28/06/2019 - Curcuma 3x1
HB/HT/E/L/T : - Tramadol 50mg 2x1 Lab 27/06/2019
Lab 25-06-2019 12,5/35/4/5,8/93 - Ketorolac syr 3xcl HB/HT/E/L/T :
Hb/Ht/E/L/T MCV/MCH/MCHC : - Novalgin 1 amp exxtra 11,8/32/4/7,3/389
18,2/51/6,1/5,6/246 88/32/36 - Sucralfat syr 3xc1 MCV/MCH/MCHC : 80/30/37
MCV/MCH/MCHC Diftel : 3/1/0/74/13/9 Diftel : 3/1/0/52/34/10
85/30/35 UR/CR; 39/0,55 Lab 26/06/2019 PT/kontrol:14.1/13,1
Diftell : 2/1/0/57/24/16 Na/K/Cl : 138/4,8/107 Alb 2,63 APTT/kontrol 32,5/36,5
HBSAG Anti HCV negatif Na/K/Cl 135/4,2/109 UR/CR 12/1,3
Alb 5,54 Lab 22/06/2019 Na/K/Cl : 136/4/111
Gds 111 HB/HT/E/L/T : Hbsag hcv negatif
Na/K/Cl : 133/3,8/106 9,8/26/3,1/7,2/200
Ur/Cr : 33/1,32 mCV/MCH/MCHC :
82/32/38
Diftel : 2/1/0/73/15/9
GDS : 123
UR/CR 24/0,55
Na/K/Cl : 136/3,8/110
SGOT/SGPT : 146/82
Alb : 2,66
 K5B1 K5B2 K5B3 K5B4
K5B5
DPJP : dr. Islamuddin, DPJP: dr. Kurnia F. Jamil, DPJP :dr. T Mamfaluti DPJP : dr. Kurnia, sp.PD DPJP: dr. Azhari
Sp.PD Sp.PD SPPD COW : dr. Rahmi
COW : dr. Febri COW : dr. rahmi COW : dr. T. M. Reza DR : dr. Wahyu Gani SPPD
DR : dr. Akmal DR : dr. Wahyu DR : dr. Okdimur Raber : COW: dr. Rahmi
RABER: Neuro Raber: kardio, EMD
Dr: dr. Wahyu
Nama: Ibrahim Muhammad Nama: M Nurdin Rusli Nama: Suryanullah Zainuddin Nama: Husaini Nurdin Nama: Furqan Abdullah
TTL : 31/12/1957 (61 thn) TTL : 7/7/1986 (32 thn) TTL : 17/7/1985 TTL : 30/05/1963(56thn) TTL : 01/11/1991(27
Alamat : Bireun Alamat : Aceh Besar Alamat :Bireuen Alamat :Aceh Pidie thn)
CM : 1-17-05-97 CM : 1-21-29-7 CM : 1163405 CM : 1-21-05-52 Alamat : bireun
Hari Rawatan :6 Hari Rawatan :3 Hari rawatan : 7 Hari Rawatan :12 CM : 1-20-31-05
Hari Rawatan :7
A/ A/ A/ A/
1.PSMBA ec dd/ 1. Leukositosis ec dd - Struma nodusa toksik 1.
dd/ A/ pansitopenia ec dd/
-gastritis erosive - CML - DM tipe 2 -
Trombositosis esensial -anemia aplastic
-ulcus gaster - LLL - Hiponatremi -
Trombositosis relatif -leukemia
-ulcus duodenum - AML 2.
