AQSHA 3 (PENYAKIT DALAM WANITA)

Hari/Tanggal : Selasa, 19 Februari 2019

Dokter Jaga : dr. Intan/dr. Ayak
Dokter Muda Jaga : Haris, S.Ked/ Halim, 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. Okdimur Hayadi DR : dr. Okdimur Hayadi DR : dr. Okdimur Hayadi DR : dr. Okdimur Hayadi
DM : Alif DM : Alif DM : Alif DM : Alif
Nama: Nurlaila Nama: Cut Suriani Nama: Erlina Manan Nama : Siti Ridwan
Umur :35 th Umur: 36 thn Umur: 46 thn Umur : 04-06-1970 (48thn)
CM: 1199981 CM: 1096042 CM: 1096042 CM: 1200733
Alamat:Aceh Barat Alamat: Aceh besar Alamat: Aceh besar Alamat: Aceh barat daya
Hari Rawatan: 9 Hari Rawatan: 2 Hari Rawatan: 11 Hari Rawatan: 3

A/ A/ A/ A/
1. Tumor Tiroid 1. CKD stg V on HD reg ec dd HN, 1). Dd/ 1. Tumor paru, 2. Metastase 1. Massa ar illiaka sinistra ec dd/
2. SLE PNC dengan udema paru akut paru, 2. CAP, 3. TB Paru metastase proses MBC,
3. Oral candidiasis 2. Hipertensi on theraphy 2). pneumonia (CAP )dd/infeksi paru osteosarcoma, multiple myeloma
spesifik 2. massa intrakranial
Th/ Th/ 3). DM tipe II normoweigt 3. HT grade II on terapi
- Bed rest - Bed rest 4). ISK 4. Dyspepsia tipe like ulcer dd tipe
- Diet MII 1700 kkal/hari - O2 2-4 L/I nasal kanul 5). Post mastektomi + kemoterapi + radiasi mixed
- IVFD futrolit 20tpm - Three way a.ica mamae dex dextra 5. Massa ar mamma sinistra ec dd/
- IV Omeprazole 40 mg/12 jam - Diet MB 1700 kkal/hari + 50 gr 6). Susp metastase proses ar paru dextra FAM, Kista, lipoma
- Domperidone 3 x 10 mg tab protein 7). Hipoalbuminemia sedang Th/
- Nystatin Drop 4 x 2cc - As folat 2x400 mg - Bedrest
- Propanolol 1 x 10 mg - Lnal ace 2x169 mg Th/ - Diet MB 1700kkal.hr
- Paracetamol 3 x 500 mg (k/p) - Vectrin 3x1 -bedrest - IVFD futrolit 20 tpm
- Metil prednisolone 3x16mg - Bisoprolol 1x5 mg -diet mb 1700 kkal/hr + ekstra putih telur - IV omeprazole 40mg/12j
- Myfortic 2x360mg - Domperidone 3x10 mg -IVFD futrolit 20gtt/i - Domperidon 3x10mg
- Betadine - IV ceftriaxone 2gr/24 jam (H2) -drip pct 1 gram/ 8 jam (k/p) - Sucralfat syr 3xcI
- IV furosemide 1 amp/8jam -domperidon 3x10 mg - Amlodipine 1x10mg
Lab 14/02/2019 -levemir 0-0-0-10 unit(22.00) - Valsartan 1x160mg
Hb/Ht/E/L/T : 11,5/33/4,2/2,7/140 Lab 18-2-2019 -novorapid 6-6-6 unit(sebelum makan
MCV/MCH/MCHC : 78/27/35 Hb/L/Tr 7,8/5,9/83 siang) Lab 16/02/2019
Diff.Count : 0/1/0/70/23/6 MCV/MCH/MCHC 82/28/34 - vectrin 3x1 Hb/Ht/E/T/L : 8,7/26/3,4/417/11,6
Urinalisa Gds: 118 MCV/MCH/MCHC : 76/25/33
Warna : kuning, leukosit (-), protein (+2), Ur/Cr 80/9,98 Lab 16/02/2019 Difftel : 0/0/0/71/21/8
glukosa (-), darah (+) Hb/Ht/E/L/T Alb : 3,58
9,2/28/3,4/8,9/205 GDS : 105
Lab 13/02/2019 MCV/MCH/MCHC Ur/Cr : 33/0,85
Faktor Rheumatoid: Negatif 82/27/33 Na/K/Cl : 149/3,9/102
Diftell : 1/1/0/73/17/8
Lab 11/02/2019 Ur/Cr : 9/0,55
Free T4:14,77 Na/K/Cl : 137/5,0/97
TSHs:3,358
Lab 11/02/2019
Lab 09/02/2019 Hb/Ht/E/L/T
Hb/Ht/E/L/Tr 10,1/31/3,7/10,7/331
11,2/33/4,1/3,2/176 MCV/MCH/MCHC
MCV/MCH/MCHC 84/27/32
81/27//34 Diftell : 0/0/0/79//14/7
Diff.Count : 1/1/0/72/22/4 Bil.total/Bil.direk/Bil.indirek
