AQSHA 3 (PENYAKIT DALAM WANITA)

Hari/Tanggal : Selasa, 12 Februari 2019

Dokter Jaga : dr. Nisa, dr. Perdana,
Dokter Muda Jaga : Ika, S.ked, Duma, S.ked
K1B1 K1B2 K1B3 K1B4
DPJP : dr. M. Darma MS Sp.PD DPJP : dr. M. Darma MS Sp.PD DPJP : dr. M. Darma MS Sp.PD DPJP : dr. M. Darma MS Sp.PD
COW : dr. Febri COW : dr. Febri COW : dr. Febri COW : dr. Febri
DR : dr. Eko DR : dr. Eko DR : dr. Eko DR : dr. Eko
DM : Ika, S.Ked DM : Ika, S.Ked DM : Ika, S.Ked DM : Ika, S.Ked

Nama: Nur Maulidar Nama: Nurlaila Nama: Asmah Nama: Siti Zubaidah
Umur :34 th Umur :35 th Umur: 85 th Umur :49 th
CM: 1132559 CM: 1199981 CM: 1199764 CM: 1199681
Alamat:Aceh Besar Alamat:Aceh Barat Alamat: Peuniti Alamat:Aceh Selatan
Hari Rawatan: 8 Hari Rawatan: 4 Hari Rawatan: 6 Hari Rawatan: 5

A/ A/ A/ A/
1. Dacryocystitis + selulitis pre septal 1. DD/ 1. Grave Disease 2. Struma 1. Obstruksi jaundice ec dd/ 1.PSMBA ec dd:
ocullo dextra diffusa Toksik 3. Tiroiditis 1). kolesistitis kronis -ulkus gaster
2. SLE derajat ringan dengan kehamilan autoimun 2). kolelitiasis -ulkus duodenum
G4P3A0 hamil 16-17 minggu 2. Oral Candidiasis 3). choledocolithiasis -gastritif erosif
3. CKD stage V ec dd 3. Dyspepsia Type like ulcer dd/ 4). ca caput prankeas -variceal bleeding
- Nefritis lupus Type Dismotility 5). Ca ampula vateri 2 Anemia sedang Hipokrom mikrositer ec.
-nefropati infeksi (pielonefritis) 4. Dd/ 1. SLE 2. RA 3. Poliautoimun dd defisiensi besi
4. Anemia sedang Hipokrom mikrositer ec. disease 2. Hipertensi stage I 3.DM tipe II normoweight
dd 4.Hipoalbuminemia berat
- penyakit kronik Th/ Th/ 5.Hipokalemia sedang
- defisiensi besi - Bed rest -Bedrest 6.ISK asimtomatis
5. hipoalbuminemia - Diet MII 1700 kkal/hari -Diet MII 1700 kkal/hari
- Threeway -ivfd aminofusin hepar 1 fls/hari 20gtt/i Th/
Th/ - IV Omeprazole 40 mg/12 jam -Three way -Bedrest
-Bedrest - Domperidone 3 x 10 mg tab -iv cefoperazone sulbaktam 1,5 gr/12jam -Diet MB 1500 kkal/hari + tinggi kalium
- kateter urine (pasien belum bersedia) - Nystatin Drop 4 x gtt II -urdafalk 2x250 mg -IVFD Nacl 0,9 % 20 gtt/i
-Diet cair via oral 6x200 kkal/hari - Propanolol 1 x 10 mg -graphalac 3xCI syr -IV lansoprazole 30mg/12j
-IVFD NaCl 0,9% 20gtt/i - Paracetamol 3 x 500 mg (k/p) -curcuma 3x1 -Iv ceftriaxone 2gr/24jam
-Iv ceftriaxone 2gr/24jam -sistenol tab (k/p) -drip albuminar 25% 100cc 1fls/hari
- drip albumin 25% 100 cc1 flash/hari Lab 09/02/2019 -KSR 2x600mg tab
-transfusi PRC s/d HB >10 gr/dl Hb/Ht/E/L/Tr Lab 7/2/2019 -sucralfat syr 3x2C
- Metilprednisolon 4 mg(2-0-1) 11,2/33/4,1/3,2/176 Hb/Ht/E/L/Tr - Domperidone 3 x 10 mg
- Paracetamol tab 3x500mg (kp) MCV/MCH/MCHC 11/32/3,5/15,7/356
- As Folat 1x400 mg 81/27//34 MCV/MCH/MCHC 91/31/35 Lab 08/02/2019
- Lenal ace 2x169mg Diff.Count : 1/1/0/72/22/4 DIFTEL 0/1/1/84/7/7 Hb/Ht/E/L/Tr
- vigamox 6xgtt OD Albumin 3,34 Bil tot/dir/indir 15,33/11,86/3,47 11,8/34/4,7/15,4/640
- xitrol 2x applay OD GDS 101 SGOT/SGPT 170/136 MCV/MCH/MCHC 72/25/34
- rawat luka abses dengan kompres NaCl Ur/Cr 41/0,73 GDS 129 DIFTEL 1/1/0/68/24/6
0,9% Na/K/Cl 133/4,7/105 Ur/Cr 28/0,52
- balance cairan = 0 Na/K/Cl: 137/3,9/95 Lab 07/02/2019
- HD konfirmasi div.GH PT/APTT 11,4/49,5
Ferritin 664,26
Lab 8/2/2019 Anti HCV –
Hb/Ht/E/L/Tr HbsAg –
7,0/21/2,9/6,1/138 Fe/iron 33
MCV/MCH/MCHC 74/25/33 GDPuasa 76
DIFTEL 0/0/1/83/11/5
Ur/Cr 190/7,07 Urinalisis (+)
Na/K/Cl: 130/5,0/104 Analisa tinja (+)

