AQSA 2 (Minggu, 24/oktober/2021)
AQSA 2 (Minggu, 24/oktober/2021)
DPJP: dr. Diana Erlita, DPJP:dr. Sarah Firdausa, Dpjp: dr. Desi Salwani DPJP: dr. Diana Erlita, Sp.PD
Sp.PD Sp.PD Sp.PD
COW: dr. M. Firdaus Kamil
COW: dr. M. Firdaus Kamil COW: dr. Suprinardi Cow : dr. Suprinardi
Ruangan: dr. Putri
Ruangan: dr. Putri Ruangan: dr. Santun Ruangan : dr. Ira
Nama : Ikhsani Nama : Muchsin Nama : Muktarudin bin J. Nama: Rizal Hariadi
Tgl masuk : 20/10/2021 Tgl masuk : 22/10/2021 TTL : 01/07/1974 TM: 12-10-2021
(HD)
1. sepsis ec dd 1. Syok Sepsis ec sepsis bilier 1. Obs. Jaundice ec dd 1.Ulkus diabetikum e/r pedis
dextra
1. pneumonia 2.Hepatomegaly ec. dd 1) choledocolithiasis
2.DM tipe II NW
2. urosepsis 1) hepatitis viral 2) Colangiocarcinoma
3. Anemia Sedang NN
2. Krisis Hiperglikemia ec dd 2) abses hepar 3) Ca caput pankreas
4. Neuropati Diabetik
1) KAD 2)HHS 3) kista hepar 2. AKI stg I prerenal
IV lansoprazole 30/12 jam IVFD NaCl 0,9% 20 tpm Cetirizine 1x10 mg Silostazol 100mg/hari
Globulin: 3,0
AQSA 2 (Minggu, 24/Oktober/2021)
K2B1 K2B2 K2B3 K2B4 K2B5
DPJP: dr. Desi Maghfirah, DPJP : dr. M.Riswan, DPJP: dr. Sarah Firdausa,
Sp.PD Sp.PD-KHOM Sp.PD
TiBC :163
LDH : 478 p/
Mcv : 66/20/31
Na/K/Cl: 142/2,9/98
Lab 20/10/21
PT/APTT : 1,17/1,4
Lab 19/10/2021
Na/K/Cl/Cal: 140/3,10/106/8,0
Lab 17/10/2021
Hb/L/T: 10.4/12.4/176
MCV/MCH/MCHC:69/25/37
Diftel: 0/0/0/81/9/10
Albumin: 3.50
Ur/Cr: 147/8.9
DPJP : dr.Cut Mela, DPJP: dr. Diana Erlita, DPJP: dr. Desi Maghfirah,
SpPD,KGH Sp.PD Sp.PD
COW : dr. Fadhila COW: dr. M. Firdaus COW: dr. M. Firdaus Kamil
Kamil
Ruangan : dr. Umar Ruangan: dr. Suhemi
Ruangan: dr. Putri
TM : 18/10/2021
-Bicnat 3x500 mg
Ur/Cr: 84/5,9
Lab 11/10/2021
Urinalisis: Hb/Ht/e/l/t:
6,8/19/2,4/4,0/128
Kuning muda keruh, leukosit
(+), protein (+1), darah (+) Mcv/mch/mchc: 80/29/36
Diftell : 1/0/0/74/13/12
Albumin : 2,5
GDS : 98
Ur/Cr : 74/5,3
Na/K/Cl/Ca : 133/3/104/7,4
DPJP: dr. Desi Maghfirah, DPJP : Prof Dr. dr. Kurnia DPJP: Dr. Islamuddin, DPJP : Prof. Dr. Dr. Kurnia
SpPD F.J Sp.PD KPTI Sp.PD F.J Sp.PD KPTI
COW: dr. Firdaus COW : dr. M.Firdaus COW: dr. Suprinardi COW : dr. M. Firdaus
Ruangan: dr. Suheimi Ruangan : dr. Imam Ruangan dr. Merizka Ruangan : dr. Imam
Nama : M. Abd Gani Nama : Tarmizi Nama : Muhammad Nasir Nama : T. Hermansyah
1. 1.Diare kronik ec dd 1. Ca
rectosigmoid 2. IBD
1.CKD Stage V uremic ec dd 1. AKI stage 3 post renal ec 1. CKD stg V on HD reguler
