AQSHA 3 (PENYAKIT DALAM WANITA)

Hari/Tanggal : Minggu, 21 Juli 2018

Dokter Jaga : dr. Yunita / dr. Muna
Dokter Muda Jaga : Ufi/Difa/Acut/Andi

K1B1 K1B2 K1B3 K1B4

DPJP : dr. Chacha M, DPJP : dr. M. Riswan, Sp.PD DPJP : dr. DPJP : dr. M. Darma, Sp. PD
Sp.PD COW : dr. Emier COW : dr. COW : dr. Nadi
COW : dr. Cut DR : dr. Reyza DR : dr. DR : dr. Husna
DR : dr. Riza Raber: Rheumato Raber : Raber : Neuro
Raber : HOM
Nama :Sabariah Ganuh Nama : Ramaini Bancin Nama : Nama : Maryani M. Adan
Umur : 14/6/1974(45 th) Umur : 11/06/1979 (40th) Umur : Umur : 53 th
CM : 1-20-45-64 CM : 1214319 CM : CM : 1203268
Alamat : Aceh barat Alamat : aceh singkil Alamat : Alamat : Bireuen
Hari rawatan : 8 Hari rawatan : 11 Hari rawatan : Hari rawatan : 9

A/ A/ A/ A/
1.ALL dd AML 1. CAP 1. Penurunan kesadaran hemiparase (s)
2. DM tipe 2 OW 2. ISK Th/ e.c.infark cerebral luas
3. hipertensi stg 1 2. Sepsis (Perbaikan ) e.c.d.d.
4. Selulitis pedis sinistra Th/ - Urosepsis
(perbaikan) - Diet MB 1700 kkal - Pneumonia
5. ISK - IV cefepim 1 gr/12 jam 3. HCAP dd infeksi paru spesifik
- IV OMZ 40 mg/12 jam 4. urosepsis
Th/ - Paracetamol 3x500 mg 4. Candidiasi oral
- Bedrest - Fursemid 20 mg/12 jam 5. ulcus diabetic pedis dekstra
- Diet DM I 1.700 kkal/hari - KSR 2x600 6. Ulkus decubitus grade II
- IVFD NaCl 0,9% 30 tpm - Flumucyl 2x300 mg 7. CKD stage V on HD regular
-sc novorapid 10-10-10 unit - Sucralfat syr 3xC1 8. Ulkus decubitus grd III
-sc Levemir 0-0-0-18 unit - fosen enema extra 9. DM tipe 2 NW
-Aspilet 1x 80mg - buscopan 10mg extra 10. Hipoalbuminemia berat
- Valsartan 1x80mg
- IV. Levofloxacin 500 lab 17/7/2019 Th/
mg/24 jam Hb/Ht/E/L/T : 10,3/29/3,4/6,1/302 - Bedrest
MCV/MCH/MCHC: 83/30/36 - O2 2-4 lpm
lab 16/7/2019 Diftel : 2/0/1/80/8/9 - Diet Ginjal sonde 6x200 cc/hari
Hb/Ht/E/L/T : Na/K/Cl: 140/3,9/115 - IVFD NaCl 0,9% 20 tpm
8,8/31/3,2/244,2/102 Alb/Ca : 2,97/8 - HD rabu, sabtu
MCV/MCH/MCHC: Ur/Cr : 29/0,87 - Balance cairan
96/27/28 - As. Folat 2 x 400 mcg
Diftel :0/0/0/1/98/1 ANA profile terlampir - Lenal ace 1 x 169 mg
- Valsartan 1x80mg
lab 15/7/2019 lab 14/7/2019 - Amlodipin 1x10mg
Hb/Ht/E/L/T : Hb/Ht/E/L/T : 10,1/28/3.5/10.8/490 - Albumin 25% drip
7,6/29/2,9/243,4/95 MCV/MCH/MCHC: 80/29/37 - SC Levemir 0-0-0-8 Unit
MCV/MCH/MCHC: Diftel :3/1/0/76/12/8 - Cilostazol 1x100 mg
98/26/27 Na/K/Cl: 114/3.9/80 - Clopidogrel 1x75 mg
Diftel :0/0/0/1/99/0 - Iv Fluconazole 100 mg / 24 jam
Lab 13/7/2019 - Vancomisin 750g post HD dalam NaCl
Urinalisa Na/K/Cl : 110/3,9/78 0,9% 2 jam
Leukosit + 6-8
Glukosa+1 Lab 12/7/2019 Lab 18/07/2019
Keton nitrit + LED: 59 Warna kemerahan
Darah + CRP kualitatif: positif Kejernihan keruh
Bakteri + Bilirubin total: 0.81 Urinalisa
Bilirubin direk: 0.24 Leukosit +
As urat 7,7 Bilirubin indirek: 0.57 Keton +
Hb A1c 10,5 SGOT/SGPT: 64/30 Darah +
APTT /kontrol 25,1/33,8 Albumin: 3.32 Sel ragi +
INR 0,84
Ddimer 1670,53 Lab 11/7/2019 Lab 17/7/2019
Albumin: 3,26 PT pasien/kontrol/INR : 14,8/13,4/1,12
lab 13/7/2019 APTT pasien/kontrol : 39,5/32,7
Hb/Ht/E/L/T : Urinalisa
8,7/31/3,2/287,6/123 Lekosit (+) Lab 16/7/2019
MCV/MCH/MCHC: Urobilinogen (+) Hb/Ht/E/L/T : 9,8/29/3,4/16,2/260
97/27/28 Darah (+) MCV/MCH/MCHC: 87/29/33
Diftel :0/0/0/1/99/0 L/E/epi: 10-15/6-8/4-6 Diftel :1/0/1/77/15/6
GDS 782 Albumin : 2,16
Ur/Cr 86/0,79 Ca : 7,3