Varises vena safena -MDS
2.Anemia berate c dd/ 2. Hipernatremio Ringan Th/ magna sinistra et vena
-perdarahan 3. AKI stage 1 prerenal - Tirah baring tibialis anterior Th/
-peny.kronik 4. Kesadaran menurunan ec - Diet sonde 6x200 cc/hari 3. Hematuria ec dd/ -Bedrest
3.AKI Stage 3 dd Acute on dd - Iv ceftriaxone 2gr/24j - Isk -IVFD RL 20 gtt/i
CKD - Meningitis - Sc levemir 0-0-0-22 unit - Bsk -iv.omeprazole
4.Hipertensi terkontrol - Stroke - Propanolol tab 2x40mg - Ca Buli 40mg/12 jam
5.Post stroke (6tahun) - Metastase proses - IVFD nacl 0,9 20tpm 4. Hiperkalemia ringan - Sucralfat Sir 3x CL
- Imbalance Elektrolit - Thyrozal tab 1x20mg - IV ondansentron
Th/ Th/ 4mg/8j
- Bed rest Th/ Lab 29-06-2019 - Bedrest -Paracetamol 500mg
- IVFD 0,9% NACL - Bedrest Hb/Ht/E/L/T - IVFD NaCl 0,9% 20tpm extra
- Lansoprazole30mg/12 - NTG, Kateter 12,7/34/4,6/10,4/117 - Diet MB 1700 kkal/hr -tranfusi PRC sampai
jam - O2 2-4l/menit MCV/MCH/MCHC - omeprazole 2x20mg HB > 10gr/dl
- Sucralfat syrup 3Xci - Diet sonde 6x200cc 75/28/37 - domperidone 3x10mg
- Transfusi prc sd - IVFD NaCl 0,9% Diftell : 0/1/0/74/14/11 - aspilet 1x80mg Lab 29-6-2019
HB>10gr/dl 20gtt/menit Na/K/Cl 135/2,5/99 - Kalitake 3x1 sach Hb/Ht/E/L/T :
- Paracetamol 3x500mg - Cytodrox 1x500mg 9,6/27/3,3/1,1/47
- Paracetamol 1gr (extra) - Drip heparin 300 MCV/MCH/MCHC :
Lab 29-6-2019 - Meropenem 2gr/24j Lab 27-06-2019 unit/24jam (h3) diberikan 82/29/35
Hb/L/T - Deametason 1 amp/6 jam Free t4/TSHs : 19,38/0,018 selama 5-7 hari (saran Diftel : 0/0/0/14/81/5
10.2/9,6/220 - Ranitidin 1 amp/12 jam dari BTKV)
MCV/MCH 77/26 - Citicolin 500/12 jam Lab 25-06-2019 Lab 27-6-2019
Diftel 2/0/0/74/16/8 - Fosen enema extra supp Hb/Ht/E/L/T Lab 29-6-2019 Hb/Ht/L/T
Ur/Cr: 22/2,8 15,8/47/5,6/31,7/245 PT/APTT 8,0/23/0,7/37
Lab 29-6-2019 MCV/MCH/MCHC 15,50/48,7 MCV/MCH/MCHC
Lab 27-6-2019 Hb/Ht/E/L/T : 84/28/34 83/29/35
Hb/L/T 12.2/37/4.3/129,9/571 Diftell : 0/0/1/87/7/5 Diftell
7,5/7,9/141 MCV/MCH/MCHC : GDS 448 Lab 28-6-2019 0/0/0/11/84/5
MCV/MCH 77/27 86/28/33 Ur/Cr 35/0,63 Hb/Ht/E/L/T :
Diftel 2/0/0/77/14/7 Diftel : 1/12/0/75/10/2 Na/K/Cl 125/5,6/103 15.4/49/6.2/35,8/1441
MDT Kalsium : 9.1 Lab 27-06-2019 MCV/MCH/MCHC : 78/25/32 Lab 25-6-2019
Anemia hipokrom Na/K/Cl : 147/4.4/107 T4 19,38 Diftel : 7/3/0/81/6/3 Hb/Ht/L/T
mikrositer dengan Ur/Cr 69/1.23 TSHs 0,018 Na/K/Cl : 142/5.7/106 6,9/20/2,1/53
trombositopenia Diftell
Kolestoral total/LDL 0/0/0/3/92/5
88/54 Lab 25-6-2019 PT/APTT
Trigliserid 103 Hb/Ht/L/T 14,50/32,60
15,3/49/34,9/1535 GDs: 173
Lab 25-6-2019 Albumin: 4,73 Ur/Cr
PT/APTT Ur/cr: 23/0,99 44/1,15
14,40/29,30 Na/K/Cl Na/K/Cl
HBsAG: Negatif 136/5,9/110 135/3,9/109
Anti HCV: Negatif
GDs: 126
Ur/Cr: 100/3,80 Lab 23-6-2019
Na/K/Cl: 144/3,8/115 Hb/Ht/L/T
15,2/48/6,3/34,8/1704
MCV/MCH/MCHC : 77/24/31

Lab 20-6-2019
Hb/Ht/L/T
14/43/29200/1.220.000
MCV/MCH/MCHC : 80/25/31

URINALISA
Leukosit/darah: +/+
Eritrosit: 250-270

Lab 21-6-2019
PT/APTT: 16,70/50,80
 K6B1
DPJP :dr. Darma SPPD
COW : dr. Qadriyana
DR : dr. Taufik
Nama: Kamaludin Idris
TTL: 24/7/2001 (17Thn)
Alamat: Gayo Lues
CM: 1-21-24-64
Hari Rawatan: 7