Albumin 3,34 0,83/0,37/0,46
GDS 101 SGOT/SGPT/albumin 55/43/2,73
Ur/Cr 41/0,73 HbA1c : 10,40
Na/K/Cl 133/4,7/105 Ur/cr : 10/0,56
Na/K/Cl : 131/4,4//108
Urinalisa:
Protein +1
Glukosa +2

Lab 08/02/2019
Urinalisa
Warna Kuning
Berat Jenis 1,015
pH 7,0
Lekosit (+)
Protein +1
Glukosa +1
Keton +
Nitrit –
Urobilinogen +
Bilirubin +
Darah –
Leukost 20 – 25 LPB
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 (+)
 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. Okdimur DR : dr. Okdimur DR : dr. Okdimur DR : dr. Okdimur DR : dr. Okdimur
DM : Alif DM : Alif DM : Alif DM : Alif DM : Alif
Nama : Ramlah Nama : Raimah saudin Nama : Ummi Ahmad Nama : Nurmala Johan Nama : Rasimah Sulaiman
Umur ; 68 th Umur ; 45 th Umur : 75 tahun Umur : 68 tahun Umur : 61 tahun
CM ; 0893960 CM ; 1199575 CM : 1118057 CM : 0958912 CM : 1019405
Alamat ; Aceh Besar Alamat ; aceh barat daya Alamat : Pidie Alamat : Banda Aceh Alamat : Aceh Barat
Hari Rawatan : 3 Hari Rawatan : 13 Hari Rawatan : 5 Hari Rawatan : 6 Hari Rawatan : 7

A/ A/ A/ A/ A/
1. Dd pneumonia geriatric, 1. Bisitopenia ec dd 1. Colic renal ec susp 1. CAP dd infeksi paru 1. Astes ec dd sirosis hepatis
infeksi paru spesifik -Leukemia akut nephrolithiasis spesifik stadium decompensate
2. HT stg I -MDS 2. Acute on CKD dd AKI 2. Charcot foot pedis dextra 2. Ascites grade 2 ec dd
3. Selulitis ar cruris sin. Dd/ -Anemia aplastic Stage III ec PGOI dgn 3. DM Tipe II normoweight sirosis hepatis, meigh
1)thrombosis vena -Myelodisplasia uremic syndrome 4. Anemia Berat hipokrom syndrome
2)obstruksi limfatik -ITP 3. Pneumonia (CAP) mikrositer ec dd/ 1. 3. DM tipe II NW
4. Dispepsia tipe mixed dd Defisiensi Fe 2. Occult 4. HT stg I
Th/ Th/ tipe like ulcer Bleeding 5. Dislipidemia
- Bedrest -Bed rest 5. Hiperkalemia ringan 5. Neuropati diabetic
- Diet MB 1700kkal/hari -diet MB 1700kkal/hari 6. Anemia sedang HM 6. HT stg I Th/
- O2 2-4 l/I (nasal kanul) -ivfd Futrolit 20 tpm 7. ISK asimptomatis 7. Hipoalbuminemia - Bedrest
K/P -domperidon tab 3x10mg 8. ISK - Diet hati II 1700kkal/ hari
- IVFD futrolit 20tpm -TF jika trombosit <10.000 atau Th/ - IVFD Aminofusin hepar 1
- IV ceftriaxone 2gr/24jam <20.000 dengan perdarahan -Bedrest Th/ fls/hari
- Paracetamol 3x500mg - Sucralfat syr 3x 2cc -Diet ginjal 1900 kkal/hari + - Bedrest - Three way
- Valsartan 1x80mg - Paracetamol 500 mg tab (k/p) 45 gram protein / hari - Diet DM 1700 kkal/hari - Valsartan 1x80mg
- Vectrin 3x1 - fluoxentin 1x1 tab -Threeway + kateter urine - IvFD Futrolit 20 gtt/i - Simvastatin 1x10mg
- Klindamisin 3x300g -IV. Ceftriaxone 2 gr/ 24 jam - IV Ceftriaxone 2 gr/24 jam - Spironolacton 2x100mg
Lab 14/02/2019 (H6) (H6)
Lab 15/2/2019 Hb/Ht/E/L/T : 6,5/18/2,2/13,9/5 -IV omeprazole 40 mg/12 jam - IV Omeprazole 40 mg/12 Lab 14/2/2019
Hb?L/T: 9,9/12,7/148 Difftel : 0/0/0/30/43/27 -IV Ondansetron 4 mg/12 jam jam Urinalisa (+)
MCV/MCH/MCHC CT/BT : 9/3 -IV Buscopan 1 gram/12 jam - Gabapentin 2 x 300 mg Feses rutin (+)
89/32/36 GDS : 131 -Asam folat 3x400mg - Mecobalamin 3 x 500 mg