Na/K/Cl 135/4,6/100 Ur/Cr : 74/3,82
Na/K/Cl: 138/4,6/105

Lab 15/7/2019
Procalcitonin 11,52
HbA1c : 10,0
 K2B1 K2B2 K2B3 K2B4 K2B5
DPJP : dr. Islamuddin, DPJP : dr. Fauzi Yusuf, Sp. DPJP : dr. M. Diah, DPJP : dr. Chacha M, DPJP : dr. M. Darma,
Sp.PD PD Sp.PD Sp.PD Sp.PD
COW : dr. Emir COW : dr. Laura COW : dr. Nadi COW : dr. Cut COW : dr. Nadi
DR : dr. Reyza DR : dr. Akmal DR : dr. Husna DR : dr. Riza DR : dr. Husna
Raber : Raber : Raber: Rheumatologi Raber : Raber : Div. PTI ,Neuro
Nama : Ruhana Idris Nama : Dahniar Ismail Nama : Atikah Idris Nama : Fatimah Mahmud Nama : Darmawati Rakimin
Umur : 80 th Umur : 31-12 1959 (59th) Umur :79 th HJ Umur : 12/07/1965 (53th)
CM : 1138708 CM :1214816 CM : 1214064 Umur :70 th CM : 1200908
Alamat : Aceh Besar Alamat : Tanah Abang Alamat : Pidie CM : 1116913 Alamat : aceh pidie
Hari rawatan : 2 Hari rawatan : 6 Hari rawatan : 13 Alamat : Pidie Jaya Hari rawatan : 9
Hari rawatan : 3
A/ 1. Penurunan kesadaran ec A/ A/ A/
dd – SDA 1. konstipasi ec dd 1. CKD Stage V dengan A/ 1.penurunan kesadaran ec
- Sepsis -IBS tipe konstipasi uremic syndrome e.c.d.d. 1. Diare akut ec dd sepsis
- Uremic ensefalopati -polip recti - PGOI - infeksi bakteri 2.sepsis ec urosepsis
2. SDA dengan pencetus Dyspepsi tipe dismotility - PNC -infeksi viral 3. Pneumonia HCAP
infeksi 2. DM tipe 2 NW -DN -intoleransi mkanan 4. Urosepsis
3. pneumonia dd infeksi paru 3. Hipokalemia sedang ec dd/ 2. Anemia ringan NN ec 2. Sirosis hepatis std DC 5. PSMBA (perbaikan) ec dd
spesifik - GI loss PGK 3. DM Tipe 2 NW – stress ulcer
4. ISK - Low Intake 3.DM tipe 2 NW 4. infeksi - ulcus gaster
5. AKI stage III dd acute on 4. Hipertensi stage I 4. PSMBA (perbaikan) 5. instabilitas dan jatuh - ulcus duodenum
CKD 5. ISK Asimptomatik e.c. uremic bleeding 6. imobilisasi 6. CKD stg V on HD Reguler
6. Hipertensi stg I 5.Hipertensi st II 7. Gastropati Diabetik 7. Hipertensi stg II
7. Anemia berat HM ec dd Th/ 6. Hipcalsemia 8. anemia sedang NN dd 8. DM Tipe 2 NW
- Def. Besi -Bedrest (perbaikan) -penyakit kronik 9. Hipocalsemia (perbaikan)
- peny. Kronik - Bubur kecap -occult bleeding 10. Post stroke iskemik
- occult bleeding - IVFD RL 20gtt Th/
8. geriatric problem - IV Ceftriaxone 1 gr/12jam - Bedrest Th/ Th/
9. trombositopenia ec dd (H3) - Diet ginjal 1700 kkal + - Bedrest -tirah baring
- easyoption koagulasi - IV Lansoprazole 50 gr protein/ hari - O2 2-4 L/menit nasal -NGT, kateter
DIC ec sepsis 30mg/12jam - Threeway kanul -Diet sonde ginjal 6x200
- Salofalk 2x500mg - HD selasa, kamis, sabtu - Diet hati 1700 kkal + cc/hr + 0,8 gr protein/kgbb/hr
Th/ - KSR 2X600mg - IV ceftriaxone 2 gr/24 rendah garam -IV meropenem 1 gr/8 jam
-IV Ceftriaxone 2gr /24jam - Metoclorpramid 10mg/8jam jam - Threeway -lenal ace 2x69
-Flumucyl /8jam - Betahisin 6 mg/8jam - Lenal ace 2x 169 mg - IV Aminofusin hepar1 -asam folat 2x400
-Valsartan 1x80mg - Lactulaci syr 3x CI - Asam folat 2x1 fls/hari - Valsartan 1x160 mg
IV Clinimix+clinoteic - L Bio 1x1 - Bicnat 3x1 - IV Ceftriakson 2gr/hri - Drip Perdipin 1 amp dlm
- Drip KCL 25 mcg dalam - Amlodipin 1x10 mg - IV Lansoprazol 30 mg / NaCL 0,9%
Lab 20/7/2019 0,9% 20 gtt/ i - IV omeprazole 40 24 jam - IV Omeprazole 40 mg / 24
Hb/Ht/E/L/T: mg/12jam - SC Humolog 16-16-16 jam
6,7/19/2,7/29,0/77 Lab 16/07/19 - Sucralfat syr 3xCI - Curcuma 3x1 - HCT 1x12,5 mg