Lab 06/02/2019 Lab 06/02/2019

PT/APTT: 10/40,8 Hb/Ht/E/L/T: 9,9/29/4,3/19,9/825
Albumin: 1,46 MCV/MCH/MCHC 69/23/34
Na/K/Cl: 130/5,5/95 Diftell 1/1/0/70/23/5
Alb 1,8
Lab 05/02/2019 Gds 150
Anti HCV: negative Ur/Cr 16/0,71
Bil tot: 0,38 Na/K/Cl 131/2,9/91
Bil direct: 0,13
Bil indirect:0,25
SGOT/SGPT: 38/11
Protein tot: 4,14
Albumin:1,51

Lab 04/02/2019
Na/K/Cl 129/5,3/95

Lab 04/02/2019
Hb/Ht/E/L/T 7,2/21/2,9/5,2/135
MCV/MCH/MCHC 73/25/35
Diftell 0/0/0/87/9/4
Gds 105
Ur/Cr 163/4,53
Na/K/Cl 130/6,4/96
Urinalisa:
Warna :kuning coklat
Keruh
Lekosit:(+)
Protein (+1)
Glukosa (+1)
Leukosit: 30-40
Eritrosit:10-15
Epitel:3-5
 K2B1 K2B2 K2B3 K2B4 K2B5
DPJP : dr. M. Darma MS DPJP : dr. M. Darma MS DPJP: dr. M. Darma MS DPJP: dr. M. Darma MS DPJP: dr. M. Darma MS
COW : dr. Febri COW : dr. Febri COW: dr. Febri COW: dr. Febri COW: dr. Febri
DR : dr. Ecko DR : dr. Ecko DR : dr. Ecko DR : dr. Ecko DR : dr. Ecko
DM : Ika, S.Ked DM : Ika, S.Ked DM : Ika, S.Ked DM : Ika, S.Ked DM : Ika, S.Ked
Nama : Siti Aisyah Nama : Raimah saudin Nama : Nurul fitri Nama: Hafsah Ismail Nama : Fitriani M Ali
Umur ; 44 th Umur ; 45 th Umur : 25 tahun Umur: 69 th Umur : 42 tahun
CM ; 0889548 CM ; 1199575 CM : 0997466 CM: 0956342 CM : 1199928
Alamat ; Aceh Besar Alamat ; aceh barat daya Alamat : langsa Alamat: aceh jaya Alamat : Bireuen
Hari Rawatan ; 7 Hari Rawatan : 2 Hari rawatan: 3 Hari Rawatan: 7 Hari rawatan : 4

A/ A/ A/ A/ A/
1.CHF FC NYHA III-IV ec dd/ 1.Pansitopenia ec dd/ 1)Leukimia 1. DD/ 1. Sepsis ( perbaikan) ec DD 1. dyspepsia tipe dismotility
-IHD akut 2)RADS 3)anemia aplastic 1) Abses hepar pneumonia dd gastropati diabetic
-DCM 4)mielodisplasia 5)ITP 2) Kista hepar 2. Pneumonia geriatric 2. ulcus diabetic er pedis (s)
2.DM tipe 2 obese grade I 3) Hepatoma 3. PPOK stabil 3. DM tipe 2 NW
3. CKD stage V ec dd/ 2. Pneumonia (HAP perbaikan) 4) Hepatitis A 4. Anemia sedang hipokrom 4. Cholelithiasiis dengan
- diabetic nefropati 3. candidiasis oral 2. Pneumonia (HAP) dd mikrositer ec dd cholesistitis
4. OMI inferior dan iskemik infeksi paru spesifik -occult bleeding 5. Anemia sedang ec dd
lateral Th/ 3. Anemia sedang -def besi 1) Penyakit kronis
5. HT stage I on therapy -Bed rest hipokrom mikrositer ec -peny kronik 2) Perdarahan
6. hipoalbuminemia berat -diet MB 1700kkal/hari dd/ 5. massa intraabdomen ec dd 6. Efusi pleura sinistra ec dd
7. Dispepsia tipe dismotiliy dd/ -ivfd Nacl 0,9% 20 tpm 1) Penyakit kronis - mioma uteri 1) Hipoalbuminemia
gastropati diabetic -IV ceftriaxone 2gr/24jam 2) Defisiensi besi -kista ovarium 2) Pleuropneumonia
8. tinnitus AD ec oklusi tuba -IV omeprazole 40mg/12jam 4. Hipoalbuminemia -ca colon 7. Hiperkalemia ringan
eustachius -domperidon tab 3x10mg sedang -ca colorectal 8. Hipoalbuminemia sedang
-pct ta (k/p) 6. hipokalemia
Th/ - TF PRC s.d HB >10 Th/ 7. geriatri problem Th/
-Bedrest semi fowler -TF trombosit -bedrest 8. hipoalbuminemia -bed rest
-diet sonde 6x200 kkal/hari + 0,6 - diet MB 1700 kkal/hari + - diet DM 1700 kkal/hari + ektra
gram protein/KgBB/hari Lab 10/02/2019 ekstra putih telur Th/ putih telur
-O2 2-4l/I (via nasal canul) Hb/Ht/E/L/T -IVFD aminofusin hepar -bedrest - IVFD Nacl 0,9% 20 gtt/i
9,3/27/3,3/9,8/19 1fl/hari 20gtt/i - O2 2-4 L/i (kp) -iv ceftriaxone 2 gr/24 jam
-Threeway MCV/MCH/MCHC -iv cefoperazon sulbactam -diet sonde 6x200 kkal/hari + -iv metroclopamid 1 amp/8jam
-IV ceftriaxone 2 g/24 jam 81/28/34 1gr/12jam(H3) tinggi kalium + ekstra putih telur -sc lantus 0-0-0 10 unit (malam)
-IV furosemid 20mg/8jam Diftell : 1/1/0/37/30/31 -urdafalk 2x500 mg - IVFD RL 20 gtt/i -Asetil sistein 3x1
-clopidogrel 1x75 mg -Sistenol 3x1 -Drip PCT (kp) -rawat luka/hari
-ISDN 3x5 mg -curcuma 3x20mg -IV ceftriaxone 2g/24 j - B6 3 x 1
-Ramipril 1x5 mg -PRC s/d HB >10mg/dl -vectrin 3x1 tab - Alprazolam 1 x 0,5 mg (malam)
-lansoprazole 1x30 mg - nebul combiven I resp/8j - Domperidone 3 x 10 mg
-domperidon 3x10 mg Lab 09/02/2019 - Transfusi PRC s/d HB > 10 - UDCA 2x250 mg
-clobazam 1x10 mg (malam) Hb/Ht/E/L/Tr: gr/dL - kalitake 3x1 sachet
-Sucralfat syr 3xC1 7,0/23/3,1/20,3/422 -drip albumin 25% 100cc 1 - rawat luka diabetic 2x/hari
-codein 2x5 mg MCV/MCH/MCHC fls/hari dengan Nacl 0,9%
-hemodialisis + transfuse PRC 1 72/22/31 -azytromisin 1x500mg - cilostazole 2x100mg
kolf on HD (kemarin via double Diftel 11/0/0/81/12/6 - KSR 2x600mg
lumen) Alb : 2,69 Lab 09/02/2019
GDS : 102 Lab 11/02/2019 Hb/Ht/E/L/Tr:
Lab 06/02/2019 Ur/Cr : 11/0,50 Hb/Ht/E/L/T 8,6/27/4,0/9,5/482
Ur/Cr: 11913,09 Na/K/Cl : 140/4,0/102 9,4/28/3,8/15,8/193 MCV/MCH/MCHC
Na/K/Cl: 129/4,3/91 SGOT/SGPT : 94/91 MCV/MCH/MCHC 67/22/33
Biltot/bildirect/bilindirect : 75/25/34 Diftel 1/1/0/67/24/7
Lab 05/02/2019 3,74/2,45/1,29 Diftell : 0/1/0/8/3 Alb : 2,97
Hb/Ht/E/L/T 7,8/25/3,7/8,9/290 Albuin : 2,13 GDS : 291
Ur/cr; 114/12,71 Na/K/Cl : 152/3,8/115 Ur/Cr : 27/0,84
Alb : 2,59 Na/K/Cl : 127/5,8/100
Na/K/Cl 128/4,5/92 Lab 08/02/2019
Hb/Ht/E/L/Tr
Lab 02/02/2019 9,8/30/3,9/9,2/168
Hb/Ht/E/L/T MCV/MCH/MCHC : 77/25/33
8,4/27/3,9/9,4/328
MCV/MCH/MCHC 69/21/31 Lab 07/02/2019
Ur/cr; 121/12,10 Procalcitonin: 142,67
Na/K/Cl 135/4,9/99
Lab 06/02/2019
Hb/Ht/E/L/Tr
5,9/18/2,5/34/194
MCV/MCH/MCHC 74/24/32
Morfologi darah tepi: kesimpulan
Anemia Hipokrom Mikrositer
dengan neutrofilia
Alb 1,31