Difftel : 0/0/0/91/3/6 Ur/Cr : 24/0,69 -Kalitake 3xI - Valsartan 1 x 80 mg Lab 13/2/2019
Gds: 128 Na/K/Cl : 138/3,7/97 -Balance cairan seimbang - Transfuse PRC s/d Hb PT/APTT : 13,6/41,5
Na/K/Cl: 143/4,0/97 >10gr/dl HBsAg : negative
Lab 13/02/2019 Lab 17//2/2019 - Azytromisin 1x500mg antiHCV : negative
Hb/L/T : 8,4/2,1/22 Ca 9,6 - Coditam 3x50mg Kolesterol tot/HDL/LDL/Trig
MCV/ MCH : 79/27 Na/K/Cl 134/5,8/94 - Clobazam tab 1x1 343/9/242/389
Diff .count : 1/0/0/14/84/1 - Drip albuminar 25%
PT /APTT : 13,3 / 36,4 Lab 15//2/2019 100cc/hari Lab 12/2/2019
INR : 0.98 Hb/L/Tr: 8,5/13,5/372 Hb/L/T : 11,0/6,9/211
MCV/MCH/MCHC Lab 16//2/2019 MCV/MCH : 94/34
Lab 10/02/2019 80/25/32 Hb/L/T : 8,4/5,6/353 Diff. Count : 1/1/0/71/19/8
Hb/Ht/E/L/T Na/K/Cl: 134/7,1/95 MCV/MCH : 81/24 Ur/Cr : 11/0,51
9,3/27/3,3/9,8/19 Urinalisis (+) Difftel : 3/1/0/60/27/9 Na/K/CL : 141/4,2/98
MCV/MCH/MCHC HbsAg : negatif
81/28/34 Anti HCV Lab 14//2/2019
Diftell : 1/1/0/37/30/31 Hb/L/T : 6,8/5,3/380
Lab 14//2/2019 Alb: 2,28
Hb/L/T : 9,3/13,4/387 Urin: Kuning keruh, BJ 1,010,
MCV/MCH : 78/26 PH 6,5 Protein (+1), Darah (+)
Diff. Count : 0/1/0/76/12/11
GDS : 127 Lab 13/02/2019
Ur/Cr : 193/11,27 Hb/L/T : 5,3/5,3/372
MCV/MCH : 77/23
Diff : 0/1/0/64/26/9
GDS : 148
Ur.Cr : 24/0,95
Na/K/Cl : 137/3,7/96
 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. Rahmi COW : dr. Rahmi COW : dr. Rahmi COW : dr. Rahmi COW : dr. Rahmi
DR : dr. Munawwarah DR : dr. Akmal DR : dr. Munawwarah DR : dr. Munawwarah DR : dr. Munawwarah
DM : Egi DM : Egi DM : Egi DM : Egi DM : Egi
Nama: Cut Tihasanah Nama : Safrianti Hanafiah Nama : Nyak Nur Nama : Alawiyah Yahya Nama : Ratna Juwita Yusuf
Umur : 59 th Umur : 20-12-1980 (38th) Umur : 02-4-1950 (68thn) Umur : 90 th Umur : 31/07/1959 (59 th)
CM: 1178549 CM : 1200768 CM: 1199503 CM : 1028419 CM: 1200627
Alamat: aceh timur Alamat : Aceh Barat Alamat: Aceh Timur Alamat : Pidie Jaya Alamat: Banda Aceh
Hari Rawatan: 8 Hari Rawatan : 3 Hari Rawatan: 14 Hari rawatan ke : 7 Hari Rawatan: 4

A/ A/ A/ A/ A/
1. NHL relaps post kemo siklus 1.Abdominal pain ec dd/ 1. Penurunan kesadaran 1. dd/ - Ca Colorectal Dd CML, CLL
ke-6 -cholesistitis (perbaikan) ec sepsis -Ca Recti
2. High Risk Trombosis -dipepsia tipe like ulcer 2. Sepsis ec pneumonia 2. Hipertensi stg I Th/
3. Impending OSNA -appendisitis 3. DM tipe 2 underweight 3. Anemia berate normokrom -Bedrest
4. Cancer pain 4. Post stroke iskemik normositter ec perdarahan -Diet MB 1700 kkal/hari
5. hypokalemia ringan 2. Anemia ringan hipokrom 5. ISK 4. Geriatri problem -Cytodrox 2x500mg
mikrositik ec dd occult bleeding, 6. Anemia sedang NN ec dd: -Infeksi - As folat 2x1
Th/ def.besi, penyakit kronik peny kronik, perdarahan -Impairment of vision -transfusi PRC 1 kolf/hari (s.d Hb
-bedrest 7. Hipoalbuminemia sedang -konstipasi > 9)
-diet sonde 6x200 cc Th/ (2,09) -IVFD futrolit 20 tpm
-IVFD dex 5% 20 tpm -Bedrest 8. Hipokalemia ringan (3,3) Th/ -Aspilet 1x80mg
-IVFD clinimix + Clinoleit 1 fls/ -IVFD NaCl 0,9% 20 gtt/i -Bed rest -PCT 3x500