MCV/MCH/MCHC: Leukosit : positif - Valsartan 1x80 mg - Domperidon 3x10 mg - Herbesser 1x100mg
69/25/35 Keton : positif - IV omeprazole 40 mg/12 - Spironolacton 2x200mg - citicolin 2x500mg
Diftel: 0/0/0/93/3/4 Darah : Positif jam
Kalsium: 7,7 Sedimen Urine -ca glukonas 1gr/12j Lab 19/07/19 Lab 19/07/2019
GDS: 177 Leukosit : 20-25 LPB Anti HCV : negatif Hb/Ht/E/T/L:
Ur/cr: 196/5,39 Er : 4-6 LPB Lab 18/07/19 7,4/21/2,7/174/12,0
Na/k/cl: 137/3,3/109 Epitel : 8-10 LPK Kalsium : 8.2 Lab 18/07/19 MCV/MCH/MCHC:
Hb/ Ht/ E/L/T : 78/27/35
Lab 15/07/19 Lab 16/07/19 9,8/27,3,1/5,2/97 Diftel: 5/1/0/73/14/7
Hb/ Ht/ E/L/T : Hb/ Ht/ E/L/T : MCV/MCH/MCHC : Albumin/kalsium: 3,02/8,8
10,5/30/3,5/14,2/325 9,2/26/3,3/9,8/77 89/22/36 Ur/cr: 49/3,17
MCV/MCH/MCHC : Diftel: 3/0/0/73/12/12 Diftell : 4/1/0/36/43/16 Na/K/Cl: 136/2,8/102
86/30/35 Ur/Cr : 140/10,02 Hbsag: negatif
Diftel: 0/1/0/72/21/6 Na/K/Cl/Ca : Alb : 2,66 Lab 17/07/19
138/4,6/101/7,3 Globulin : 4,28 Hb/ Ht/ E/L/T :
PT/kontrol 12,2/13,2 Alb : 2,85 Na/K/Cl : 143/5,0/119 8,1/23/2,9/10,5/202
INR 0,88 Ur/Cr : 44/0,93 Diftell : 6/1/0/69/14/10
APTT/Kontrol 29/33,8 Lab 11/07/19
GDS 132 Urinalisa Lab 14/07/19
Ur/Cr 10/0,3 Leukosit (+) 8-10 Leukosit (+) 70-80
Na/K/Cl 142/2,7/102 Protein (+1) Protein : +2
HbsAg negatif Keton (+) Darah (+)15-20
Anti HCV negatif Nitrit (+) Sedimen Urine :
Darah (+) 15-20 Bakteri : Positif
Lab 14/07/19
Lab 10/07/19 Hb/ Ht/ E/L/T :
Hb/ Ht/ E/L/T : 6.8/20/2.6/13.0/151
6/17/2,2/13,1/100 MCV/MCH/MCHC :
MCV/MCH/MCHC : 78/27/34
81/28/35 Diftell : 6/1/0/78/9/6
Diftel: 2/1/0/75/15/7 Ur/Cr : 58/3,70
Ur/Cr : 100/8,35 Lab 1107/19
Na/K/Cl/Ca : Hb/ Ht/ E/L/T :
140/4,9/107/7,8 2,5/8/0,9/8,3/204
MCV/MCH/MCHC :
85/27/32
Diftell : 1/0/1/73/19/6
Procalcitonin : 1,35
Alb : 2,6
Ca/Na/K/Cl : 7,6/139/3,8/10
 K3B1 K3B2 K3B3 K3B4 K3B5
DPJP : dr. Azzaki DPJP : dr. Azzaki, SpPD DPJP : dr. Fauzi Yusuf, DPJP :dr. Islamuddin, DPJP : dr. Azzaki, Sp. PD
Abubakar, Sp.PD COW : dr Ganis Sp.PD Sp. PD COW : dr. Ganis
COW : dr. Ganis DR : dr Riza COW : dr. Laura COW : dr. Emir DR : dr. Riza
DR : dr. Riza Raber :GH,Rheumato DR : dr. Akmal DR : dr. Reyza Raber : Divisi Paru
Raber : Raber : Raber : reumatologi,b.vas

Nama : Siti intashara Nama : Fitri Santhi Muis Nama : Kartini Sarong Nama : Mislawati Hambali Nama: Mariah Mansyur
Umur: 22 th Umur: 4/7/1984 (35 thn) Umur: 69 th Umur:15/8/1971 (47 thn) Umur: 76 th
CM: 0988097 CM: 1212600 CM: 1210187 CM: 1-00-05-45 CM: 1-21-42-80
Alamat: banda aceh Alamat: Banda Aceh Alamat: Langsa Alamat: Dusun Teladan Alamat: Aceh Besar
Hari rawatan : 2 Hari rawatan : 8 Hari rawatan : 4 Hari rawatan : 11 Hari rawatan: 9
A/
A/ 1. PSMBA ec dd A/ 1. Giant ulcus ar proximal A/ A/
-gastritis erosive 1. penurunan kesadaran ec esophagus ec fundus 1. CKD Stage V 1. Gastritis Erosif
-ulcus gaster dd gaster 2. Pnemonia HAP dd 2. Ulkus gaster
-ulcus duodenum - sepsis syok 2. HHD Infeksi paru sekunder 3.Metaplasia Gaster
2. cystitis - uremic ensepalopati 3. Hipertensi on terapi 4.Massa Epigastrium ec dd/
- NP SLE Th/ - Massa paru
Th/ 2. syok sepsis ec dd - Bedrest Th/ - Massa gaster
-Bedrest - urosepsis - Diet MB 1700 kkal/hari - Bedrest - Limfoma
-IVFD Nacl 0,9% 20gtt -pneumonia - IVFD NaCl 0,9% 20 - Threeway - Kista hepar
-omeprazole 40mg/12 j 3.CKD st V ec dd tpm - Diet ginjal 1700 5. Anemia Ringan HM ec dd/