Lab 06/02/2019
Hb/Ht/E/L/Tr
6,9/21/3,0/27,6/241
MCV/MCH/MCHC 71/23/33
GDS: 96
Ur/Cr: 23/1,28
Na/K/Cl: 140/3,1/102

Lab 05/02/2019
Hb/Ht/E/L/Tr
6,9/21/3/27,6/241
MCV/MCH/MCHC/RDW
8071/23/33
Diftel: 1/0/0/93/3/3
GDS : 96
Ur/Cr : 23/1,28
Na/K/Cl : 40/3,2/102
 K3B1 K3B2 K3B3 K3B4 K3B5
DPJP : dr. M. Riswan DPJP : dr. M. Riswan DPJP : dr. M. Riswan DPJP : dr. M. Riswan DPJP : dr. M. Riswan
COW : dr. Andi COW : dr. Andi COW : dr. Andi COW : dr. Andi COW : dr. Andi
DR : dr. Wahyu DR : dr. Wahyu DR : dr. Wahyu DR : dr. Wahyu DR : dr. Wahyu
DM : Tio, S.Ked DM : Tio, S.Ked DM : Tio, S.Ked DM : Tio, S.Ked DM : Tio, S.Ked

Nama: Cut Tihasanah Nama: Fatimah Nama : Itaniswar Bukhari Nama : Yullyta Hasanusi Nama : Nur Aciah
Umur : 59 th Umur : 65 tahun Umur : 04-08-1974 (44thn) Umur : 07-07-1997 (21thn) Umur : 22 th
CM: 1178549 CM: 1055036 CM: 1199168 CM: 1183071 CM: 1199513
Alamat: aceh timur Alamat: Banda Aceh Alamat: Abdya Alamat: Banda Aceh Alamat: aceh barat daya
Hari Rawatan: 2 Hari Rawatan: 4 Hari Rawatan: 10 Hari Rawatan: 8 Hari Rawatan: 6