hari (1 tpm) -Diet MII 1700 kkal/hari Th/ - Diet MB 1700 kkal/hari
-IV cefoperazine sulbectan 1gr/8 -IV omeprazole 40mg/12j - Bedrest - IVFD Futrolit 20 tpm Lab 16/02/2019
jam -Paracetamol 3x500mg - Mika mika tiap 2 jam - IVFD NaCl 0,9 % 20 tpm Hb/Ht/E/L/Tr
- IV omeprazole 40 mg/12 jam -Buscopan 2x1 tab (k/p) - Diet DM 6x200cc/hari - IV omeprazole 40 mg / 12 jam 6,8/20/2,4/294/996
- Sucralfat syr 3xcII -Domperidon 3x10mg - Three way - IV Ceftriaxone 2 gr/ 24 jam (h7) MCV/MCH/MCHC
- IV tramadol 50 mg 1amp/8j - IV omeprazole 40mg/12j - IV transamin 500mg/8jam 82/28/35
- Metilprednisolon 2x16mg Lab 16/02/2019 - Drip albuminar 25% 100 - Amlodipin 1x5 mg Diftel : 4/10/0/73/7/6
- KSR 1x500mg Hb/Ht/E/L/T : 9,4/29/4,6/6,5/383 cc/hari (H2) - Paracetamol 3x500 mg (K/P) Ur/Cr : 11/0,59
MCV/MCH/MCHC : 63/21/33 - Amlodipine 1x10mg - Cetirizine tab 2x1 (K/P) Na/K/Cl : 147/3,5/97
Lab 15/02/2019 Difftel : 2/1/0/60/22/15 - SC novorapid 3-3-3-3-3-3 - Transfusi PRC sd Hb > 10 gr/dL
Hb/Ht/E/L/Tr: CT/BT : 9/3 - KSR 1x600 mg - Domperidone 3 x 10 mg Lab 12/02/2019 (RS
10,1/30/3,1/6,6/175 GDS : 113 - Transfuse PRC s/d Hb - Sucraflat syr 3xCII MEURAXA)
DIFTEL: 0/0/0/87/7/6 Ur/Cr : 6/0,47 10gr/dl - Kaltrofen sup II (extra) Hb/L/Tr: 7,1/330,1/1164
Ur/Cr: 116/1,09 Na/K/Cl : 142/3,7/102 - Burnazin cr 2x/hari - IV biscpoan 1 ap (extra) MCV/MCH/MCHC
Na/K/Cl: 141/3,3/100 - IV vit K 1 amp/8jam 81/28/34
Free T4: 5,34 Lab 16/02/2019 - Bolus omeprazole 80 mg LED: 90 mm/jam
TSHs: 0,854 Hb/Ht/E/T/L : 8,1/22/2,8/450/9,6 selanjutnya drip omeprazole 6,25
Bilirunin total : 0,74 Alb : 2,09 cc/jam
Bilirubin direct : 0,27 Ur/Cr : 14/0,28
Bilirubin indirect :0,47 Na/K/Cl : 137/3,3/97 Lab 18/02/2019
Protein total : 6,28 Hb/L/T 5,4/12,3/238
Alb/Glob : 3,47/2,81 Lab 7/2/2019 MCV/MCH/MCHC 89/31/35
PT/APTT : 12,7/38,2 HbA1c : 7,5
Urinalisa Lab 15/02/2019
Lab 13/02/2019 Warna : kuning, Leukosit (+), Hb/Ht/E/L/Tr:
PT/APTT: 11/34,5 protein (+1),glukosa (-), darah (+) 8,4/25/2,8/12,7/291
DIFTEL: 0/0/0/87/9/4
Lab 12/2/2019 Lab 4-02/2019 MCV/MCH/MCHC
SGOT/SGPT: 148/26 Hb/L/T: 12,0/31,3/230 89/30/34
Albumin: 3,44 Ur/Cr: 129/0,75
LDH: 378 MCV/MCH/MCHC Lab 12/02/2019
As. Urat: 11,8 80/29/36 Hb/Ht/E/L/Tr:
Albumin : 2,56 7,2/21/2,3/19,1/336
Lab 11/02/2019 GDS : 323 MCV/MCH/MCHC
hb/ht/e/l/t Na/K/Cl : 160/4,2/110 93/31/34
11,9/33/3,6/7,2/280 DIFTEL: 2/1/0/76/14/7
mcv/mch/mchc GDS: 165
92/33/36
diftell : 0/1/0/77/9/13
gds : 87
ur/cr : 118/1,41
na/k/cl : 139/3,4/87
 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. Rahmi COW : dr. Rahmi COW : dr. Rahmi COW : dr. Rahmi COW : dr. Rahmi
DR : dr. Munawwarah DR : dr. Munawwarah DR : dr. Munawwarah DR : dr. Munawwarah DR : dr. Munawwarah
DM : Egi DM : Egi DM: Egi DM: Egi DM: Egi
Nama: Sairah M Amin Nama : Zainah Nama : Nahyatul Rosa Nama : Nyak Ubit Nama : Nurhayati
Umur: 57 th Umur : 77 tahun Umur : 18 tahun Umur : 52 tahun Umur : 56 tahun
CM: 1153971 CM : 1199958 CM : 1200712 CM : 1200562 CM : 1199964
Alamat: Aceh Besar Alamat : Aceh besar Alamat : Lhokseumawe Alamat : Pidie Alamat : Aceh Besar