-sucralfat syr 3xCI - nefritis lupus - IV Lansoprazole 30 kkal/hari+40 gr protein - Def. besi
-Ceftriaxone 2gr - GNC mg/12 jam - IV Cefuroxime 750 - Occult Bleeding
-as. Tranexamat 500mg 4. fr. Femur proksimal dextra - Sucralfat syr 3xCI mg/12 jam (H6)
5. Hipokalsemia - Azytromicin 500mg/24j - IV Furosemid 20 mg/12 Th/
Lab 20/07/2019 6. Hipokalemia ringan - Amoxicilin 1000mg/12j jam - Bedrest
Hb/ Ht/ E/L/T : 7. Hipoalbuminemia - Paracetamol 1g (k/p) - IV Omeprazole 40 - Diet sonde 6x200 cc/hari
10,9/34/5,5/27,7/651 8. ISK mg/24 jam - IVFD NaCl 0,9% 10 tpm
MCV/MCH/MCHC: 9. Status Hipokoagulasi Lab 15/7/2019 - Amlodipin 1x10 mg - Paracetamol 3x500 mg (k/p)
63/20/32 Hb/Ht/E/L/T: - Attapulgit 1 tab/x - Azitromisin 100 mg/12 jam
Dftel : 0/0/0/93/4/5 Th/ 9,8/29/3,1/8,3/370 mencret PO
Ur/Cr : 31/0,50 -Bedrest MCV/MCH/MCHC: - HD Selasa Kamis Sabtu - Amoxicilin 1000 mg /12
Na/K/Cl : 144/4.2/104 -O2 2-4lpm NK 92/31/34 jam PO
-Threeway Diftel: 3/1/0/57/28/11 Lab 17/7/2019 - Lansoprazole 300 mg / 12
-Diet sonde ginjal 6 x 200cc PT pasien/kontrol/INR : Hb/Ht/E/L/T: jam PO
-Transfusi PRC sd Hb>10 12,8/13,3/0,94 9,4/27/3,3/10,8/254 - Sucralfat syr 3xcii
-IV Ca Gluconas 1amp/8jam APTT pasien/kontrol : Diftel: 9/1/0/56/21/13
-Lenal ace 2x 169mg 31,4/33,8 Ur/Cr: 98/10,12 Lab 15/7/2019
-As folat 2x400mcg Anti HCV/HbsAg : -/- Na/K/Cl/Ca : Hb/Ht/E/L/T:
-Bicnat 3x500mg GDS : 113 140/3,2/105/6,7 11,1/33/4,3/9,4/300
-PCT K/P Ur/Cr : 44/1,93 MCV/MCH/MCHC:
- KSR 2x600mg Na/K/Cl: 143/4,1/109 Lab 14/7/2019 77/26/34
-valsartan 80mg/24 j Hb/Ht/E/L/T Diftel: 2/1/0/76/11/10
- Paracetamol 2x1000 mg 7,7/22/2,8/10,4/259
-meropenem 1gr/8 jam Diftel 7/0/0/57/26/10 Lab 12/7/2019
- HD selasa, kamis, sabtu Ur/Cr113/12,56 Hb/Ht/E/L/T:
-Albuminar 25% 100cc/hari Na/K/Cl 136/3/105 8,2/26/3,5/7,7/337
- Combivent extra MCV/MCH/MCHC:
Lab 11/7/2019 75/24/31
Lab 18/07/2019 Hb/Ht/E/L/T Diftel: 2/1/0/67/15/15
Hb/Ht/E/T/L: 8.4/25/3.1/14.1/349 HbsAg/HCV : -/-
8,9/24/3,1/70/16,4 MCV/MCH/MCHC PT pasien/kontrol/INR:
MCV/MCH/MCHC: 79/27/34 14,3/13,8/1,07
79/29/37 Diftel: 1/1/0/81/13/4 APTT pasien/kontrol :
Diftel: 0/0/0/95/3/2 HbsAg/HCV : -/- 42,3/33
PT/APTT: 1,20/1,63 Albumin: 3.17 GDS : 111
Ur/cr: 117/7,43 ur/cr :160/16.22 ur/cr: 32/0,72
Na/L/Cl: 138/3,4/106 Na/K/Cl: 140/4.3/107 as.urat : 5
Lab 15/7/2019
LED : 51
CRP kualitatif/RF : -/-
Lab 15/7/2019
Hb/L/T: 11/17/157
Diftel 0/0/0/94/3/3
Ca/Na/K/Cl : 6,3/134/3,1/101
Ur/Cr 131/11,79
Alb/Globulin 2,94/2,42
Lab 12/7/2019
Hb/L/T: 7,4/8,7/135
Diftel 1/1/0/84/7/7
Ca/Na/K/Cl : 4,9/142/2,7/109
Lab 11/7/2019
Hb/L/T 7,2/8,9/149
Diftel 2/1/0/81/8/8
Albumin: 3,17
Ca 4,5
Lab 10/7/2019
Hb/L/T 4,8/8,6/170
Diftel 1/0/0/83/8/8
Albumin: 3,19
Ca 4,9
 K4B1 K4B2 K4B3 K4B4 K4B5
DPJP :dr. M. Darma , DPJP : dr. Chacha M, DPJP : dr.Islamuddin, DPJP : dr. M.Diah,Sp.PD DPJP : dr. M. Diah, Sp.PD
Sp. PD Sp.PD Sp.PD COW : dr. Nadi COW : dr. Nadi
COW : dr. Nadi COW : dr. Cut COW : dr. Emier DR : dr. Husna DR : dr.Husna
DR : dr. Husna DR : dr. Riza DR : dr Reyza Raber: GEH,Div.PTI Raber : GEH
Raber : Raber : GEH Raber :
Nama : Evi Dasmaniar Nama : Wardah M Yunus Nama : Adnen Yatim Nama: Ummiati Nama : yuswawadar usman
Umur : 28th Umur : 44 thn Umur : 1/7/1940 (79th) Abdurrahman Umur :56 th
CM : 1-20-43-60 CM :1211203 CM :0995599 Umur : 2/9/1968 (50 th) CM : 1-21-52-14