A/ A/ A/ A/ A/
1. NHL relaps post kemo siklus 1. Penurunan Kesadaran e.c. 1.CKD Stg V dengan uremic 1.Limfadenopati ec dd/ 1.leukositosis ec dd
ke-6 dd/ 1) Hiponatremia 2) SDA syndrome perbaikan ec DD/ - limfoma maligna -CML
2. High Risk Trombosis 3) sepsis 4)stroke -PGOI - limfadenitis TB -CLL
2. Hiponatremia Hipoosmolar, -Polikistik Renal desease 2.Dyspepsia tipe like ulcer dd tipe 2.anemia hipokrom mikrositer ec
Th/ euvolemic 2.Hepatitis B kronis dismotility dd
-bedrest, ngt, kateter 3. Diabetik nephropati dd/AKI 3. nephrolithiasis bilateral 3. TB paru kategori 1 -penyakit kronik
-diet sonde 6x200 cc Stage III pre renal 4. hipokalemi -occult bleeding
1500kkal/hari 4. Sepsis e.c. dd/ 1) Urosepsis 5. polikistik disease Th/
-IVFD Nacl 0,9% 20gtt/i 2)Pneumonia -Bed rest Th/
-IV sefoperazine sulbactam 5. Ulkus decubitus grade III ar -diet MB 1700kkal -bedrest
1gr/18jam gluteus posterior Th/ -IV omeprazol 40mg/12jam -Diet MB 1700 kkal/hari
-IV omeprazole 40mg/12jam 6. DM Tipe 2 NW -Bed rest, -paracetamol 3x500mg -threeway
-sc anixtra 2,5gr/hari 7. Pneumonia geriatric -O2 2-4lpm -Vectrin 3x200 mg -ivfd rl 20gtt/i
-sukralfat syr 3xCII 8. Geriatri problem -diet ginjal 1700kkal+rendah -Sucralfat syr 3 x CI -PCT 3x500 mg
9. PSMBA ec dd/streo ulcus, garam - azitromisin 1x500 mg -iv omeprazole 2x20 mg
Lab 11/02/2019 ulcus gaster, ulcus duodenum - as.folat 2x1 - Threeway -allupurinol 1x300 mg
Hb/Ht/E/L/T 10. High Risk Trombosis - lenal ace 2x1 -iv ceftriaxone 2gr/24 jam(H3) -bicnat 1x500mg
11,9/33/3,6/7,2/280 11. Stroke iskemik - BC - domperidon 3x10 -sucralfat syr 3xCI
MCv/MCH/MCHC -three way -cytodrax 2x500
92/33/36 Th/ - HD (selasa-jumat free heparin) Lab 05/02/2019
Diftell : 0/1/0/77/9/13 - Bedrest dengan mobilisasi -IV omeprazol 40mg/12 jam Hb/Ht/E/L/Tr Lab 11/02/2019
GDS : 87 ringan/kasur dekubitus -Trf 1 kolf PRC HB>9 gr/dL 12,2/ 34/4,6/11,5/256 Urinalisa
Ur/cr : 118/1,41 - NGT, Kateter - iv ceftriaxone 2 gr/24jam MCV/MCH/MCHC 74/26/36 Warna ; kuning
Na/K/Cl : 139/3,4/87 - Kasur decubitus, mika -KSR 1x600 mg/hari DIFTEL 0/0/1/87/3/9 Kejernihan ; jernih
miki/1 jam selama 15 menit Berat jenis ; 1,015
- O2 4 l/menit nasal kanul Lab 08/02/2019 Lab 04/02/2019 pH ; 7,0
- Diet sonde 6 x 700 cc, 1750 Hb/L/T : 8,1/6,9/117 Hb/Ht/E/L/T lekosit (-)
kkal/hari MCV/MCH : 78/28 12,2/34/4,6/11,5/262 protein (-)
- IVFD Ceftriaxone 2 gr / 24 Diff. Count : 2/1/0/75/14/8 GDS 131 glukosa (-)
jam Ur/Cr : 62/6,46 keton (-)
- Clindamycin 3 x 300 gram Na/K/Cl : 139/2,9/104 Lab 1/02/2019 urobilinogen (-)
- Flumucyl 3 x 200 gram Hb/Ht/E/L/Tr bilirubin (-)
- Bicnat 3 x 500 gram Lab 4/02/2019 7,3/21,5/2,75/10,3/257 darah (-)
- Rawat luka/hari Hb/Ht/E/L/Tr MCV/MCH/MCHC/ lekosit 2-3
- IVFD RL 0,9% 20gtt/i 7,7/21/2,7/11,6/123 78/26,5/34 eritrosit 1-2
- IV omeprazole 40mg/12jam MCV/MCH/MCHC/ GDs 125 mg/dl epitel 8-10
- Sucralfat syr 3x20 78/28/36 Ur/cr: 32/2,1
- Diet sonde 6x200 Diftel: 1/0/0/90/4/5 Lab 09/02/2019
Albumin : 4,20 Hb/Ht/E/L/T
Lab 11/02/2019 Ur/cr: 267/17,57 10,5/35/4,7/71,1/202
Hb/Ht/E/L/T Na/K/Cl: 135/3,5/101 MCV/MCH/MCHC/
9,1/27/2,9/5,0/365 74/22/30
MCV/MCH/MCHC Lab 31/01/2019 Diftell : 5/20/0/32/13/30
94/32/34 Hb/Ht/E/L/Tr Ur/Cr : 12/0,57
Diftell : 0//1/0/59/25/15 6,3/18/2,5/4,8/140 Na/K/Cl: 143/5,0/108
Albumin : 2,66 MCV/MCH/MCHC/
Ur/cr : 68/0,97 73/25/35 Lab 05/02/2019
Na/K/Cl : 152/4,3/111 Diftel: 1/0/0/73/17/9 Hb/Ht/E/L/T
Gds:82 7,8/27/3,8/59,8/251
Lab 09/02/2019 HbsAg positif MCV/MCH/MCHC/
Hb/L/T : 10,4/12,1/338 Ur/cr: 332/24,46 71/21/29
MCV/MCH : 89/32 Na/K/Cl: 136/4,8/86 Diftell : 7/14/0/32/18/29
Diff. Count : 0/0/0/86/6/8
GDS 96 Lab 07/02/2019
Ur/Cr : 125/3,31 LDH 1793
Na/K/CL 118/4,6/94 Asam urat 4,8

Lab 06/02/2019
Hb/Ht/E/L/T
7,8/27/3,6/55,2/211
MCV/MCH/MCHC/
74/22/29
Diftell : 7/10/0/32/26/25
Morfologi darah tepi: kesimpulan
susp. hematologi malignancy

