AQSHA 2 (PENYAKIT DALAM PRIA)

Hari / Tanggal : Selasa, 03 Maret 2020

Dokter Jaga : dr. hambali/ dr. vincen
Dokter Muda : zouhra / syarifah

*K1B1* *K1B2* *K1B3* *K1B4* *K1B5*

DPJP: Dr.dr.Azhari Gani, SpPD-
DPJP: dr. Diana erlita, Sp.PD DPJP: dr. Azzaki, Sp.PD DPJP: dr.T. Mamfaluti, SpPD DPJP: dr.T. Mamfaluti, SpPD
KKV
COW: dr. Fardhiansyah COW: dr. Munawar COW : dr. Dedi COW : dr. Dedi
COW: dr. T. Fahril
DR: dr. Amelia DR: dr. Zulfikar DR : dr. Amelia DR : dr. Amelia
DR: dr. Viencen
Raber : GEH Raber : Raber: Raber:
Nama: Risno Ariswansyah Nama: Safari Basyah Nama: M. Ali Ishak Nama:M.Yusuf Nama: Nain M Noer
TTL: 05/09/1983 TTL: 01/07/1955 TTL: 25/04/1979 (40th) TTL: 02/09/1947(72th) TTL: 06-02-1968 (52 th)
Alamat: Simeulue Alamat: Aceh besar Alamat: Bireun Alamat: Aceh Barat Alamat: Sabang
CM: 1238759 CM: 1167469 CM: 1239574 CM: 1239166 CM: 1237990
Hari rawatan: 12 Hari rawatan: 1 Hari rawatan: 2 Hari rawatan: 6 Hari rawatan: 18

A/ A/ A/ A/ A/
1. Hepatomegali ec dd 1. PSMBA ec dd / 1. CKD stage V ec dd 1. PSMBA ec dd/ 1. CKD stg V dengan uremic
-Susp abses suprarenal 1. Ulcus gaster 1. DN 1. gastritis erosif syndrome ec PNC
- Multiple nodul a/r liver sinistra 2. Ulcus duodenum 2. PNO 2. ulkus gaster 2. DM tipe 2 NW
- Nodul a/r corpus panceas 3. Gastritis erosif 3. HN 3. ulkus duodenum 3. Anemia berat NN ec peny.
2. DM tipe 2 NW 2. anemia sedang NN ec dd/ Kronis-Def besi
Th/ 3. Hipertensi Heart Disease 1. perdarahan akut 4. Hipokalemia Berat
- Bedrest Th/ 4. hipoalbuminemia 2. penyakit kronik 5. Hipokalsemia
- Bedrest
- IVFD Aminofusin hepar 1fls/hari 3. geriatri problem 6. Hiponatremia hipoosmolar
- Coditam 3x1 - Diet MB 1800kkal/hari Th/ 4. hipoalbuminemia hipovolemik
- Threeway
- Curcuma 3x1 - Bed rest 5.ISK
- Ceftriaxone 1gr/12j - IV Lansoprazole 30mg / 12 jam - Diet DM 1700kkal/hari + 0,8 gr Th/
- Sucralfat syr 3 x CII
- Kaltropen sup K/P protein/kgbb/hari + rendah garam Th/ - Bedrest