Alamat : Aceh Barat Alamat : Pidie Alamat :Aceh besar CM: 120-45-40 Alamat : Kota Sabang
Hari rawatan : 23 Hari rawatan : 5 Hari rawatan : 6 Alamat: aceh besar Hari rawatan : 2
Hari rawatan: 8
A/ A/ A/ A/
1. Penurunan Kesadaran 1. Sirosis Hepatis std 1.Anemia berat hipokrom A/ 1. Penurunan kesadaran ec
ec SLE derajat berat decompensata hepatitis B mikrositer ec Defisiensi Fe 1. HE grade III dengan dd
(NP SLE) dd Sepsis 2. hepatoselular carsinoma - Penyakit kronis pencetus PSMBA dan - Sepsis
2. Sepsis ec urosepsis dd 3. Hepatitis B - Ca Colon infeksi - Imbalance
pneumonia - Sperocitosis 2. sirosis hepatis std elektrolit
3. ISK Th/ 2.Konstipasi ec dd decompensate realated Hep - HE
4. Pneumonia (HAP) - Bedrest - Kolitis B - Uremic
5. PSMBA ec Stress - Diet hati 1.700 kkal/hari - Keganasan (Ca recti) 3. PSMBA ec Varises ensefalopati
ulcer - Ivfd Aminofusin hepar 1 Esophagus grd IV 2. Sepsis ec dd
6. AKI Stage II dd acute fls / hari Th/ 4. Multiple Ulcus gaster et - Biliersepsis
on CKD - IV ceftriaxone 1 gr/12 jam - Bedrest duodenum - Pneumonia
7. Hipoalbuminemia - IvLansoprazole 30 mg / - IVFD NaCl 0,9% 20 gtt/i 5. Hepatitis B kronik - urosepsis
8. Hipocalsemia 12 jam - Transfusi PRC 2 kolf 6. Hepatorenal syndrome 3. Obstruksi jaundice
9. Status hipokoagulasi - Iv furosemid 1 amp/8jam ec AKI stg I prerenal ec dd/
- Lactulac syr 3xcii Lab 18/7/2019 7. SBP - Hepatomegali
- Curcuma 3x1 Hb/Ht/E/L/T : - Choledolithiasis
Th/ - Morphine extrA 10,1/31/4,4/7,1/263 Th/ 4. Pneumonia
- Bedrest - Duragesic patch 12,5 MCV/MCH/MCHC : - Bed rest 5. ISK
- Diet sonde via NGT /3hari 61/16/27 -O2 2-4 l/i 6. Hipoalbuminemia
6x200cc/hari - Furosemide 40mg /8jam - IVFD comafusin hepar sedang
- IVFD NaCl 0,9%  - Spironolakton 200mg 1fls/hari 7. AKI stg III dd
20gtt/mnt /12jam Lab 16/7/2019 - IVFD NaCl 0,9% 20gtt acute on CKD
- Drip Omeprazole 6,2 - Albumin 25% Hb/Ht/E/L/T : - Bolus ocreotide 1 amp Th/
cc/jam 3,6/14/2,2/3/316 selanjutnya drip Acreotide - Bedrest
- IV. Tocoplanin Lab 18/7/2019 MCV/MCH/MCHC : 4 amp dilanjutkan NaCl 50 - O2 2-4 nasal canule
400mg/12 jam Hb/Ht/E/L/T : 61/16/27 cc dengan kecepatan 3,125 - NGT/kateter
- Sucralfat syr 3xCI 10,5/30/3,7/19,7/306 Diftel : 5/0/1/54/28/12 cc/jam selama 2 hari. - Diet sonde 6x200cc
- Ostriol 2x0,25mg MCV/MCH/MCHC : PT pasien/kontrol/INR : -IV Cefotaxime 1 gr/8jam - IVFD NaCl 0,9% 20gtt/i
- Valsartan 1x160mg 82/28/35 13,1/13,6/0,96 - iv lansoprazole 30 mg/12 - Drip Tramadol 100mg/12
- Metilprednisolon Diftel : 1/1/0/71/17/10 APTT pasien/kontrol : jam jam
3x4mg Bilirubin total : 1,47 34,6/35 - iv vit k 1 amp/8 jam - Iv. Omperazol 40mg/12 j
- IV Ca Gluconas 1 gr/ Diret : 0,65 Anti HCV/HbsAg : -/- - iv transamin 500 mg/ - Curcuma 3x1
12 jam SGOT/SGPT : 76/13 Albumin : 3,37 8jam - Flumucyl 3x1
- Clobazam 1x1 Ur/Cr : 10/0,21 - curcuma 3x1 - IV meropenem
- Amlodipin 5mg Na/K/Cl :135/3,7/104 Urinalisa : dbn -Sucralfat syr 3xCI - Evaluasi urin output
- Myfortic /12jam -paracetamol 500mg /24jam target 0,5 – 1
Lab 15/7/2019 3x1(k/p) cc/kgBB
Lab 19/07/2019 Hb/Ht/E/L/T : -fosen enema supp - Evaluasi HD + VS /2 jam
Hb/Ht/E/T/L: 4,1/15/2,5/3,5/412 -spironolakton 200mg 1x1
7,2/20/2,4/20/5,1 MCV/MCH/MCHC : - Lactulose /8jam
MCV/MCH/MCHC: 61/17/27/22,6 Lab 19/7/2019
81/30/37 Diftel :5/1/0/60/25/9 Lab 16/7/2019 Hb/Ht/E/L/T :