Lab 05/02/2019
Hb/Ht/E/L/T
7,8/27/3,8/59,8/251
MCV/MCH/MCHC/
71/21/29
Diftell : 7/14/0/32/18/29
 K4B1 K4B2 K4B3 K4B4 K4B5
DPJP :dr. M. Riswan DPJP :dr. M. Riswan DPJP : dr. M. Riswan DPJP : dr. M. Riswan DPJP :dr. M. Riswan
COW : dr. Andi COW : dr. Andi COW : dr. Andi COW : dr. Andi COW : dr. Andi
DR : dr. Wahyu DR : dr. Wahyu DR : dr. Wahyu DR : dr. Wahyu DR : dr. Wahyu
DM : Tio, S.Ked DM : Tio, S.Ked DM: Tio, S.Ked DM: Tio, S.Ked DM : Tio, S.Ked

Nama: Yusrawati Nama : zainah Nama : Nurlani Nama: Erlina Manan Nama : Nurhayati
Umur: 49 th Umur : 77 tahun Umur : 49 tahun Umur: 46 thn Umur : 56 tahun
CM: 1199511 CM : 1199958 CM : 1199967 CM: 1096042 CM : 1199964
Alamat: Bireuen Alamat : Aceh besar Alamat : Simeulu Alamat: Aceh besar Alamat : Aceh besar
Hari Rawatan: 6 Hari rawatan : 3 Hari rawatan : 1 Hari Rawatan: 5 Hari Rawatan : 4

A/ A/ A/ A/ A/
1. CKD stage V ec. dd : 1. Artritis septik 1. DD 1) Demam Tifoid 2) 0bs febris ec dd/ 1. Sindrom delirium akut
- diabetik nefropati 2. Coxitis dxtra Demam Dengue 3) Malaria 1). pneumonia (CAP)dd/infeksi 2. Diare kronis (perbaikan) ec
- PNC 3. Geriatric problem ( 2. AKI Stage III Prerenal paru spesifik dd/ colitis tb, chorn disease,
2. Pneumonia dd.infeksi paru immobilisasi, inanisi, 3. Trombositopenia ec dd/ 1) 2). DM tipe II normoweigt dd colitis ulceratif
spesifik instabilitas dan jatuh) Viral Infection 2) DIC reaktif hiperglikemi 3. DM tipe 2 NW
3. Trombositopenia dd : 4. Ulcus decubitus grade II-III 4. Hipokalemia Ringan 3). Hiponatremi hipoosmolar 4. ulcus decubitus er gluteus dextra
- TTP HUS 5. Hiponatremia, hipoosmolar, hipovolemik grade II
- Compsumption hipovolemik Th/ 4). ISK 5. oral candidiasis
coagulopati 6. Spondilisis lumbal -Bedrest 5). Post mastoidektomi dextra
4. Susp Ca Mammae Dextra 7. Degenarasi discus -Diet MII 1700 kkal/hari 6). Susp metastase proses ar Th/
5. Hiperkalemia, Hiponatremia , -IVFD NaCl 0,9% 30 gtt/i paru dextra -Bedrest
hipovolemia Th/ -NGT, Kateter -diet MII 1700 kkal/ hari
6. DM tipe II normoweight -Brdrest - IV Ceftriaxone 2 gr/ 24 jam Th/ -mika-miki /2jam selama 15 menit
-mika-miki tiap 2 jam selama 15 - Paracetamol 3 x 500 mg -bedrest -IVFD NaCl 0,9% 20 gtt/i
Th/ menit - Domperidone 3 x 10 mg -diet mb -iv meropenem I gr/8 jam
-Bedrest -kateter - Mecobalamin 2 x 500 mg -ivfd nacl 0,9% 20 gtt -Iv prosogar 30 gr / 12 jam
-Diet Ginjal 6x200 cc dengan -o2 2 l/ menit - KSR 2 x 600 mg -iv ceftriakson 2g/24j -SC novorapid 4-4-4 unit
protein 40 gr/hr -iv omeprazole 40 g/12 jam - Transfusi Tc jika 1) < 10.000 -drip pct (k/p) -Sc levemir 0-0-0-8
-ngt -iv mecobalamin 500g/12 jam tanpa perdarahan 2) < 20.000 -domperidon 3x100mg - curcuma 3x20 g
-IV omeprazole 40mg/12 jam -iv ceftriaxone 2 gr/24 jam dengan perdarahan -flumocyl 3x200mg -sucralfat syr 3xCI
-IV ceftriaxone 2gr/24 j -coditam 3x10 mg - drip pct 1 gr -Synbio 2x1
- Amlodipin 1x10 mg -clindamisin 3x300 mg Lab 09/02/2019 -levemir 0-0-0-10 unit(22.00) -attapulgit 1x1 tiap diare max 10
-threeway - IVFD NaCl 0,9 % 20gtt/i Hb/L/T : 12,4/13,3/12 - novorapid 0-6-0 unit(sebelum -burnazin zalf 3x1
-hemodialisa (free heparin) - Diet MII 1700 kkal/hari MCV/MCH : 69/23 makan siang) -diet sonde 6x200cc oral
-tf prc 2 kolf on HD - Mupirocin Cream Diff. Count : 1/0/0/79/17/3 1700kkal/hari
-valsartan 1x160mg tab - pasang ngt diet sonde via ngt GDS : 107 Lab 11/02/2019 -nystatin drop 4x2
6x200 Ur/Cr : 260/2,15 Hb/Ht/E/L/T -oral hygiene
Lab 10/2/2019 Na/K/CL : 136/3,2/106 10,1/31/3,7/10,7/331 -IV levofloxacin 500mg//24jam
Hb/L/T : 8,4/20/92 Lab 11/02/2019 MCV/MCH/MCHC
MCV/MCH : 78/28 Urinalisis 84/27/32 Lab 11/02/2019
Diff. Count : 1/1/0/84/5/9 warna ;kuning Diftell : 0/0/0/79//14/7 Lemak darah
Alb : 2,59 kejernihan ; keruh Bil.total/Bil.direk/Bil.indirek Kolesterol.Tot/HDL/LDL
GDS : 335 berat jernih ; 1,015 0,83/0,37/0,46 25/14/15
Ur/Cr : 122/4,50 pH ; 7,5 SGOT/SGPT/albumin Trigliserida : 48
Na/K/CL : 129/4,0/105 lekosit ; negative 55/43/2,73 HBA1C : 6,10
protein ; negative HbA1c : 10,40
Lab 08-02-2019 glukosa ; negative Ur/cr : 10/0,56 Lab 09/02/2019
Bil tot: 0,40 keton ; negative Na/K/Cl : 131/4,4//108 Hb/Ht/E/L/T
Bil direct: 0,18 nitrit ; negative 11/ 32/3,9/11,9/100
Bil indirect: 0,22 urobilinogen ; negative Lab 08/02/2019 MCV/MCH/MCHC 812835
SGOT/SGPT: 35/31 bilirubin ; negative Urinalisa Diftel 1/0/0/78/8/13
darah ; positif Warna Kuning Gds 191
Lab 07-02-2019 Berat Jenis 1,015 Na/K/Cl 139/3,6/118
Na/k/cl 130/4,6/103 albumin : 2,35 pH 7,0
Lekosit (+)
Lab 05-02-2019 Lab 09/02/2019 Protein +1
Hb/Ht/E/L/T Hb/Ht/E/L/T Glukosa +1
8,3/23/3,1/26,4/33 11,0/31/3,7/16,8/347 Keton +
MCV/MCH/MCHC MCV/MCH/MCHC 83/30/35 Nitrit –
75/27/36/ Diftel 7,4/2/0/0/82/8/8 Urobilinogen +
Diftel : 1/0/0/92/4/3 Gds 129 Bilirubin +
GDS : 68 Na/K/Cl 113/4,7/92 Darah –
Ur/Cr : 250/7,71 Leukost 20 – 25 LPB
Na/K/Cl : 126/6,1/88 Eritrosit 1 – 2 LPB
Epitel 6 – 8 LPK