Hari Rawatan: 1 Hari rawatan : 11 Hari rawatan : 4 Hari rawatan : 5 Hari rawatan : 10

A/ A/ A/ A/ A/
1. Prolonged fever ec dd 1. Artritis septik ar genu 1. Bisitopenia ec dd/ 1. Leukositosis ec dd CML, 1. Penumonia (HAP)
pneumonia, ISK, malaria, bilateral ec OA genu KL IV - ITP AML 2. Diare kronik (perbaikan) ec
infeksi paru spesifik, 2. Coxitis dextra - anemia aplastik 2. DM tipe 2 normoweight dd colitis ulseratif, colitis
endocarditis 3. Geriatric problem - leukemia akut 3. Neuropati diabetik TB
2. Dd/ pneumonia, infeksi (immobilisasi, inanisi, - autoimun disease 3. Chron disease
paru spesifik instabilitas dan jatuh) 2. dyspepsia tipe dismotility dd Th/ 4. Ulkus decubitus ar gluteus
3. ISK 4. Ulcus decubitus grade II tipe mixed -Bedrest grade II
4. CHF NYHA II-III ec dd 5. Hiponatremia, hipoosmolar, - O2 2-4 L/i 5. ISK
IHD, HHD, DCM hipovolemik (127) Th/ - DM MB 1700 kkal/hari 6. Anemia sedang NN ec dd
6. Spondilisis lumbal -Bedrest - IVFD futrolit 20 gtt/i peny kronik, PSMBA
Th/ 7. High risk thrombosis -diet MB 1700kkal/hari - Drip Levofloksasin 500 mg/24 7. Hipoalbuminemia sedang
-Bedrest 8. Hipoalbuminemia ringan -IVFD futrolit 20tpm jam (H5) (2,02)
-diet 1500 kkal (perbaikan) 2,94 - IV omeprazole 40mg/12jam - Aspilet 1 x 80 mg
- IVFD NaCl 0,9 % 20 tpm 9. HT stg II - domperidon 3x10mg - SC apida 8-8-8 Unit Th/
- IV ceftriaxone 2gr/24 jam (ST) -sucralfat syr 3xCII - SC lantus 14 unit - Bedrest
- IV furosemide 20 mg/12 jam Th/ - gabapentin 1x300mg - Diet sonde 6x200cc/hari
- IV omeprazole 40 mg/12 jam -Bedrest Lab 17/02/2019 - cytodrox 2x500mg - IVFD NaCl 0,9% guyur 1
- Aspilet 1x80mg -mika-miki tiap 2 jam selama 15 Hb/Ht/E/L/T : 9,4/28/2,9/5,2/50 fls lanjut 20 tpm
-CPG 1x75mg menit MCV/MCH/MCHC : 97/33/34 Lab 15/2/2019 - IV ceftriaxone 2 gr/24 jam
- Atorvastatin 1x20mg -kateter, NGT Difftel : 2/1/0/35/57/5 LDH : 879 (H6)
- PCT 3x500mg -Diet sonde 6x200 cc Kolesterol - SC levemir 0-0-0-8 unit
- Domperidone 3x100mg -O2 2-4 l/ menit Lab 15/2/2019 Total/HDL/LDL/trigli : - Drip albuminar 25% 1
- sucralfat syr 3xCI - IVFD NaCl 0,9% 20 tpm Hb/L/T : 9,8/6,7/45 188/36/162/233 fls/hari (H5)
-iv ceftriaxone 2 gr/24 jam (H11) MCV/MCH : 96/33 Ur/Cr/As.Urat : 38/0,54/4,0 - Drup fluconazole 450
Lab 14/2/2019 -clindamisin 3x300 mg (H11) Diff. Count : 1/0/0/67/27/5 Na/K/Cl : 142/4,3/109 mg/24 jam (H4)
Hb/L/T : 9,6/20,7/152 - Mupirocin Cream GDS : 123 Urinalisa (+) - Curcuma 3x1
MCV/MCH : 79/27 - pradaxa 1x75 mg (stop sementara) Na/K/Cl : 146/3,9/103 - Sucralfat syr 3xCI
Diff. Count : 0/0/0/88/7/5 - drip albumin 25 % fls/hari Lab 14/2/2019 - Symbio 3x1
Ur/Cr : 99/4,26 - drip PCT 1gr Hb/L/T : 10,8/190,3/1152 - Attapulgite 1 tab/kali
Na/K/CL : 134/4,8/97 - attapulgit 1 tab/mencret maksimal MCV/MCH : 86/30 mencret max 12 tab/hari
12 tab/hari Diff. Count : 1/8/0/84/3/4 - Burnazine zalf 2x/hari
Lab 10/2/2019 -IV omeprazole 40mg/12j - Transfuse PRC 1 kolf s/d
Hb/L/T : 8,4/20/92 - amlodipine 1x5mg Hb >9 gr/dl
MCV/MCH : 78/28