- lactulac 3xCII - Domperidon 3 x 10mg - Threeway - Bedrest - Diet ginjal 1700kkal/hari, protein
-Drip Metronidazole 500 mg/8 jam - IV Furosemide 1 amp / 8 jam - Diet MB 1700 kkal/hari + 0,8 gr/kgBB/hari
-omeprazole 40mg/12j iv - Valsartan 1 x 80mg ekstra putih telur - IVFD NaCl 0,9% 20 tpm
- Albumin 25% / 24 jam - IVFD RL 20 gtt/i - lenal ace 2x169mg
Lab 2/03/2020 -ramipril 5mg/24j po - IV. Omeprazole 40 mg/12j - asam folat 2x0,4mg
Hb/Ht/E/L/T: 10,1/31/3,9/15,7/465 -sucralfat syr 3Xcii - IV ondancetron 4mg/12j
MCV/MCH/MCHC: 79/26/33 Lab 01/03/2020 -Ceftriaxone 1gr/12j iv - Paracetamole 1gr extra
Diftel : 2/1/0/72/15/10 Hb/Ht/E/L/T: 7,7/22/2,8/14,5/357 -attapulgite 2 tap tiap bab mencret
MCV/MCH/MCHC: 79/27/35 Lab 27/02/2020 -alprazolam 0.5mg/24jam
Diftel : 9/1/0/67/16/7 Hb/Ht/E/L/T: - Novomix 12-12-12 SC
Lab 24/02/2020 8,3/25/2,9/11,6/211 - KCL 25 meq extra
AFP : 13,44 MCV/MCH/MCHC: 87/29/33 -mecobalamin 500mg/12j po
Diftel : 2/0/0/82/10/6 -meropenem 1gr/24j iv
Lab 21/02/2020 INR : 1,28
Hb/Ht/E/L/T: 10,6/33/4,1/15,1/532 Kalsium : 6,5
MCV/MCH/MCHC : 80/26/32 GDS: 125 Lab 1/03/2020
Diftel : 3/1/0/66/19/11 Na/K/Cl : 140/3,6/112 Ca:5.5
Anti HCV : nefatif Na/k/cl:128/2,0/101
HbSag : non reaktif Urinalisis 27-02-2020
Bil. Total/direct/indirect : Warna: kuning Lab 29/02/2020
1,21/0,70/0,51 Kejernihan: keruh Hb/Ht/E/L/T: 7,4/20/2,8/13,2/159
SGOT/SGPT: 100/25 Berat Jenis: 1,027 MCV/MCH/MCHC: 72/26/37
GDS : 116 pH: 5,0 Diftel : 1/1/0/79/8/11
Ur/cr : 17/0,60 leukosit : positif
NA/K/cl 140/3,80/103 protein : negatif Lab 28/02/2020
glukosa :negatif Hb/Ht/E/T/L: 6,7/18/2,5/156/21,6
keton: positif MCV/MCH/MCHC: 71/26/37
Nitrit : negatif Diftel : 0/0/0/85/3/12
urobilirubinogen: positif Na/K/Cl/Ca : 131/2,0/99
bilirubin: negatif Ur/Cr : 148/6,20
darah: positif
leukosit: 8-10 Lab 27/02/2020
eritrosit: 10-15 Hb/Ht/E/T/L: 5,8/15/2,2/186/17,2
epitel: 3-5 MCV/MCH/MCHC: 71/27/38
bakteri : positif Diftel : 0/0/0/84/6/10
Na/K/Cl/Ca : 127/1,9/96/5,2
Ur/Cr : 130/5,5
 *K2B1* *K2B2* *K2B3* *K2B4* *K2B5*