Diftel: 2/0/0/85/10/3 Ur/Cr 47/0,59 Hb/Ht/E/L/T : 8,8/24/3/18,2/283
PT/APTT: 1,05/1,60 Na/K/Cl 143/4,4/111 7,6/21/2,8/282/10,1 MCV/MCH/MCHC :
Albumin: 2,09 MCV/MCH/MCHC : 78/29/27
Ca: 7,8 78/28/36 Diftel : 0/0/0/86/8/6
Ur/cr: 118/2,41 Diftel :0/0/0/80/13/7 Bilirubin total : 16,76
Na/K/Cl: 125/3,9/97 Ur/Cr :165/1,74 Diret : 12,85
PT/kontrol : 21,5/13,6 Indirect : 3,91
Lab 16/7/2019 APTT : 44,7/35 GDS : 181
Na/K/CL : 128/4/99 Ur/Cr : 86/3,51
Ca/Mg :7,2/1,3 Lab 16/7/2019 Na/K/Cl :127/4,4/101
Lekosit : Postif SGOT/SGPT : 64/85
Darah : Positif Alb : 2,89
Lab 16/7/2019 Sedimen Urine :
Hb/Ht/E/L/T : Leukosit : 50-60
10,1/27/3,5/8,0/94 Eritrosit : 8-10
MCV/MCH/MCHC : Epitel :2-4
79/29/37
Diftel : 0/1/0/88/8/3 Lab 14/7/2019
Na/K/CL : 128/3,8/99 Hb/Ht/E/L/T :
Ca/Mg : 6,5/1,1 6,1/18/2,2/23,3/356
MCV/MCH/MCHC :
82/28/34
Diftel : 0/0/1/81/10/8
PT/kontrol 22/13,1
INR 1,82
APTT/kontrol 39,60/33,5
 K5B1 K5B2 K5B3 K5B4 K5B5
DPJP : dr.Azzaki, Sp.PD DPJP: dr. Hendra Zufry, DPJP: dr. M. Darma, DPJP : dr. Chacha, Sp.PD DPJP : dr.Islamuddin,
COW : dr. Ganis Sp. PD Sp.PD COW : dr. cut Sp.PD
DR : dr . Riza COW: dr. Arie COW: dr. Nadi Dr : dr. Riza COW : dr. Emier
Raber: Dr : dr. Muna Dr : dr. Husna DR : dr Reyza
Raber : Raber : Raber: GH,GEH
Nama : Jahani Abdullah Nama : Husniati Husin Nama : Khatijah Abd. Nama : Safrinahayati Sofyan Nama Ermi Samsu
Umur : 03/12/1959 (59th) Umur : 04/03/1972 (47 thn) Wahab Umur : 38th Umur : 30/04/1972 (47th)
CM : 1178870 CM : 1215047 Umur : 80 th CM : 1188196 CM : 1-20-45-29
Alamat : aceh barat daya Alamat : Pidie Jaya CM : 1178862 Alamat : Aceh pidie Alamat : Aceh Barat
Hari rawatan : 9 Hari rawatan : 4 Alamat : Banda Aceh Hari rawatan : 2 Hari rawatan : 17
Hari rawatan : 5
A/ A/ A/ 1. CKD stage V dengan A/
1. gastritis erosif ar antrum 1. Gangren Diabetik A/ edema paru akut on HD 1. Sepsis ec dd/ (perbaikan)
2. Hipoalbuminemisaa sedang Pedis (D) 1. Pneumonia geriatri Reguler ec DN a. urosepsis
3. Anemia ringan NN ec dd/ 2. DM Tipe 2 Poorly 2. Geriatri problem 2. Efusi pleura b. pneumonia
-Peny. Kronik Controled 3. Hipokalemia ringan bilateral ec dd 2. Pneumonia
- Defisiensi Fe 3. Gastropati 4. Neglated fr femur - Related CKD 3. Cholelithiasis multiple
4. Hipokalemia ringan diabetik Sinistra - Hipoalbuminemia dengan cholesistitis
Th/ - Pleurapneumonia 4. Fr lumbal kompresi
Th/ -Bedrest Th/ 3. Pneumonia dd infeksi 5. ISK (perbaikan)
-bed rest - Diet DM 1700 kkal/hari - Bedrest paru spesifik 6. DM tipe 2
-diet sonde 6x200 cc/hari via - IVFD RL 20 gtt/ menit - Diet Sonde 1700kkal/hari 4. DM tipe 2 OW 7. Hipertensi on terapi
oral - IV Ceftazidine 1gr/12jam - IVFD NaCl 0,9% 20 tpm 5. HT stage II 8. Hipoalbumin
-IVFD Futrolit 20tpm - SC Levemir 0-0-0-18 Unit - IV omeprazole 40 mg/12
-IV elip+clinimix 1fl/hari - SC Novorapid 8-8-8 Unit jam Th/ Th/
-Lansoprazol 30 mg/12 jam - omeprazol 40mg/24 jam - IV ondansentron 4 mg/8 - bedrest - Bedrest
-sucralfat syr 3xC1 - domperidone 10mg/8jam jam - O2 2-4 l/menit - Diet ginjal 1700kkal/hari +
- Albumin 25% 100 cc/24 jam - Drip paracetamol 1 gr/8 - diet ginjal lunak 1700kkal 50 gr protein
-Attapulgite 1 tab/mencret Lab 19/07/19 jam Threeway - threeway
-Hidrocortison /12jam Hb-A1c : 14,8 - IV ceftriaxone 2 gr/24 IV meropenem 1x500mg - IV omeprazole 40mg/12j