Diff. Count : 1/1/0/84/5/9 Lab 16/02/2019 Lab 18-02-2019
Alb : 2,59 Hb/Ht/E/L/T : 8,9/26/3/10,9/388 Hb/L/T 9,4/5,5/40
GDS : 335 Difftel : 7/0/0/79/9/5 Ptotein total: 5,11
Ur/Cr : 122/4,50 Alb : 2,94 Alb: 2,00
Na/K/CL : 129/4,0/105 Na/K/Cl : 127/4,5/91 Ur/Cr 24/0,29
Na/K/Cl 133/3,7/115
Lab 08-02-2019 Lab 13/2/2019
Bil tot: 0,40 Hb/L/T : 10,1/8,3/351 Lab 17-02-2019
Bil direct: 0,18 MCV/MCH : 87/29 Hb/L/T 8,9/6,2/45
Bil indirect: 0,22 Diff. Count: 7/0/0/69/12/12 Alb: 2,12
SGOT/SGPT: 35/31 PT/APTT: 9,9/38,4 Ur/Cr 35/0,43
Ur/Cr : 25/0,48 Na/K/Cl 135/3,7/102
Lab 07-02-2019 Na/K/CL : 130/5,1/102
Na/k/cl 130/4,6/103
Lab 12/2/2019
Lab 05-02-2019 Hb/L/T : 10,1/6,2/339
Hb/Ht/E/L/T MCV/MCH : 87/29
8,3/23/3,1/26,4/33 Diff. Count : 11/1/0/59/11/18
MCV/MCH/MCHC Alb : 2,19
75/27/36/ Ur/Cr : 25/0,47
Diftel : 1/0/0/92/4/3 Na/K/CL : 126/4,6/99
GDS : 68
Ur/Cr : 250/7,71 Lab 11/02/2019
Na/K/Cl : 126/6,1/88 Urinalisis
warna ;kuning
kejernihan ; keruh
berat jernih ; 1,015
pH ; 7,5
lekosit ; negative
protein ; negative
glukosa ; negative
keton ; negative
nitrit ; negative
urobilinogen ; negative
bilirubin ; negative
darah ; positif

albumin : 2,35

Lab 09/02/2019
Hb/Ht/E/L/T
11,0/31/3,7/16,8/347
MCV/MCH/MCHC 83/30/35
Diftel 7,4/2/0/0/82/8/8
Gds 129
Na/K/Cl 113/4,7/92
 K5B1 K5B2 K5B3 K5B4 K5B5
DPJP : dr. M. Riswan 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. Rahmi COW : dr. Sabarina COW : dr. Sabarina COW : dr. Sabarina COW : dr. Sabarina
DR : dr. T Fahril DR : dr. Akmal DR : dr. Akmal DR : dr. Akmal DR : dr. Akmal
DM : Duma DM : Duma DM : Duma DM : Duma DM : Duma

Nama : Aidar Hasan Nama : Rihan M Salim Nama : Nurhayati Mahmat Nama: Asmani A Bakar Nama : Nurlena Nyak Umar
Umur : 51 th Umur : 54 tahun Umur : 72 th Umur : 59 thn Umur : 54 tahun
CM : 1200803 CM : 1-19-76-00 CM : 1200718 CM: 1198367 CM : 0954861
Alamat : Aceh Besar Alamat : Aceh Selatan Alamat : Aceh Besar Alamat: Bireuen Alamat : Banda Aceh
Hari rawatan ke : 2 Hari rawatan : 2 Hari rawatan ke : 1 Hari Rawatan: 1 Hari rawatan : 1

A/ A/ A/ A/ A/
1.PSMBA ec dd/ 1. PSMBA ec dd 1. Gastriif 1. Syok sepsis (perbaikan) ec PSMBA pro EGD 1. CKD stg V ec dd PNC, HN
-gastritis erosive erosive, 2. Ulkus gaster, 3. Ulkus dd 1. Pneumonia, 2. dengan uremic syndrome
-ulkus gaster duodenum Urosepsis Th/ 2. DM tipe 2 NW
-ulkus duodenum 2.OA genue bilateral 2. Geriatric problem (inanisi, -Protap colonoskopi dan EGD 3. Hipertensi
2. Anemia berat HM ec dd : 3. DM tipe 2 obese grade I infeksi, instabilitas dan 4. Anemia
-occult bleeding 4. HCAP jatuh, demensia) Lab 11/2/2019
-penyakit kronik 3. ISK asimptomatis Hb/Ht/E/L/T : Th/
-defisiensi besi Th/ 4. CAP dd infeksi paru 12,4/37/4,1/8,0/371 - O2 2-4 L/I nasal kanul
3. OA genue bilateral -Bed rest spesifik MCV/MCH/MCHC : 91/30/33 - Diet ginjal 1700 kkal/hari +
-NGT jika bersih aff 5. Oral candidiasis CT/BT: 7/2 protein 30 gr/hari
Th/ -Diet MII 1700 kkal/hari 6. Hipoalbumin (2,7) SGOT/SGPT: 266/120 - Kateter
- Bed rest -IVFD NaCl 0,9% 20 gtt/menit 7. AKI stg 3 pre renal GDS: 101 - As Folat 2x400 mg