DPJP: dr Abdullah SpPD-GH DPJP: dr. Kurnia Fitri, Sp.PD DPJP: dr.M.Riswan, SpPD
COW: dr Aidil COW: dr. Nadi COW : dr
DR: dr Teguh DR: dr. Riyanda DR : dr. Amelia
Raber : Raber : HOM, GEH Raber:
Nama : Basyarudin Matbari Nama: M. Tali Nama: Rustam Affan
TTL : 01-07-1974 (34th) TTL: 08/05/1967 (52th) TTL: 05/08/1965 (54th)
Alamat : Aceh selatan Alamat: Simeulue Alamat: Banda Aceh
CM: 1-00-00-86 CM: 1-23-79-95 CM: 1-07-63-71
Hari Rawatan: 10 Hari rawatan:19 Hari rawatan: 2

A/ A/ A/
1. CKD stage V on CAPD 1. Diare kronis ec dd: 1.penurunan kesadaran ec dd
2. Pneumonia HAP - Colitis TB -sepsis
3. Hipertensi std I on terapi - Ca Colon -uremic encephalopati
2.Hipoalbumin sedang ec dd/ -stroke recurrent
Th/ 1. Low intake 2.CKD stg 5 ec dd
- Bedrest 2. Liver failure -HN
- Diet ginjal 1700 Kkal/hari + 3. Hiponatremia dengan -PNC
0,8 gr protein /kgbb/hari hipoosmolar (perbaikan) 3.BSK
- Lenal Ace 169 mg/12j 4.TB paru dengan sekunder infeksi 4.Pneumonia
- AS folat 400 mcg /12j 5. Hepatitis B kronik 5.HHD
- KSR 600mg/12j 6. Syndrome frailty (sarkopenia) 6.Anemia sedang ec peny ginjal
- Curcuma /8j kronik
- Fluconazole on CAPD Th/ 7.recurrent stroke iskemik\
- Ceftriaxone 2gr/24jam -IVFD NaCl 0,9% 30tpm
-Diet hati III 1800kkal/hari (30gr Th/
Lab 28-02-2020 protein/hari) + ekstra putih telur 6 - Bedrest
Hb/Ht/E/L/T: 7,9/24/2,9/24,4/707 butir / hari - Diet ginjal 6x200cc/24j+pro
MCV/MCH/MCHC: 84/27/33 -attapulgite 1 tab/x BAB cair 65mg/hr
Diftel: 1/0/0/86/8/5 -PCT 500mg/8j -NGT/Kateter
-Ceftriaxone 2gr /24j -vancomycin 500mg
Lab 25-02-2020 -Albumin 25% 200cc/24j -lansoparazole 30mg/24j iv
Hb/Ht/E/L/T: 7.7/23/2.8/18.6/681 - Zinc 10mg/12j -as folat 400mg/12j
MCV/MCH/MCHC: 83/27/33 - Aminofluid 1fl/24j -lenal ace 169mg/12j
Diftel: 5/0/0/78/9/8 - Vit K 1 amp/24 jam -flumucil 200mg/8j
- Asetilsistein 200mg 3x1 -amlodipin 10mg/24j
Lab 21-02-2020 - Vit D 0,25mg/24 jam -citicolin 500mg/12j iv
Anti HCV negatif -kalsitriol 1,25mg/24j po
HBsAg Non reaktif Lab 28/02/2020 -clopidogrel 75mg/24j po
Albumin 2,49 LED : 10 -pct 500mg/8j po
Ca : 8,1 Bilirubin tot/direk/indirek : -alb 25% 1fls/24j
2,47/1,75/0,72
Lab 20-02-2020 SGOT/SGPT : 40/26 Lab 28-02-2020
Hb/Ht/E/L/T: 8.3/24/2.9/17.3/631 Albumin : 2,34 Hb/Ht/E/L/T: 8,6/25/3,0/6,4/235
MCV/MCH/MCHC: 83/38/34 MCV/MCH/MCHC: 83/29/34
Diftel: 3/1/1/79/8/8 Lab 25/02/2020 Diftel: 2/1/0/76/13/8
Albumin 3,20 Ratio PT /APTT :1,2/1,45 Pt/aptt:17,30/42,70
GDS 100 protein total: 5,0 Ca/mg:5,5/2,0
Ur/cr 83/14.10 albumin: 2,0 GDS:118
NA/K/CL 140/2,7/96 globulin: 3,0 Ur/cr:172/11,60
Na/k/cl:126/5,5/95
Lab 24/02/2020
PT : 17,00 Lab 25/02/2020
APTT :53,50
Hb/Ht/E/L/T: 8,4/24/3,1/67,3/378
Lab 22/02/2020 MCV/MCH/MCHC: 80/27/34
Ratio PT/APTT : 1,24/1,75 Diftel: 4/0/0/67/19/10
D-dimer : 470

*K3B1* *K3B2* *K3B3* *K3B4* *K3B5*

DPJP : dr.T.Mamfaluti,Sp.PD DPJP: dr. Kurnia Fitri Jamil,

DPJP: dr. Kurnia Fitri, Sp.PD DPJP: dr.M Riswan, SpPD DPJP: dr.Azhari Gani
Sp.PD-KPTI
COW: dr. Nadi COW : dr. Dedi COW: dr. Reza COW: dr. T. Fahril
COW:
DR: dr. Riyanda DR : dr. Amelia DR: dr. Nelvi DR: dr. Viencen
DR: dr. Rianda
Raber : GEH Raber: GH Raber: Raber : GH
Raber: Bedah Urologi, hom
Nama : Muratip Simin Nama: Abdullah Ahmad Nama: Abdul Karim Nama : Zaino Syamaun Nama :Zakaria Yahya
TTL : 16-04-1954 (65th) TTL: 07/02/1955 (65th) TTL: 24-05-1999 (60th) TTL :03/07/1957 TTL :01-07-1966 (53th)
Alamat:Aceh Tengah Alamat: Bireun Alamat: Banda Aceh Alamat : Pidie Jaya Alamat : Bireuen
CM: 1-23-88-70 CM: 1-23-88-57 CM: 1238869 CM : 1-23-90-37 CM : 1-23-90-37
Hari Rawatan: 10 Hari rawatan: 10 Hari rawatan: 10 Hari rawatan : 5 Hari rawatan :8