Ur/cr : 22/0,41 jam -lenal aceh 2x169mg - domperidone 3x10 mg
Lab 17/07/2019 - KSR 1x600 mg -Asam folat 2x400mg - paracetamol 3x500mg
CT/BT : 7/2 Lab 17/07/19 - attapulgite 3x1 -Herbesser 1x100mg - lenal ace 2x169
Hb/ Ht/ E/L/T: -Valsartan 1x80mg - as folat 2x400mg
Lab 15/07/19 10,8/33/4,2/16,5/281 Lab 18/07/19 -Flumucyl 3x200mg - diltiazem 1x10mg
Hb/ Ht/ E/L/T : MCV/MCH/MCHC: Urinalisa - lactulac syr 3xCII
14,4/42/5/4,3/322 77/26/33 Protein (+1) Lab 20/07/2019 - Cefoxime 1 gr/ 12 jam
MCV/MCH/MCHC: 84/29/35 Dftel : 3/1/0/72/19/5 Granular Cast (+) Hb/ Ht/ E/L/T : - novorapid 6-6-6
Dftel :1/1/0/61/30/7 GDS : 675 Hyalin Cast (+) 8,8/25/3,3/34,2/330 - UDCA 2x250 mg
Alb 2,67 MCV/MCH/MCHC: 76/27/35 - Diltiazem 100mg 1x1
Na/K/Cl 145/4,5/113 Albumin 2,63 Dftel : 1/0/0/90/6/3 - Tramadol 1 amp kp drip
Ca 8,4 Ur/Cr : 95/4,49 - albumin 100cc/24jam
Lab 16/07/19 Na/K/Cl : 131/4.0/99 - kaltropen supp /12jam
Lab 12/07/19 Hb/ Ht/ E/L/T: - iv. Iv.cefoxime 1gr/12
Retikulosit: 2.0 14,7/43/5,2/10,6/114 - HD rabu dan sabtu
MCV/MCH/MCHC: - Buscopan 1 amp (extra) IV
Lab 11/07/19 83/29/34
Hb/ Ht/ E/L/T : Dftel : 0/1/0/88/6/5 Lab 15/07/19
7.9/25/2.8/4.3/344 GDS : 140 Hb/ Ht/ E/L/T :
MCV/MCH/MCHC: 88/28/32 Ur/Cr : 22/0,15 9,5/2832,4/17.3/17,3
Dftel : 2/1/0/35/53/9 Na/K/Cl : 142/3,1/108 MCV/MCH/MCHC:
Anti HCV - 82/28/34
HbsAG : - Dftel : 1/0/1/87/5/6
Albumin: 2.35 Ur/Cr : 152/3.32
Ur/Cr : 28/0.45 Na/K/Cl : 132/4.7/100
Na/K/Cl : 145/2.5/102
Urinalisa
Leukosit (+) 8-10
Protein (+2)
Keton (+)
Urobilinogen (+)
Darah (+) 4-6
Bakteri (+)

Lab 12/07/19
Hb/ Ht/ E/L/T :
7.8/23/2,7/14.3/245
MCV/MCH/MCHC: 84/29/34
Dftel : 2/0/0/85/7/6
Ur/Cr : 139/3.99
Na/K/Cl : 130/4.9/100
Lab 10/07/2019
Albumin: 2,27
Ur/Cr: 164/4,59
Na/K/Cl: 128/5,2/96
Lab 09/07/2019
Hb/Ht/E/L/Tr:
7/21/2,5/17,1/267
MCV/MCH/MCHC/RDW :
85/28/33
Diftel: 1/0/0/89/5/5
 K6B1 K6B2 K6B3 K6B4 K6B5
DPJP : dr. Azzaki DPJP : dr M. Darma M, DPJP : dr. Chacha M, Sp.PD DPJP : dr. M. Diah,
DPJP : dr. Azzaki , Sp.PD
Abubakar, Sp.PD Sp. PD COW : dr. Cut Sp.PD
COW : dr. Ganis
COW : dr. Ganis COW : dr. Nadi DR : dr. Riza COW : dr. Nadi
DR : dr. Riza
Dr : dr. Riza DR : dr. Husna Raber : Rheumatologi Dr : dr. Husna
Raber:
Raber : Raber : Raber :
Nama : Surhayati Abd Nama : Zawiyah Ismail Nama : Darmiati Usman Nama : Cut Kasmawati Nama : Rahmah Juned
Rahman Umur : 01/07/1950 (69th) Umur : 17/8/1980 (38 th) Umur : 40 th Umur :69 th
Umur : 32th CM :1-21-45-21 CM : 1-03-92-93 CM : 1214939 CM : 1203925
CM : 1215305 Alamat : Seulimum Alamat : Aceh Besar Alamat : Abdya Alamat : Banda Aceh
Alamat : aceh Hari rawatan : 9 Hari rawatan : 11 Hari rawatan : 5 Harirawatan : 4
Hari rawatan : 2 A/ A/
1. Penurunan kesadaran ec A/ A/ 1. Sirosis hepatis satdium
A/ 1. Leukositosis dengan dd/ 1. Severe headache 1. obs febris ec dd/ decompensata related
bisitopenia ec dd -Sepsis 2. Abses Bilateral ar gluteus -ISK hep C
- AML 2. Sepsis ec CAP bilteral -pneumonia 2. Anemia sedang NN ec
- CML 3. Pneumonia (CAP) 3. SLE derajat Berat dengan 2. trombosiosis ec dd dd
- ALL 4. AKI stage 1 pre-renal ec Keterlibatan -Trombositosis reaktif dd - - Peny. Kronis
2. Hipokalemia sedang infeksi 1/ mocokutan 2/ hematologi trombositosis esensial - Perdarahan
5. ISK Asimptomatis 3/neurologi 4/ musculoskeletal 5/ 3. Anemia sedang NN 3. Hiponatremia
Th/ 6. Hipertensi grd II nefrologi e.c.d.d. hipoosmolar