1.DN 2).GNC 3).HN 4). PNC dd 1. Nefrolithiasis 2. Infeksi dengan edema paru akut 2. Hipoalbuminemia berat ec
(perbaikan) dd 1) GI loss 2) low intake
2. Anemia sedang NN ec dd 2. HT stage 2
2. Efusi pleura minimal dextra 3. Multipel ulkus gaster ar
AQSA 2 (Minggu, 24/Oktober/2021)
1)penyakit kronis 2.) perdarahan 3. Hematuria mikroskopis ec dd 1) related CKD 2) antrum
pleuropneumonia
3.DM tipe 2 NW 4.hipokalemi ringan
3. Pneumonia CAP dd infeksi (perbaikan)
4 Hipoalbuminemia sedang Th/ paru spesifik
6. Hiponatremi hipoosmolar
6. Impairment of vision IVFD. RL 20 tpm 4. Hipertensi stg II hipovolemik (perbaikan)
8. Isk asimptomatik IV. Omeprazole 40mg/12j 6. Anemia sedang NN ec dd/ Th/
Diet Dm 1700 kkal/hari rendah Amlodipin 10mg - diet ginjal 1700 kkal IV Omeprazole 40mg/12mg
garam
- iv omeprazole 40mg/12jam PO amocxicillin 1000mg/12mg
Threeway (H-7)
21/10/21 - iv ceftazidime 500mg/24jam
IV ceftriaxson 2grm / 24 jam PO Azitromisin 500mg/24 jam
Na/K/Cl : 139/4,4/108 - sc heparin 5000u/12jam
PO Domperidon 1tab/8jam
Hb/L/Tr : 14,3/9,2/225 - valsartan 1x160mg
Lab 23/10/2021 PO metilprednisolon 2x16mg
Diftel : 0/0/0/81/12/7 - herbesser 1x200mg
Hb/L/T : 9,0/10,4/363 Zinc 1X20mg
Ur/Cr : 127/12,4 - hytrin (terasozin) 1x1mg
MCV/MCH/MCHC : 78/34/27 Curcuma: 3x1tab
PT/APTT : 0,8/1,0 - clonidine 1x0,15mg
Diftel : 4/1/0/70/16/9 Lacbon 3x1tab
D dimer 1240 - sucralfat syr 3xCI
Albumin : 2,7 Salofalk 1x500mg
Anti HCV neg -threeway
Ur/Cr : 44/4,8 PO Sukralfat syr 3xCI
HbsAg neg P/
Na/K/Cl/Ca: 139/3,7/106/7,5 Symbio 1 capsul /12jam
Albumin 4,0 - BVT stage II Senin
25/10/2021 Attapulgit 1tab/BAB cair
Calcium 8,0
Lab 20/10/2021 - swab PCR 23/10/2021
GDS 111
CKMB/Troponin T : <16/0,11 - HD Senin Rabu Jumat, UF P/ Ct scan abdomen kontras
2500 non kontras (21/10/21)
- Konsul ulang KKV
Lab 18/10/2021
Monitoring: Cek TTV, cek
Hb/L/T : 8,6/13,0/296 tanda dehidrasi
MCV/MCH/MCHC : 77/27/36
P/
Diftel : 2/0/0/67/12/5 Lab 20/10/2021
- transfusi PRC 1 kolf
Albumin : 2,7 Hb/L/Tr: 10/5,3/113
- Cek DR 4 jam post transfusi
GDS : 123 Na/K/Cl/Ca: 133/3,2/105/6,4
Ur/Cr : 62/6,4 Albumin: 2,10
Lab 23/10/2021
Na/K/Cl/Ca: 137/3,6/104/7,8
PT/APTT: 1,05/41,3
Urinalisa 18/10/2021
D-Dimer: 1170
Protein : +1 CEA : 0,91
Darah : +
Lab (18/10/2021)
Leukosit : 25-50 17/10/2021
Hb/ht/eri/leuko: 8,9/26/3,1/3,7
Eritrosit : 200-250 Na/K/Cl/Ca
MCV/MCH/MCHC: 83,29,34
Epitel : 0-1 128/3,20/100/6,5
RDW/MPV: 14,3/8,9
K5B2 K5B3 K5B4
Ur/Cr: 135/10,50
Ur/Cr; 69/6,9