A/
1. PSMBA (perbaikan) ec dd
- Gastritis Erosif
- ULkus gaster
-Ulkus Duodenum
-Ca gaster
2. Anemringan NN ec PSMBA
3. PPOK derajat sedang stabil
Th/
-IVFD NaCl 0,9% 30 tpm
-Diet MII 1700 Kkal/hari
-IV Ceftriaxone 2gr/24 jam
-Sucralfat syr 3xCII
- Nebule Combivent 1 resp/12 jam
- Paracetamole 1000mg/24 jam
-Omeprazole 40mg/12j
- Asetil sistein 3x200mg
Lab 28-02-2020
Hb/Ht/E/L/T: 11,2/34/4,1/7,1/317
MCV/MCH/MCHC: 83/28/33
Diftel: 9/1/0/68/13/9
Lab 25-02-2020
Hb/Ht/E/L/T: 6,9/21/2,4/6,7/282
MCV/MCH/MCHC: 86/29/34
Diftel: 5/0/0/69/14/12
Lab 23-02-2020
Hb/Ht/E/L/T: 4,9/15/1,7/7,2/219
MCV/MCH/MCHC: 89/29/33
Diftel: 2/0/0/71/15/12
PT/APTT: 14,20/32,70
Anti Dengue IgM : negatif
Anti Dengue IgG: Negatif
Anti HCV :negatif
HBsAg: Non reaktif
Bilirubin total : 0,28
Bilirubin Direct : 0,06
Bilirubin Indirect : 0,22
GDS: 190
Ur/cr : 46/1,10
A/
1.AKI stg 3 renal dd akut on CK
D egali ec dd
2.Pneumonia
3.post ureterolitotomi a/r BSK
4. ISK
5. Anemia sedang NN ec dd
- Perdarahan
- Penyakita kronik
6.Hipoalbumin
Th/
Bedrest
-Diet ginjal 1700 kkal/hari + 35
gr protein
- IV Omeprazole 40mg/12 jam
- Bicnat 3x1
- Fluimucyl 200mg/8jam
- Allopurinol 100mg/ 24 jam
- Kalitake 3x1 sach
-Ramipril 5 mg / 24 jam
- Asitelsitein 200mg/8j
- Gentamycin 1 gram?/8 jam
- Fluconazole 200 mg/24 jam
- Anti hemoroid supp / 12 jam
Lab 01-03-2020
Hb/Ht/E/L/T:
7,3/22/2,5/11,3/469
MCV/MCH/MCHC: 87/29/33
Diftel: 1/1/0/71/16/11
Lab 29-02-2020
Hb/Ht/E/L/T:
7,1/22/2,5/12,5/525
MCV/MCH/MCHC:88/29/32
Diftel: 1/1/0/76/13/9
Albumin : 2,9
Lab 26-02-2020
Hb/Ht/E/L/T:
8,2/24/2.9/18.3/428
MCV/MCH/MCHC:84/24/34
Diftel: 1/0/1/78/9/11
Psa total 6,57
ur/cr 117/2,54
Lab 23-02-2020
Hb/Ht/E/T/L:
8,7/25/3,1/22,4/159
MCV/MCH/MCHC: 81/28/35
Diftel: 2/0/0/78/10/10
Anti HCV : negatif
HBsAg : Non reaktif
Bilirubin total : 4,35
Bilirubin Direct : 3,11
Bilirubin Indirect : 1,24
Albumin : 2,50
Na/K//Ca : 137/5,3/7,5
Ur/cr: 199/4,50
A/ A/ A/
1. Pansitopenia dengan hepatosplenom 1. Pansitopenia ec dd 1. CKD stg 5 ec dd
- Anemia aplastik -PNC
- Thalasemia - MDS -DN
-MDS - Acute leukimia -HN
-Chronic Leukimia 2. Herpes zooster dd impetigo 2. HT Stage II
- Aplastik bulosa 3. BSK
2. CAD (septal iskemik) kompensata 3. Hiperglikeia reaktif induced 4.DM Tipe 2 NW
3. Nefrolithiasis dextra steroid dd MDT2 dengan critical
4.. DM Tipe II NW ill Th/
5. Hipoalbuminemia ringan (3,2) 4. AKI stage I prenal -Bedrest
6. PPOK stabil 5. Hipoalbumin - diet ginjal 1700kkal/ha
7. Susp HCC dd 6. Candidiasis oral gr/ KGBB/Hari
- Cholelithiasis - IVFD NaCl 0,9% 10 t
- Cholesistitis chronic Th/ - Bicnat 500 mg/ 8 jam
- Bedrest -Allopurinol 300mg/ 24
Th/ - Diet DM 1700 kkal/hari - Fluimucyl 200 mg/ 8 j
Bedrest - IVFD NaCl 0,9% 30gtt -Amlodipin 10 mg/ 24 j