- Diet lunak 1700kkal/hr - IV ceftriaxone 2gr/24 jam (ST 8. RBBB komplit Ur/Cr: 18/0,60 - Domperidon 3x10 mg
-IVFD NaCl 0,9% 20tpm H1) - Amlodipine 1x5mg
- IV omeprazole 40mg/12j - IV Omeprazole 40 mg/ 12 jam Th/ - HD konfirmasi GH
-sucralfat syr 3xCI -IV asam traneksamat 500mg/ 8j - bedrest
-transfusi PRC s/d Hb > 10gr/dl - SC Levemir 0-0-0-14 Unit - O2 2-4L/I (K/P) Lab 18-02-2019
- SC Novorapid 3-3-3-3-3-3 Unit, -NGT, Kateter Hb/L/T 10,7/8,9/305
Lab 17/02/2019 jika NGT lepas gantu 16-16-16 -diet sonde 6x200cc Alb: 3,10
Hb/Ht/E/L/T: 4,6/14/1,9/9,5/494 unit -IVFD Nacl 0,9% 20tpm Gds: 215
MCV/MCH/MCHC : 75/25/33 -Sucralfat syr 3xCI - IV cefepime 1gr/8jam Ur/Cr 168/5,16
DIFTEL: 1/0/0/77/17/5 -Paracetamol 3x500mg -Balance cairan Na/K/Cl 127/4,6/88
CT/BT : 8/2 -nystatin drop 4x2cc AGD: pH 7,42, pCO2 31,0, HCO3
HBsAg : negatif Lab 17/02/2019 -clindamisin 3x300mg (H2) 20,4, pO2 27
GDS: 93 Hb/Ht/E/T/L : 4,4/14/1,6/268/20,8
Ur/Cr: 43/0,84 Difftel : 3/0/1/58/31/7 Lab 18/02/2019
Na/K/Cl: 135/3,6/90 PT/APTT : 11,3/24,2 Urinalisa: warna kuning keruh BJ
HBsAg : negatif 1,015 pH 7,0 Leu (+) Protein (+1)
GDS : 410 Nitrit (+) Darah (+)
Ur/Cr : 53/0,6
Na/K/Cl :139/4,9/101 Lab 14/02/2019
Hb/Ht/E/L/T
Lab 14/2/2019 9,1/27/3,4/53,1/360
Urinalisa: warna kuning keruh, BJ MCV/MCH/MCHC
1,010, pH 6,5, leu (+), protein 81/27/34
(+1), glukosa (+1), keton (+), L Albumin : 2,76
(30-40), E (2-3), Epitel (20-30) Gds: 88
Ur/Cr: 74/3,72
Lab 13/2/2019 Na/K/Cl: 142/3,9/101
Hb//E/L/T
9,8/3,4/13,5/389
MCV/MCH/MCHC
79/29/36
Gds: 279
Ur/Cr: 39/1,39
Na/K/Cl: 137/3,9/88
 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 DPJP : dr. M.Diah Sp.PD
COW : dr. Sabarina COW : dr. Sabarina COW : dr. Sabarina COW : dr. Sabarina COW : dr. Sabarina
DR : dr.Akmal DR : dr. Akmal DR : dr. Akmal DR : dr. Akmal DR : dr. Akmal
DM : Duma DM : Duma DM : Duma DM : Duma DM : Duma
Nama : Syarlidar Nama : Nurlela M. Saleh Nama : Marlinda M Daud Nama : Saidah Ali Nama : Safridah
Umur : 65 tahun Umur : 65 tahun Umur : 25 tahun Umur : 50 tahun Umur : 53 TH
CM : 1200823 CM : 0855895 CM : 1200601 CM : 1200606 CM : 1150100
Alamat : Aceh Selatan Alamat : Aceh Besar Alamat : Aceh Utara Alamat : Aceh Timur Alamat : Aceh Besar
Hari Rawatan : 1 Hari Rawatan : 8 Hari Rawatan : 5 Hari Rawatan : 4 Hari Rawatan : 2

A/ A/ A/ A/ A/
1. Penurunan kesadaran ec 1. Hematoschezia ec dd/ 1. Hepatomegali ec dd 1. Sirosis hepatis Std DC 1. HE grd I pencetus
dd/ 1. Sepsis, 2. Imbalance 1. Hemoroid interna 1. Abses hepar piogenik Related Hep B child pugh konstipasi, infeksi
elektrolit, 3. SDA, 4. 2. Polip recti 2. Sbses hepar amoboik B 2. obs vomitus ec dd/-ulkus
Stroke 3. Ca colorectal 3.Kista hepar 2. Hipoalbuminemia berat ec gaster, -gastropati
2. Sepsis ec dd 1. Urosepsis, 2. Penyakit jantung hipertensi 4. Hepatoma sirosis hepatis hipertensi portal, -
2. Pneumonia 3. Candidiasis oral 2. Upper right quadran 3. Susp SBP gastropati diabetik
3. Urosepsis ec dd BSK abdominal pain e.c. 3. sirosis hepatis st dekom
4. Pneumonia (CAP) Th/ Perenggaan capsul glison, Th/ related hepatitis B