Lab 07/02/2019
Hb/Ht/E/L/T
10,3/31/3,7/14,1/321
MCV/MCH/MCHC 84/28/34
Diftel 0/0/1/82/10/7
Gds 393
Na/K/Cl 126/4,7/94
Urinalisis (+)
 K5B1 K5B2 K5B3 K5B4 K5B5

DPJP : dr. M. Diah Sp.PD DPJP : dr. M. Diah Sp.PD DPJP : dr. M. Diah Sp.PD DPJP : dr. M. Diah Sp.PD DPJP : dr. M. DiahSp.PD
COW: dr. Sabarina COW : dr. Sabarina COW : dr. Sabarina COW : dr. Sabarina COW : dr. Sabarina
DR : dr. Riza DR : dr. Riza DR : dr. Riza DR : dr. Riza DR : dr. Riza
DM : Haiqal, S.Ked DM : Haiqal, S.Ked DM : Haiqal, S.Ked DM : Haiqal, S.Ked DM : Haiqal, S.Ked

Nama: Nurhayani Nama : Saudah Syamaun Nama : khatijah husen Nama: Sarwani Nama : yusnita
Umur :75 tahun Umur : 54 th Umur : 52 tahun Umur : 47 thn Umur : 20 th
CM:1198834 CM : 1199915 CM : 0951399 CM: 1-11-40-02 CM : 1199834
Alamat:aceh barat daya Alamat : aceh besar Alamat : pidie Alamat: Aceh selatan Alamat : aceh utara
Hari Rawatan: 12 Hari rawatan ke : 4 Hari rawatan: 4 Hari Rawatan: 4 Hari rawatan ke : 4