-Diet DM 1700 kkal/hari - Drip Albummin 25% 100cc - Lenal Ace 16 mg/ 12 j
- IVFD Nacl 0,9% 20 gtt/i /24jam - IV Levofloksaxine 500
- IV Ceftriaxone 2gr/24 jam - Drip novorapid 50unit jam
- Nebul combivent 1 supp/12 jam - Novalgin drip dalam 50 cc NaCl - resfar 1000mg + 200c
- Tramadol 2x50mg 0,9% 500cc 0,9% habis dalam 4 jam
- Asetil sistein 3x1 - IV ceftriaxone 1gr /12jam - Sucralfat syr C1 / 8 jam
-transfusi PRC s/d hb >10 - Sandimun 2x100cc -omeprazole 40mg/12j i
- Nystatin drop 4x 2cc -kopolac syr c2/8j
Lab 01-03-2020 -Donperidon 10mg/12j
Hb/Ht/E/L/T: 9,3/29/5,0/3,0/88 Lab 28-02-2020
MCV/MCH/MCHC: 59/19/32 Hb/Ht/E/T/L: 4,6/13/1,6/8/3,4 Lab 27-02-2020
Diftel: 2/1/10/59/27/11 MCV/MCH/MCHC: 81/29/35 Hb/Ht/E/L/T: 11,8/33/4
Diftel: 0/1/0/82/12/5 MCV/MCH/MCHC:75/
Lab 26-02-2020 Albumin : 2,2 Diftel: 2/1/0/68/23/6
Bilirubin total : 1,71 GDS : 565 Kalsium :L 8,4
Bil. Direct/ indict : 0,84/0,87 Na/K//Ca : 132/5,8/97 Na/K//Ca : 139/4,6/101
SGOT/SGPT: 283/149 Ur/cr: 126/1,6 Ur/cr: 188/16,20
Lab 25-02-2020 Lab 26-02-2020
Ratio PT/APTT : 2,0/1,57 Glukosa puasa 111
Albumin : 3,24 glukosa darah 2 jam pp
Urinalisis 24-02-2020 Urinalisis 25-02-2020
Warna: kuning Warna: kuning
Kejernihan: jernih Kejernihan: keruh
Berat Jenis: 1,019 Berat Jenis: 1,008
pH: 6,0 pH: 5,0
leukosit : negatif leukosit :positif
protein : negatif protein : positif (1)
glukosa : negatif glukosa :positif (1)
keton: negatif keton: negatif
Nitrit : negatif Nitrit : negatif
Urobilirubinogen: negatif Urobilirubinogen: posit
bilirubin: negatif bilirubin: negatif
darah: negatif darah: positif
leukosit:1-2 leukosit:10-15
eritrosit: 0-1 eritrosit: 8-10
epitel: 2-3 epitel: 3-5
Lab 23-02-2020 Lab 24-02-2020
Hb/Ht/E/T/L: 7,7/25/4,5/4,1/98 Hb/Ht/E/L/T: 12,6/35/4
MCV/MCH/MCHC: 54/17/31 MCV/MCH/MCHC:75/
Diftel: 2/1/0/64/25/8 Diftel: 0/1/0/907/2
Anti HCV : negatif
HBsAg : Non reaktif
GDS : 174
Na/K//Ca : 131/5,3/97
Ur/cr: 250/20
 *K4B1* *K4B2*
DPJP: dr. M. Diah, Sp.PD-
DPJP : dr.T.Mamfaluti,Sp.PD
KKV
COW : dr. Dedi
COW: dr. Muhamaji
DR : dr. Amelia
DR: dr. Dedi
Raber:
Raber :
Nama : Busra Sofyan
TTL : 9/5/1987(32 th) Nama : Suherly Usman
Alamat :Sabang TTL : 27-06-1957 (62th)
CM : 1175652 Alamat : Aceh Barat
Hari Rawatan : 2 CM: 1-23-45-69
Hari Rawatan: 1
A/
1. CKD stage V on CAPD ec dd A/
1.HN, 2. PNC dengan udem paru akut 1. Penurunan Kesadaan ec dd :
2. Hipertensi Stage 1 on terapi -SDA
3. Anemia sedang NN on PGK - Sepsis
4. Hipoalbumin - Stroke
2. Sepsis ec dd :
Th/ - Urosepsis
Bed rest - pneumonia
Threeway 3.Nefrolithiasis D
O2 2-4 l/i K/P 4.hematuria ec dd/
Diet ginjal 1700 kkal / hari + 50 gr -cystisis
protein / hari -BPH
Diet NTG 10mg dalam Nacl 0,9% 5.DM tipe 2 OW
50cc mulai dari 5 meq 6.AKI stg 3 diabetic nefropati