A/
1.Bisitopenia ec dd
1.AML
2.Hepatitis viral
2.Post PSMBA ec dd
1.Varises esofagus
bleeding
2.Varises fundus bleeding
3.Massa intraabdomen
4. Cancer pain
5. curiga budchiari syndrom
Th/
- Tirah baring
- Diet hati II 1700
kkal/hari
- IVFD Aminofusin hepar
1 fl/hari
- IVFD Dextrose 5%
10tpm
- IV Omeprazole
40mg/12jam
- Domperidone 3x10mg
- Cucuma 3x1 tab
- Lactulac syr 3XCII
- Transfusi PRC sd Hb
>10gr/dl
- MST tab 2x10mg
- Katrofen supp ekstra
- Cetirizine 1x10mg
- Paracetamol 1 gr extra
Lab (29/06/19)
Hb/Ht/E/L/T:
8,1/2/2,5/11,2/20
MCV/MCH/MCHC:
95/33/35
Diftel:
0/1/0/32/26/41
Lab (26/06/19)
Hb/Ht/E/L/T:
6.2/18/1,8/11,6/40
MCV/MCH/MCHC:
102/35/34
PT/APTT: 16,70/43.30
MDT :
Kesimpulan : Anemia
Normokrom dengan
atypical mononucklear sel
+, + trombositopenia
Saran L: Follow up MDT 1
lagi
Lab (26/06/19)
Hb/Ht/E/L/T:
6,2/18/1,8/11,6/40
MCV/MCH/MCHC
102/35/34
Diftell
1/0/0/30/28/41
MDT anemia normokrom
dg atypical mononuklear
sel+ trombositopenia
PT/kontrol 16,7/13,1
APTT 43,30/32,2
K6B2 K6B3 K6B4 K6B5
DPJP: dr. Hendra Z,Sp.PD DPJP: dr. Azhari Gani DPJP: dr. Islamuddin SPPD DPJP UROLOGI
COW : dr. T. M. Reza SPPD COW: dr. Afrizal
DR : dr. Okdimur COW: dr. Rahmi Dr:
Raber: GEH Dr: dr. Wahyu
Nama: Rahmad Saman Nama: M. Yati Nama: M. Daud
TTL : 1/7/1983 (35th) TTL: 01-07-1951 TTL: 01/04/1979
Alamat : Gayo Lues Alamat: Aceh Selatan Alamat: Aceh Besar
CM : 0941205 CM: 1-21-22-28 CM: 1-21-10-40
Hari Rawatan :6 Hari Rawatan: 9 Hari Rawatan: 2
A/ A/ A/
1.PSMBA ec dd/ 1. Hematoskezia ec dd 1. Obs. Jaundice ec dd: 1.
1.Varises esofagus - Polip recti Kolesistitis,2. Kolelitiasis dg
bleeding - Hemoroid interna kolesistitis, 3. Kolengitis
2.Varises fundus - Ca recti
bleeding Th/
2. Hipertensi on Terapi Th/ - Bed Rest
3. .Sirosis hepatis std - Bed Rest - Diet hati 1700kkal/hr
decompesata related - Diet MB 1700kkal/hr - IVFD NACL 0.9 20gtt
hepatitis B - IVFD NACL 0.9 30gtt - IV Cefoperazole 1 gr/12 jam
4. Anemia Berat Hipokrom - IV omeprazole 40mg/12j - IV omeprazole 40mg/12j
Mikrositer ec dd - IV asam traneksamat - Kolestiramin 4 mg/12 jam
1. Perdarahan 150mg/8j - Urdafalk 250 mg/8 jam
2. Penyakit Kronis - Attapulgit 1/mencret
-Nystatin drop/6jam 27/6/19
Th/ PT/kontrol 13,6/13
- Bedrest 30/6/19 APTT/kontrol 38,5/33,2
- NGT Hb/Ht/E/L/T
- IVFD NaCl 0,9% 20tpm 11,2/31/,7/11,8/548 24/6/19
- Omeprazole 40 mg/ 12 MCV/MCH/MCHC Hb/Ht/E/L/T
jam 85/31/36 11,4/33/3,7/7,8/300
- Sucralfat syr 3xci Diftell : 3/1/0/6/8/20/8 MCV/MCH/MCHC
- Propanolol 1x10mg Ur/Cr : 16/0,68 89/30/34
- Domperidone 3x10mg Na/K/Cl: 142/3,5/107 Diftell : 5/1/0/62/24/8
SGOT/SGPT: 59/433 HBSAG Anti HCV negatif
Lab 29-06-2019 Bilirubin total/direct: GDS 78
Hb/Ht/E/L/T 38,39/24,67 Alb 5,91
6,4/21/2,8/2,6/50 Ur/Cr : 14/0,78
MCV/MCH/MCHC Na/K/Cl: 137/3,4/109
75/23/31
Diftell : 9/0/0/61/20/10
PT/APTT : 18.30/38.40
Billirubin T/D/I :
1,12/0,36/0,76
Lab 25-06-2019
Hb/Ht/E/L/T
6,4/20/2,8/2,4/23
MCV/MCH/MCHC
73/23/31
Diftell : 3/0/0/63/22/12
GDS : 102
Hbsag: positif
Ur/Cr : 36/0,75
Na/K/Cl: 135/3,4/111
Lab (25/06/19)
Hb/Ht/E/L/T:
5,6/16/2,1/19,0/203
MCV/MCH/MCHC
73/26/36
Diftell
2/1/0/80/10/7