5. Nephrolithiasis bilateral - Tirah baring perdarahan - Bed rest 4. hyperkalemia (6,3)
6. Hidronefrosis dextra - Diet MII 1700 kkal/hari 3. Anemia sedang NN ec dd - Diet hati MII 1700kkal + 5. AKI stage 1 prerenal dd
7. PSMBA ec dd 1. Stress - IVFD Futrolit 20 gtt/i 1) penyakit kronik ekstra putih telur hepatorenal sindrom
ulcer, 2. Ulkus gaster - Drip metronidazole 500 mg/8 2) perdarahan - Three way 6. DM tipe 2 NW
8. VES jam - IVFD aminofusin hepar 1
9. DM tipe 2 NW - IV Omeprazole 40 mg/12 jam Th/ fls/hari 15 gtt/i Th/
10. AKI stg 3 post renal dd - Salofalk 3 x 500 mg -Diet MII 1700 kkal/hari - IV cefotaxime 1gr/8j - Bed rest
akut on CKD - Sinbio 3 x 1 -IVFD Aminofusin hepar 1 - IV furosemide 20 mg/8j - Diet hati ;unak 1700
11. Anemia ringan NN ec dd - Paracetamol 3 x 500 mg fls/hari - Drip albuminar 25% 100 kkal/hr  NGT diet hati
1. Perdarahan, 2. Penyakit - Sukralfat 3 x CI - IVFD NaCl 0,9% + novalgin cc 1 fls =/hari sonde 6x200cc/hr
kronis - Nystatin drip 4 x 2 cc 20 tpm - Spironolakton 2x100 mg - IV metoclopramide
12. Hipertensi terkontrol - IV ondansetron 4mg/8j - drip metronidazole - Propranolol 2x10mg 10mg/8jam
13. Geriatric problem: 1. 750mg/8jam - Lactulac syr 3x15cc - Iv omeprazole 40mg/12j
Infeksi, 2. Imobilisasi, 3, Lab 15/2/2019 - Codein 3 x 10 mg - fosen enema (k/p) - SC lantus 0-0-0-14
instabilitas dan jatuh Hb/L/T : 10,8/8,6/591 - Kaltropen sup (k/p) - SC apidra 5-3-5-3-5-3
Th/ MCV/MCH : 979/27 -IV ondancetron 4mg/8jam 14/2/2019 - Curcuma 3x1
- Bedrest Na/K/Cl : 143/3,8/95 - transfuse PRC s/d Hb >10gr/dl SGOT/SGPT: 93/52 - Kalitake 3x1
- Miring kanan miring kiri PT/APTT: 12,7/34,0 - lactulac syr 3CII Protein tot: 6,47 - Lactulac syr 3xcII
tiap 2 jam selama 15 menit Alb: 1,79 - IVFD comafusin 10 tpm
- O2 4L/menit Lab 13/2/2019 Lab 16/02/2019 Ur/Cr: 45/1,25 1 fls/hari
- NGT  diet sonde DM LDH: 299 Hb/Ht/E/L/T : 9/27/3,3/6,8/241 Na?K/Cl: 143/4,2/104 - Sucralfat syr 3xCI
6x200 ml Asam Urat: 4,1 Difftel : 1/0/0/59/30/10 - Balance cairan
- Kateter Tinja rutin (+) Hb/L/Tr: 9,5/7,40/53 - Fosen enema (ekstra)
- Monitor Lab 15/2/2019 Gds: 119
- IV omeprazole 40 mg/12j Lab 12/2/2019 AFP: < 0,50 MCV/MCH/MCHC Lab 17/02/2019
- IVFD NaCl 0,9% 20tpm Urinalisa Bil tot/Bil direct/Bil indirect 83/29/34 PT/APTT : 13,4/43,9
- Amlodipine 1x10 mg Protein : +1 0,48/0,19/0,29 SGOT/SGPT : 85/68
- iV meropenem 1gr/8jam Leukosit : 8 – 10 LPB SGOT/SGPT: 24/14 Alb : 2,61
- amiodaron 2x200 mg Epitel : 3 – 5 LPK ALP: 125
PT/APTT : 12,1/34,0 Lab 16-2-2019
18-02-2019 Jantung Lab 14/2/2019 Hb/Ht/E/L/T :
PH 7,4, PCO2 22,40, HCO3 15,1 LDH 299 Hb/L/T – 8,1/5,6/224 10,6/30/3,1/5,9/68
Ginjal Hipertensi MCV/MCH : 8,2/27 MCV/MCH/MCHC : 96/34/36
1702-2019 Asam Urat : 4,1 Diff.Count 1/1/0/59/29/10 Ur/Cr : 85/1,67
Hb/L/T 9,3/15,8/127 GDS 87 Na/K/Cl : 139/6,3/96
Gds 164 Na/K/Cl : 144/5,1/150
Ur/Cr 75/4,42 Lab 11/02/2019 Ur/Cr : 42/160
Na/K/Cl 143/5,3/107 Hb/L/Trom : 11,9/14,2/556
MCV / MCH : 77/26
Diff. Count : 0/1/0/74/13/12
GDS : 95
Ur/Cr : 9/0,42
Na/K/Cl : 136/3,0/88