Drip Furosemid 2cc / jam 7.hipernatremia
Amlodipine 10mg/24 jam 8.HHD
Lab 01-03-2020 Th/
Hb/Ht/E/L/T:6,1/18./2,2/10,1/156 -Bedrest, senifouler
MCV/MCH/MCHC: 82/28/34 - NGT, kateter
Diftel: 5/0/0/77/12/6 -Diet sone 6x200cc + pro
Na/K/Cl : 141/3,8/101 -IVFD nacl :DEX 2;1 20gtt
Ur/Cr : 167/21,00 -ceftriaxone 2gr/12j/iv
GDS: 119 -omeprazole 40mg/12j iv
-citicolin 500mg/8j/iv
-flumucyl 200mg/8j po
As folat 400mg/24j po
-atorvastatin 20mg/24j po
-valsartan 80mg/24j po
Lab 26-02-2020
Hb/Ht/E/L/T:
10,7/34/3,8/12,9/600
MCV/MCH/MCHC: 88/28/32
Diftel: 6/1/0/75/13/5
*K4B3* *K4B4* *K4B5*
DPJP: Dr.dr.Azhari Gani, SpPD-
DPJP: Dr.dr.Azhari Gani,
KKV DPJP : dr. Diana Erlit
SpPD-KKV
COW: dr. T. Fahril COW : dr. Fardiansya
DIVISI KARDIO
DR: dr. Viencen DR: dr. Amelia
Raber : pulmo, remato, GH
Nama : Irsandi Nama: Syamsul Mak Arif Nama : Ajibullah M Ali
TTL : 2/2/1992 (28 thn) TTL: 05-01-1943 (77th) TTL : 01/07/1950 (69th)
Alamat : Banda Aceh Alamat: Aceh Besar Alamat : Aceh Besar
CM : 1239404 CM: 00995255 CM : 0897842
Hari Rawatan : 5 Hari rawatan: 20 Hari rawatan : 10
A/ A/ A/
DD/ 1. CHF Fc NYHA II-III 1. PSMBA (perbaikan)
- Flebitis 2.CKD Stage 5 2. AKI stage III renal
- Selulitis 3.Efusi genu dextra ec dd 3. Anemia sedang ec dd
- Erisipelas -oa genu - perdarahan akut
- Facies necrotizing -gout atritis - penyakit kronis
2. Dyspepsia ec dd 4,susp OA lumbal
- tipe dismotility Th/
- tipe mixed Th/ -Bedrest
- Bedrest -Diet ginjal 1700 kkal/h
Th/ - Diet Ginjal 1700 kkal/hari+ 0,8gr protein /kgbb/hari
-Bed rest protein 60gr/hr putih telur
- Diet MB 1700 kkal -Threeway Sucralfat syr 3xCII Drip
- IVFD NaCl 0,9 % 20 gtt/i - Lansoprazole 30mg/24j -IV Transamin 1 amp /
- Paracetamol 500 mg/8 jam PO - Domperidone /8j -Vit K 1 amp/8j
- Clindamycin 400 mg/ 6 jam - Lactulac syr CI/24j -Albumin 25% /24j
- Ceftriaxon 2 gram/24 jam - Clopidogrel 75mg/24j -Ceftriaxone 2gr/24j
- Iv omeprazole 40mg/ 12jam - ISDN 5mg/8j -Metronidazole 1500mg
- Domperidone 2 x 10mg - Fluimucyl 200mg/8j -Omeprazole 20 mg/12
- Sucralfat syr 3x CI - Bicnat 500mg/8jam -bicnat 500mg/8j
- Allopurinol 100mg/24j -allopurinol 100mg/24j
Lab 28-02-2020 - Moxifloxacin 400mg /24jam IV -flumycil 200mg/12j po
Hb/Ht/E/L/T: 14,6/42/4,8/18,4/306
MCV/MCH/MCHC: 87/31/35 Analisa Cairan Pleura 2 Lab 29-02-2020
Diftel: 0/0/1/87/6/6 6/02/2020 Hb/Ht/E/L/T:
GDS ; 158 Warna : Kuning 11,6/35/4,1/13,8/205
Kejernihan : keruh MCV/MCH/MCHC: 85
Bekuan : Negatif Diftel: 3/1/0/77/14/5
PMN :18
MN: 82 Lab 26-02-2020
Leukosit 79 Hb/Ht/E/L/T: 8,9/27/3,1
Total protein 4,1 MCV/MCH/MCHC: 86
Glukosa 134 Diftel: 3/0/0/85/6/6
Albumin/Globulin : 2,7
Ur/Cr : 235/3,5 Mg 1,5
Na/K/Cl : 145/3,4/117
Ur/Cr : 192/5,8
 *K5B1* *K5B2* *K5B3* *K5B4* *K5B5*

