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(22.45) Mapping Aqsa 2 Minggu 14 - 02 - 2021
(22.45) Mapping Aqsa 2 Minggu 14 - 02 - 2021
Ass/
1. Odema paru akut
2. CKD Stg V on HD
regular
3. Anemia Berat ec dd
1. Penyakit Kronis
2. Perdarahan
4. Hipertensi
5. Hipoalbumin ec dd
1. Renal loss
2. Low intake
Th/
- Bedrest
- Diet ginjal 1900 kkal +
50 gr protein /hari
- threeway
- Nitrogliserin 10 mg
dalam 50 cc Nacl 0,9 %
(titrasi dosis):titrasi
- Asam folat 2x04 mg
- Lenal Ace 1x169 mg
- Bicnat 2x500 mg
-amlodipine 1x5mg
Lab 11/2/21
Hb/ht/T/L
9,9/29/14/22,3
mcv/mch/mchc
81/28/34
diftel
0/0/93/0/1/6
Lab 12/02/2021
Hb/ht//t : 6,5/20/5,3/93
Mcv/mch/mchc :
87/29/33/16,8/11,1/14,8
Diftel : 0/0/1/80/14/5
Lab 11/02/2021
Hb/ht/l/t : 6,2/19/5,8/89
Mcv/mch/mchc : 88/29/33
Diftel : 4/1/0/70/20/5
Albumin : 2,4
Ur/cr : 58/4,2
Na/k/cl : 142/3,1/106
K4B1 K4B2 K4B3 K4B4 K4B5
DPJP : dr.M.Fuad, DPJP : dr.M.Fuad,
Sp.PD,KHOM Sp.PD,KHOM
COW : dr. Indah Fajarini COW : dr. Indah
Ruangan : dr. Rossyta Fajarini
Ruangan : dr. Rossyta
Nama : Rusdi daud Nama : Saiful Bahri
TTL: 04/06/1951 (27th) TTL : 12/12/65
CM: 1251359 CM: 1265487
Tgl Masuk: 09/02/2021 Tgl Masuk: 11/02/2021
Ass/ Ass/
1.penurunan keasadaran 1. dd 1/ hepatoma
(perbaikan) ec.hipoglikemia 2/ kista hepar
2.hipoglikemia ec.dd: 3/ massa intra abd
-drug induced 4. ileus paralitik
-low intake 2. asites ec dd : 1.
3.DM tipe 2 hipoalbuminemia, 2.
4.Ht stage I sirosis hepatis
3. kosntipasi
Th/
-bed rest Ass/
-IVFD D 10% 20tpm -. bed rsst
-bolus D40% 1flacon - diet hati 1700kkal
-curcuma 3x1 - three way
-N.asetilcystein 2x1tab - IV cefperazone 1gr/8j
- Drip NTG 10 mg dalam 50 - IV omeprazole
cc nacl 0,9 % 1,5 cc/jam 40mg/12j
(titrasi dosis) - furosemid 1x40 mg
- Drip Furosemide 1 cc/jam - spironolakton 2x100
- lactulac 3xC1
lab 13/02/21 - curcma 3x1
hb/ht/T/L
12,2/35/132/19 Lab 12/12/2021
mcv/mch/mchc PT/APTT: 1,13/1,07
85/30/35 D-dimer : 1470
diftel
1/0/6,3/6/-1/75 Lab 11/2/21
gds Hb/L/T : 9,1/7,7/193
202 MCV/MCH/MCHC :
ur/cr 64/21/34
136/6,2 Diftel : 0/0/1/79/13/7
Na/K/Cl
131/4,0/103 Anti HCV : negatif
HbsAg : reaktif
Foto thorax PA 13/2/21
jantung membesar Bil Total : 1,2
tampak infiltrat di paru Bil Direct : 0,63
kanan kiri Bil Indirect : 0,57
sinus phrenicocostalis kanan OT/PT : 38/12
kiri tidk tervisualisai KGDS : 115
kesmpilan : kardiomegali, Albumin : 2,5
pneumonia Ur/Cr : 15/0,7
Na/K/Cl : 137/3,2/ 105
Lab 09/02/2021
HB/L/T : 10,8/7,4/154
Ur/cr: 68/4,10
MCV/MCH/MCHC:
90/30/34
Diftel: 0/0/1/87/4/8
Albumin 3,0
Ca 7,8
GDS 203
Ur/cr: 68/4,1
Na/k/cl:133/4,3/105
K5B2 K5B3 K5B4 K5B5
DPJP : dr. Mahriani DPJP : dr. Abdullah Sp.PD DPJP : Dr.dr.Kurnia F
Sylvawani Sp.PD-KR KGH, Jamil, Sp.PD,KPTI,
COW : dr. Indah Fajarini COW : dr. Yudistira FINASIM
Ruangan : dr. Rossyta F Ruangan : dr. Umar COW : dr.Rizqi
Ruangan : dr. Julia
Nama : Wahidin bin Abu Nama : M. Jamil A Nama : Jumaidi bin A.