A/ A/ A/ A/ A/1. DD/
1.penurunan kesadaran ec dd/ 1. penurunan kesadaran ec 1. CKD stage V ec DD/ 1. Penurunan kesadaran 1. ISK
- stroke dd/sepsis 1) DN perbaikan ec sepsis 2. Demam tifoid
- syok sespsis (perbaikan) 2. sepsis ec dd/ ulkus diabetic, 2) PNC 2. sepsis ec urosepsis 3. Demam dengue
-imbalance elektrolit parotitis Dengan udem peru 3. CKD stage V ec PNC on HD 4. limfadenitis
-SDA 3. ulkus diabetic ar gluteus grade akut(perbaikan) 4. Kista renal dextra 2. caries dentis
2. ulkus decubitus grade III II 2. DM tipe 2 obes grade I 5. DM tipe II Obes grade I
3. infark serebri 4. parotitis (s) 3. Pneumonia (HAP) ec 6. Hipokalemia sedang Th/
4. Ulkus pedis dex 5. DM tipe 2 (dengan KAD) infeksi paru spesifik 7. Hipertensi Stage I -bed rest
5.AKI stg III akut prerenal 6. hipoalbuminemia 4. Hipertensi stage II 8. ISK -diet MB
6. anemia berat ec dd/ 9. Anemia sedang ec PGK -IVFD RL 20gtt/i
-perdarahan Th/ Th/ 10. efusi pleura (D) -IV ceftriaxone 2gr/24 jam
-peny.kronik -bed rest -bedrest 11. hipoalbuminemia -paracetamol tab 3x500 gr/hari
7.hipoalbuminemia -diet sonde DM 6x200cc -02 2-4 l/i 12. oral candidiasis -curcuma tab 3x1
8. High risk trombosis @200kkal/hari -diet ginjal 1700 kka/hari + 0,09 13. neuropati diabetik -IV omeprazole 40 mg/12 jam
-IUFD Nacl 0,9% 20gtt/i protein /kgbb/hari
Th/ -IV meropenem 1gr/2jam(H4) -threeway Th/ Lab 11/02/2019
-bedrest -drip novorapid mulai 2cc/jam -iv furosemide 40mg/8jam -Bedrest Urinalisa (+) dbn
-Mika-miki per 2 jam -drip pct 1gr(k/p) -iv ceftriaxone 2gr/24 jam (H1) -diet sonde ginjal 6x200 cc/hari + Imunoserologi (+)
-Kasur decubitus -drip plasbumin 100cc/hari -as folat 2x200mg 0,8 protein/kgBB/hari
-O2 2-4 liter/menit -burnazin cream ue 2x1 -lenal ace 2x 169mg -threeway Lab 10/02/2019
-diet sonde 6x200 cc/hari + ekstra -raat luka per 12jam -Hemodialisa - IV meropenem 1 gr/12jam Anti Dengue
putih telur -transfusi PRC sampai Hb -herbesser cd 1x100g - IV furosemide 20 mg/8jam IgM/IgG : -/-
-IVFD NaCl 0,9% 20gtt/i >10(premed furosemide -Sc novorapid 10-10-10 unit - IV omeprazole 40 mg/12jam
-dobutamin, mulai dari 5mcg/jam, -sc lantus 0-0-0-10 - Herbesser CD 1x200mg Lab 08/02/2019
titrasi dosis Lab 09/02/2019 -Valsartan 1x160mg Hb/Ht/E/L/T
-Drip plasbumin 100ml/hari Hb/Ht/E/L/T Lab 10/02/2019 - KSR 2x600mg 13,9/41/4,8/10,3/291
-IV omeprazole 40mg/hari 7,1/21/2,7/26,1/97 Anti HCV : - -nystatin drop 4x2 MCV/MCH/MCHC 85/29/34
-IV mecobalamin 500mg/12 jam MCV/MCH/MCHC HbsAg : - -gabapentin 2x300mg Diftel 03/1/0/53/37/6
-clindamicin 3x300mg 80/27/33 Alb : 2,38 -sc novorapid 10-10-10 unit Gds 99
-sucralfat syr 3xcII Diftell : 1/0/0/89/8/2 GDS : 360
-burnazin zalf Ct/bt : 7/2 Lab 06/02/2019
-rawat luka/12jam HBsAg : negative Lab 09/02/2019 Hb/Ht/E/L/Tr
-BC seimbang Bilirubin.Tot/direct/indirect pH 7,184 9,4/26/3,4/21,6/309
- Xarelto 1x1 tab 1,31/0,77//0,54 PCO2 47,3 MCV/MCH/MCHC 76/27/36
SGOT/SGPT : 31/15 PO2 56 Diftel : 4/0/0/82/7/7
Lab 11/02/2019 Protein.Tot/albumin/globulin HCO3 18 Kalsium:8,2
Hb/Ht/E/L/T 6,06/2,40/3,66 CO2 19,5 Ur/cr;28/2,84
9,1/27/3,1/6,6/111 Ca : 8,1 GDS : 442 BE-9,3 Na/k/cl 138/2,9/99
MCV/MCH/MCHC Ur/cr : 162/0,96 Sat.O2 80,7
87/29/34 Na/K/Cl : 143/3,9/113 Lab 04/02/2019
Diftell : 6/1/0/47/41/5 Lab 09/02/2019 LED: 90
Albumin : 2,51 Hb/Ht/E/L/T GDP: 165
Na/K/Cl : 144/3,0/107 11,1/36/4,4/13,1/293
MCV/MCH/MCHC 82/26/31 Lab 31/01/2019
Lab 07/02/2019 Diftel 00/1/0/94/4/1 Urinalisa normal
Hb/Ht/E/L/Tr Gds 316 HbsAg positif
10,5/30/3,6/5,8/82 Na/K/Cl 126/4,7/94 SGOT/SGPT 24/26
MCV/MCH/MCHC/ 83/29/35
Diftel : 3/0/0/56/35/6 Lab 30/01/2019
Hb/Ht/E/L/Tr
Alb 2,29 12.8/38/4,6/16.3/292
Ur/cr 180/3,19 MCV/MCH/MCHC
Na/k/cl 141/4,2/106 82/28/34
Diftel: 1/0/0/80/12/7
Lab 05/02/2019 GDS: 203
Albumin : 2,10 Na/K/Cl: 142/3.9/93

Lab 04/02/2019
Hb/Ht/E/L/Tr
7,2/22/2,5/7,9/53
MCV/MCH/MCHC/
86/29/34
Diftel : 2/0/0/65/27/6
PT/APTT : 11,4/44,7

Lab 02/02/2019
Hb/Ht/E/L/Tr
5.1/15/1.7/9/4.7
MCV/MCH/MCHC/
89/30/33
PT/APTT: 1,24/1,54
Ddimer 2606,72
Ur/Cr: 238/5,31
Na/K/Cl:144/3.9/105
 K6B1 K6B2 K6B3 K6B4 K6B5
DPJP : dr. M. Diah Sp.PD DPJP : dr. M. Diah Sp.PD DPJP : dr. M. Diah Sp.PD DPJP : dr. M. Diah Sp.PD
COW : dr. Sabarina COW : dr. Sabarina COW : dr. Sabarina COW : dr. Sabarina
DR : dr. Lisa DR : dr.Lisa DR : dr.Lisa DR : dr. Lisa
DM : Haiqal, S.Ked DM : Haiqal, S.Ked DM : Haiqal, S.Ked DM : Haiqal, S.Ked
Nama: Jamilah Nama: Asrita Arifin Nama : Hendon M Ali Nama : masati dormi
Umur: 68 th Umur: 48 th Umur : 81 tahun Umur : 53 tahun
CM: 1060778 CM: 1092129 CM : 1199046 CM : 0850562
Alamat: Aceh Besar Alamat: Aceh selatan Alamat : Aceh besar Alamat : Aceh barat
Hari Rawatan: 3 Hari Rawatan: 9 Hari rawatan : 3 Harai rawatan : 3