- bedrest 7. High risk trombosis 4. PSMBA (perbaikan) -autoimun hemolitik hipovolemik
- O2 2-4 l/menit 8. Geriatric problem (infeksi, 5. Hiponatremi hipoosmolar anemia 4. Hipoalbuminemia
- Diet MB 1700kkal/hr immobilisasi, instabilitas dan - Penyakit kronis Berat
hipovolemik
- IVFD RL 20gtt/menit jatuh, inanisi) - Perdarahan 5. AKI stg II prerenal
6. Hipertensi stg I
- Drip lefofloxacin 1x500mg 9. Anemia sedang hipokrom
- Drip Paracetamol 1gr/8jam mikrositer 7. Pneumonia (perbaikan) Th/
Th/
- IV Omeprazole 40mg/8jam 8. AKI stg II Prerenal dd akut - Bedrest - Bedrest
- KSR 2X600mg Th/ on CKD ec dd/ Nefritis Lupus - Diet MB 1700 kkal - Diet hati 1.800 kkal/hari
-Bedrest 9. Hipokalemia ringan - IVFD NaCl 0,9% 20 - Ivfd Aminofusin hepar 1
Lab 20/07/2019 -NGT dan kateter tpm fls / hari
Hb/Ht/E/L/T: -O2 2-4 L/i Th/ - Transfusi PRC sampai - Iv furosemid 1 amp/8jam
10,8/31/3,3/114,9/26 -Diet sonde 6x200 cc/hari - Bedrest Hb 10 g/dl - Lactulac syr 3xcii
MCV/MCH MCHC: -IVFD NaCl 0.9% 20 tpm - Diet lunak 1700 kkal/hari - IV omeprazole 40 - Drip albumin 25% 100
96/33/35 -IV Meropenem 1 gr/8 jam - IVFD NaCL 0,9% 20 g/i mg/12 jam cc / hari
Diftel: 0/0/0/13/10/77 -Flumucil 3x300 mg - Hidrofloraquin 200mg 1x1 - Paracetamol 500 mg - Spironolakton 200mg
Ur/cr: 28/0,57 - paracetamol 3x500mg - Valsartan 1x80 mg (k/p) 2x1
Na/K/Cl: 147/2,9/113 -Valsartan 1 x 80 mg - Iv omeprazole 40mg/12 jam - IV meropenem 1 gr/12
GDS: 121 - Pradaxa 1x75mg - Nystatin 2cc/6jam jam Lab 18/07/19
Anti HCV/HBsAg: -/- - Sulfas ferosus 1x1 - Myfortic 2x360mg - Clopidogrel 1 x 75 mg Hb/ Ht/ E/L/T :
- IV Levofloxacin 750mg/24 - Aspilet 1x80mg 8,7/24/2,9/5,6/223
Lab 19/07/2019 jam - Sukralfat syr 3xcI MCV/MCH/MCHC :
Hb/Ht/E/L/T: - IV ondancentron 4 mg/8 jam 81/30/37
9,4/26/3,6/9,8/336 - IV citicolin 500 mg/12 jam Lab 19/07/19 Diftel: 2/0/0/63/21/14
MCV/MCH MCHC: - IV. Ceftazidine 2gr/24 j GDS : 154
73/26/36 - Sukralfat syr 3xCI Urinalisa Ur/Cr 78/2,45
Diftel: 3/0/0/67/22/8 - Ostriol 1tab/24 jam leukosit +1 Alb: 2,46
Albumin: 2,76 - Amlodipin x10 mg Glukosa +2 Ca:8,1
Na/K/Cl: 137/4,0/106 - Azytromicin 500mg /24 jam Na/K/Cl 125/4,4/92
- Paracetamol 1000 mg/8 jam Sedimen urin
Lab 17/07/19 PO Leukosit 8-10
Feritin : 346,90 - Metyl Prednisolon 3x8 mg Eritrosit 6-8
Besi :21 - KSR 600mg /12jam Epitel 4-6

Lab 15/07/19 Lab 18/07/19 Lab 18/07/19

Hb/ Ht/ E/L/T : Kolesterol total : 283 Hb/Ht/E/L/T
8,4/25/3,4/8,5/80 10,0/28/3,1/25,8/800
MCV/MCH/MCHC: Lab 15/07/19 MCV/MCH/MCHC:
72/25/34 Hb/ Ht/ E/L/T : 89/32/35
Procalcitonin : 1,18 8,1/22/3,1/6,8/392 Diftel : 0/0/0/88/9/3
Ur/Cr: 45/1.19 MCV/MCH 73/26
Dftel : 3/0/1/65/23/8 Diftell : 0/0/0/92/4/4 Lab 17/07/19
Na/K/Cl : 145/3,6/115 Ca 9,1 Hb/Ht/E/L/T
Urinalisa : Ur/Cr 105/2,42 7,7/22/2,6/26,5/901
- Berat jenis : 1,020 Na/K/Cl 129/3/94 MCV/MCH/MCHC:
- pH : 6,0 Urinalisa 86/29/34
- Leukosit : Positif Protein +1 Diftel : 2/0/0/76/14/8
- Protein : +1 Glukosa +1 Retikulosit : 1,6
- Glukosa : Negatif Darah + GDS : 132
Granular cast,sel ragi positif Ur/Cr : 37/0,84
Lab 14/07/19 Na/K/Cl : 142/4,6/109
PT pasien/kontrol/INR : Lab 14/07/19 Albumin : 2,92
12,90/13/0,95 Na/K/Cl : 123/3.0/87 Bil. Total/dir/ind:
APTT pasien/kontrol : Ca/Mg 9.0/1.8 0,53/0,27/0,26
30.70/33,5 Lab 12/07/19
Hb/ Ht/ E/L/T :
8.9/24/3.4/13.9/380
MCV/MCH/MCHC:
70/26/37
Dftel : 0/0/0/96/3/1