DPJP: dr. Kurnia Fitri Jamil, DPJP: dr. Azzaki, Sp.PD

Sp.PD-KPTI DPJP: dr.M Riswan, SpPD COW: dr. Munawar DPJP: dr.M Riswan, SpPD
COW: COW: dr. Reza DR: dr. Zulfikar COW: dr. Reza RUSAK
DR: dr. Rianda DR: dr. Nelvi Raber : DR: dr. Nelvi
Raber: Raber:

Nama:Muhammad nur Nama : Abdul Mutaleb Nama: T. Nurzaman Nama: Muhamad Abubakar
TTL: 2/10/1950 TTL : 01/07/1952 (67 th) TTL : 10/07/1957 (62th) TTL : 05-03-1992
Alamat: Aceh pidie Alamat : Pidie Jaya Alamat : Aceh Barat Alamat : Aceh Barat
CM: 1188771 CM : 1238936 CM : 1238315 CM : 1010844
Hari rawatan: 2 Hari rawatan : 7 Hari rawatan : 14 Hari rawatan : 12

A/ A/ A/ A/1.CML
1. PSMBA ec dd 1. Anemi sedang hipokrom 1. Jaundice ec dd 2.Abses ar Femur
-ulkus gaster mikrositer ec dd/ - ca caput pancreas
-ulkus duodenum -ancylostomiasis - ca ampula vateri Th/
-gastritis erosive -Peny. Kronis 1. Hidronefrosis ringan ginjal - Bedrest
2.ulkus diabetikum et region pedis -Def. FE kanan - Diet MII 1700 kkal/hari
S 2. Ancylostomiasis 2.ileus paralitik dd - IVFD NaCl 0,9% 20 gtt/i
3.DM TIPE 2 -ileus obstruktif - Tasigna 1x300mg
4.anemia berate c dd Th/ - Paracetamol 3x500mg
-perdarahan akut -Bedrest -Ceftriaxone 2gr/24j
-Peny kronik -Diet MB 1700 kkal/hari Th/ -Metronidazole 500mg/8j
-IVFD NaCl 0,9 % 20 tpm -Bedrest
Th/ -IV omeprazole 40 mg / 12 jam -Diet Hati + aminofusin hepar 20gtt/i Lab 01-03-2020
-Bed Rest - Albendazole 200 mg/24 jam --IV aminofusin hepar 1 fls/hari 20 Hb/Ht/E/L/T: 8,4/26/3,3/49,3/47
-diet sonde 6x200 selama 3 hari gtt/i MCV/MCH/MCHC: 79/26/33
- IVFD nacl 0,9% -Curcuma 3x1 Diftel : 0/2/0/86/10/3
-ceftriaxone 2gr/24j Lab 02-03-2020 -IV ondancetron 4 mg/12 jam
-lansoparazole 30mg/12j Hb/Ht/E/L/T: 10,2/34/34,7 -IV omeprazole 40 mg/12 jam Lab 28-02-2020
-transamin 500mg/8j iv /8,8/215 - IV cefoperazone 2 gram/12 jam Hb/Ht/E/L/T: 7,5/22/2,9/100,3/31
-metronidazole 500mg/8j iv MCV/MCH/MCHC: 72/22/30 - Laxadyn syr 1x CII PO MCV/MCH/MCHC: 78/26/34
-apidra 10-10-10 Diftel : 3/1/0/86/9/1 Diftel : 0/1/0/88/7/3
-lantus 0-0-0-14 Malaria:- Lab 29-02-2020
Sukralfat syr 3xc2 Hb/Ht/E/L/T: 12,3/34/4,1/17,4/488 Lab 27-02-2020
MCV/MCH/MCHC: 84/30/36 Hb/Ht/E/L/T: 7,2/22/2,8/130,5/28
Lab 29-02-2020 Lab 29-02-2020 Diftel : 0/1/0/90/4/5 MCV/MCH/MCHC: 81/26/32
Kalsium : 8,2 Hb/Ht/E/T/L: Ca 8,2 Diftel : 0/2/0/88/6/4
Na/K/Cl : 148/4,3/110 8,4/28/4,0/10,9/236 Na/k/cl 138/3,9/99
MCV/MCH/MCHC: 70/21/30 Lab 25-02-2020
Lab 27-02-2020 Diftel: 4/1/0/75/11/9 Lab 24-02-2020 Hb/Ht/E/L/T: 6,5/20/2,5/237,2/37
Hb/Ht/E/L/T: 5,6/16/1,8/24,9/300 Ur/Cr : 38/0,5 MCV/MCH/MCHC: 80/26/33/18,6
MCV/MCH/MCHC: 89/31/35 Analisa feses rutin 27/02/2020 Diftel : 0/2/0/86/8/4
Diftel: 0/0/0/92/6/2 Warna : hijau Lab 22-02-2020
Ur/Cr: 75/0,90 Bau : Khas Ratio PT/APTT : 1,2/1,06
Albumin 2,30 Eritrosit : negatif GDS : 116
Na/K/Cl : 139/4,8/105 Leukosit : negatif
GDS 220 Parasit : negatif Lab 18-02-2020
PT/APTT 15,70/37,80 Konsistensi : Lunak Hb/Ht/E/L/T: 13,1/37/4,2/12,2/352
Darah : negatif MCV/MCH/MCHC: 86/31/36
Lendir : negatif Diftel: 1/1/0/83/8/7
Telur cacing : Ancylostoma Du Bil tot/di/in: 16,48/11,90/4,58
odenal (2-3) Albumin: 3,10
Globulin: 3,10
Protein tot: 6,20
SGOT/SGPT: 96/108
Lab 24-02-2020 HbsAg : non reaktif
Hb/Ht/E/T/L:
2,8/12/2,2/458/5,7
MCV/MCH/MCHC: 56/13/23
Diftel: 7/0/0/57/26/10