A/ A/ A/ A/
1. Obs. Febris e.c. dd 1) ISK 1. Penurunan kesadaran ec dd 1. 1. PSMBA(perbaikan) ec dd 1. CKD stage V dengan
komplikata 2. Abses hepar Sepsis 2. Metastase proses 1) Ulcer gaster uremic syndrome
3. Malignancy 3.Imbalance elektrolit 2) Ulcer duodenum (perbaikan)ec dd
2. Anemia sedang NN e.c. dd/ 2. Ca Mamae stad IV post 3) Gastritis erosif -DN
1) penyakit kronik 2. kemoterapi 6 siklus 2. CAD (perbaikan) -HN
Perdarahan 3. Sepsis ec dd 1)pneumonia, 2) ISK 3. Geriatric problem -PNC
3. Dispepsia tipe like ulcer 4. Trombositopenia ec 4. Anemia sedang NN ec 2. Anemia sedang normokrom
4. Hiponatremia hipoosmolar dd/malignancy PSMBA normositer ec CKD
euvolemik 5. High risk thrombosis 3. DM tipe 2 NW
5. NHL post kemo siklus ke 6 6. Limfadenopati ec Metastase Th/
pneumonia proses -bed rest Th/
Th/ 7. Hypernatremia normosmolar -diet sonde 6x200ncc/hari -bedrest
-Tirah Baring euvolume -IVFD NaCl 0,9% -diet ginjal 1700 kkal/hari + 50
-Diet MII 1700 kkal/hari 8.Hipercalcemia -IV ceftriaxone 2gr/24jam gr protein/ hari
-IV Ceftriaxone 2 gr/ 24 jam 9. alkalosis respiratori kompensasi -iv omeprazole 40 mg/12 jam -domperidone 2x10 g
-IV. Omeprazole 40 mg/8 jam 10. oral candidiasis -domperidone tab 3x10 mg - bicnat 3x500 g
-Domperidone 3 x 10 mg 11. PSMBA ec dd/stress ulcer, ulkus -laxadin syr 3 CII -lenal ace 2x 169 gr
-Lactulosa syrup 3 x CII gaster -asam folat 2x400mg
-Transfusi PRC s.d. Hb > 10 g/dL 12. anemia berat ec malignancy Lab 08/02/2019 - cetirizine 2x10 mg
Setelah cek MDT GDS 166 -valsartan 1x80 mg tab
-asetat 2x1 Th/ -sinvastatin 1x 10 mg
-pct 3x500 mg -bedrest, mika miki tiap 2jam Lab 03/02/2019 -PRC s/d HB > 10 gr/dl
-O2 2-4 L/menit HB/Ht/E/L/T: -HD rabu-sabtu
Lab 11/02/2019 -diet sonde 6x200 cc 1500 kkal/hr 9,6/29/3,6/128 -gabapentin 1x3000mg
Hb/Ht/E/L/T -IVFD sol 2:1 20 tpm MCV/MCH/MCHC:
8,1/26/.2,6/20,8/428 -IV meropenem 1 gr/ 8 j 80/27/3 Lab 09/02/2019
MCV/MCH/MCHC - IV omeprazole 40 mg/12 j Diftel: 4/1/0/59/28 Hb/Ht/E/L/T
10031/31 - IV furosemide 40mg/2jam Ur/Cr : 29/0,71 9,3/28/3,3/12,9/321
Diftell : 7/10/67/1312/2,2 -Drip PCT 1 gr/ 8 j Na/K/Cl : 142/4,5/100 MCV/MCH/MCHC
SGOT/SGPT : 46//14 - nystatin drip 4x2cc 83/28/34
Albumin : 3,10 -laxadine syr 3xCII Diftell : 1/1/0/93/3/2
MDT, kesan:anemia normokromik -suction berkala
normositik -transfusi PRC s/d HB 10 Lab 08/02/2019
Urinalisa
Lab. 09/02/2019 Lab 10/02/2019 Berat Jenis 1,015
Hb/L/T : 8,4/23/430 Hb/L/T : 5,9//16,7/25 pH 7,5
MCV/MCH : 96/32 MCV/MCH : 95/30 Protein +1
Diff. Count : 5/3/1/70//10/11 Diff. Count : 2/1/0/27/67/3 Glukosa +1
GDS : 96 Alb : 2,88 Leukosit 8 – 10 LPB
Ur/Cr : 20/0.90 Ca : 14,1 Epitel 15 – 20 LPK
Na/K/Cl : 127/5,0/98 Na/K/Cl : 163/3,8/131
As urat 4,9
Lab 08/02/2019 Kolesterol total : 300
Ca : 14,7 HDL/LDL/trig :36/274/180
Na/k/Cl : 160/4,5/133
Lab 06/02/2019
Lab 07/02/2019 Hb/Ht/E/L/T 5,8/18/2,0/7,7/354
Hb/Ht/E/L/T MCV/MCH/MCHC 88/29/33
8,9/27/3/24/18,9 Diftel 7/1/0/74/11/7
MCV/MCH/MCHC 91/30/33 Gds 108
Diftel: 2/0/-1/45/49/4 Na/K/Cl 148/4,5/114
PT/APTT: 10,4/40,1
LDH 1072
As urat 13,7

Agd
Ph 7,581
Pco2 38,7
Po2 120
Hco3 36,7
Total co2 37,9
BE 14,4
Sat O2 98,3

Lab 06/02/2019
Ca 15,8

Lab 04/02/2019
Hb/Ht/E/L/T
10/293,3/16,7/37
MCV/MCH/MCHC
89/31/34
Diftel: 11/0/45/49/4
Ur/Cr : 70/1,37
Na/K/Cl : 154/3,6/104
PT/APTT: 10,2/37,6
SGOTSGPT: 180/33