bakar TL : 57 Ajid
TTL : 06/ 04/ 1988 CM : 1216114 TTL : 11/06/1972
CM : 1259485 Tanggal Masuk : 04/2/2021 CM : 0952651
Tgl Masuk : 3/ 2/ 2021 Tgl masuk: 2/2/2021
Ass/ Ass/ Ass/
1.CKD stage 5 ec dd : 1. 1. Bisitopenia ec dd 1.CKD stageV dengan
PGOI 2. HN on HD 1. Related NHL uremic syndrom dd/
regular dengan edem Paru 2. Induced Kemoterapi 1.PGOI 2. HN 3. PNC
akut 2. NHL stg 3 pro kemoterapi 2. Anemia berat ec dd/
2. Anemia Berat NN ec siklus V regimen (ICE - PGK
MESNA ) Karnofsky 80 %
Penyakit Kronik - Perdarahan (ISK)
3. HT on theraphy
Th/
Th - Bedrest
4. Hiperkalemia
-Bedrest - Diet MB 5.ISK
-O2 simple mask 7liter - IVFD NaCl 0.9% 20gtt/i 6.Hiperurisemia
permeit - curcuma 3x1
-Threeway - mecobalamin 3x1 Th/
-IV Levofloxacin 500mg/ - Bedrest
24jam Lab 05/02/2021 - Diet Ginjal
- Drip NTG 1A dlm 50cc SGOT/ SGPT :31/41 1700kkal/hari+ 0,8
NaCl 0,9 % titrasi Ur/cr : 30/0,8 kalori/kgBB/hari
dosis Na/K/Cl : 145/4/113 - Thereway
- Diovan 1x160 mg - IV Omeprazole 40
- Ramipril 1x5 mg mg/12 jam
Lab 02/02/2021 - IV Ondansetron
lab 10/2/21 Hb/l/t : 7,3/ 10,1/13 4mg/8jam
Mcv/mch/mchc : 78/28/34
HB/HT/T/L - IV ceftriaxone 2
Diftel : 1/0/0/9/85/6
7,4/21/140/8,0 gram/24 jam (4/2/2021)
mcv/mch/mchc H3
73/25/35 - Lenal ace 2x169 mg
Diftel - As. Folat 2x0,4 mg
5/1/8/3/0/83 - Bicnat 3x500 mg
na/k/cl/ca - Flumucyl 3x200mg
141/5,1/106/8,6 - Amlodipine 1x 5 mg
D-dimer : >4000 - Cendo lyteers
Albumin : 2,6 -Allupurinol 1x100mg
lab 10/2/21
Lab 5/ 02/ 2021 hb/ht/T/L
Hb/ Ht/ L/ Tr : 6,5/ 19/ 9,2/27/264/11,7
16.100/ mcv/mch/mchc
Diftel : 3/0/0/88/4/5 84/29/34
LED : 16 led : 58
Na/ K/ Cl : 142/ 5/ 102 diftel
CA : 10 6/1/7/14/0/72
Cr: 14,99 na/k/cl/ca
142/3,5/104/7,4
Lab (3/2/2021) albumin : 3,1
Hb / L/ Tr : 6,6/ 17 700/ ur/cr : 104/7,25
172000
Diftel : 3/1/0/86/6/4 FEses:
Na/K /Cl : 144/ 5,6/ 105 bau/konsitensi/warna:
Ca : 9,7 khas/lunak/kuning