MDT
Erit: Hipokrom, pencil cell,
target cell, cigar shape, ovalosit,
mikrosit, tear drops
Leu: netrofil hiperpigmentasi
Trom: giant trombosit
 *K6B2*
*K6B1* *K6B3* *K6B4* *K6B5*

DPJP: Dr.dr.Azhari Gani, DPJP: dr.T. Mamfaluti,

DPJP: Prof. Dr. dr Maimun
SpPD-KKV SpPD
Syukri, Sp.PD-KGH FINASIM
COW: dr. T. Fahril COW : dr. Dedi
DIVISI GH
DR: dr. Viencen DR : dr. Amelia
Raber:
Nama : Basri M Alim Nama : Yusri
Nama : T Abdullah TTL : 07/04/1999 (21th) TTL : 01/07/1974
TTL : 20/05/1976 (43th) Alamat : Nagan Raya Alamat : Bireun
Alamat : Pidie Jaya CM : 1238689 CM : 1239517
CM : 1239505 Hari rawatan : 11 Hari rawatan : 3
Hari rawatan : 4
A/ A/
A/ 1. PSMBB 1. Anemia sedang HM ec dd
1. CKD Stg V ec dd 2. Anemia sedang HM - Penyakit kronik
- PNC - Thalassemia
- HN Th/ - Defisiensi Fe
2. Hipertensi stage 2 - IVFD Nacl 0,9 % 20 tpm 2. Hepatosplenomegali ec dd
3. Anemia berat ec PGK - IV Lansoprazole 30mg/12 - Thalassemia
4. Pneumonia jam - Siroseis
5. DM tipe 2 - IV Transamin 500mg /8jam - Metastase hepar
6. Retardasi mental - IV Vit K 1 amp/ 8jam
- IV ondansetron 4mg /12jam Th/
Th/ - Anti hemoroid supp - Bedrest
- Bed rest - Paracetamol drp 1 gr kp - Diet MII 1700 kkal/hari
- Diet ginjal 1700kkal /hari, - IVFD NaCl 0,9% 20gtt/i
rendah garam, protein 1,2 Lab 28-02-2020 - Omeprazole 40gr/12jam
gr/KgBB/hari Hb/Ht/E/T/L :
- IV ceftriaxone 2gr /24jam 8,3/25/3,0/10/278 Lab 29-02-2020
- Fluimucyl 3x200mg MCV/MCH/MCHC: 83/28/33 Hb/Ht/E/T/L :
- Amlodipin 10mg Diftel: 7/0/0/69/17/7 7,8/22/2,9/74/5,9
- Lenal ace 169mg 2x1 Kalsium/Magnesium: 7,7/2,2 MCV/MCH/MCHC: 75/27/36
- Valsartan 1x80mg Na/K/Cl: 140/4,3/109 Diftel: 10/1/0/24/61/4
- Asam Folat 400mg 2x1 HbsAg : non reaktif
Lab 27-02-2020 Bil. Total : 7,94
Lab 29-02-2020 Hb/Ht/E/T/L : Bil direct/ indirect : 5,01/2,93
Hb/Ht/E/T/L : 7,7/22/2,8/11/142 7,8/23/2,8/10,9/240 Albumin : 2,90
MCV/MCH/MCHC: MCV/MCH/MCHC: 82/28/34 GDS : 98
Diftel: 0/0/0/74/21/5 Diftel: 5/1/1/66/18/9 Ur/cr : 59/1,10
DGS : 137 Kalsium/Magnesium: 6,8/2,1 Na/k/Cl : 143/4,2/110
Ur/ Cr : 22/0,7 Na/K/Cl: 137/4,4/107
Na/K/Cl: 149/3,1/110