HbsAg : non reaktif eritrosit/leukosit/parasit/te
Albumin : 3,3 lurcacing : negatif
GDS : 111
Ur/ Cr : 295/ 18,3
Urinalsisa 8/2/2021
Lekosit +
Protein + 1
Darah +
Leukosit 25-50
Eritrosit 500-600
Epitel 0-1
Sel ragi +
Bakteri +
Lab 7/2/2021
Hb/Ht/L/Tr : 10/29/9,9/84
MCV/MCH/MCHC:
84/29/34
Diftel : 10/1/0/0/73/8/8
Na/K/Cl/Ca:
140/3,10/103
Ur/Cr : 330/10,50
Alb 3,1
Ca 8,2
Lab 5/01/2021
As urat : 11,6
Lab 4/2/2021
Hb/Ht/L/Tr :
7,4/21/8,5/304
MCV/MCH/MCHC:
79/28/35
Diftel 3/0/0/84/6/7
Na/K/Cl/Ca:
140/3,80/103/91
Ur/Cr : 287/13,77
Albumin 3,33
Eco 4/2/2021
EF 52% LA , AO dan LV
dilatasi
MR,AR severe,TR
moderate PH dan PR mild
LVH konsentrik disfungsi
diastolic
Sesuai HHD dan CAD
Lab 2/2/2021
Hb/Ht/Eri/L/T :
5,2/15/1,8/6,2/369
MCV/MCH/MCHC :
83/29/35
Diftel : 5/1/0/72/15/7
AntiHCV : negative
HbsAg : non reaktif
Albumin : 3,4
Ur/Cr : 455/20,10
Na/K/Cl/Ca :
138/5,80/103/8,1
Nabawi Mina 1 K5B3
Ass/ Ass/
1. Sirosis stadium DC 1.PSMBA dd :
Childpugh B 1. ulkus gaster
2. Anemia berat HM ec 2. ulkus duodenum
dd/ 1. Perdarahan 3. gastritis erosif
2. penyakit kronis 4. drug induced
. def besi 2. hemiparese sinistra +
3. dd/1. Selulitis parese VI ,Xii
2. DVT Sinistra sentral ec
a/r pedis dextra stroke iskemik
4. hipokalemia ringan 3.Dm type 2
5. hipoalbumnemia 4.OMI inferior anterior
5.HT Stage II dg therapi
Th/
- bed rest Th/
- 02 2L/i -Bedrest
- diet hati 1700 kkal -NGT
- IVFD aminofusin -Drip lansoprazole 60
- lasix 20mg/12j mg dalam
- spironolakton 2x200 nacl 0,9 dg
- IV cefperazon 1gr/12j kecepatan 5 cc/ jam
- Sucralfat syrp 3 x
Lab 10/2/21 30 cc
Hb/L/T L 3,9/3,1/100 -Domperidone 3 x 10
Diftel : 4/0/1/64/21/10 mg
MCV/MCH/MCHC : -lactulac syrp 3 x 30
75/22/30 mg
KGDS : 202
Ur/Cr : 24/ 1. Lab 03/02/2021
Hb/Ht/Eri/L/T :
18.8/52/6.5/14.4/362
MCV/MCH/MCHC:
81/29/36
Diftel: 4/0/0/66/22/8
Ur/cr:44/1.10
Na/K/cl 146/4.60/103
GDS : 118