MAPPING AQSA 3

Senin, 19 Juli 2021

No Nama DPJP Kamar Jumlah

1. dr. Vera Abdullah Sp.PD-Kpsi K3B3,K4B1 2

2. dr. M. Riswan Sp.PD-KHOM K2B4, K3B5, K4B5, Zamzam 3 K15 4

3. dr. T. Mamfaluti Sp.PD K2B2, K4B3, Nabawi K5B5fa 3

4. Dr. dr. Fauzi Yusuf, SP.PD KGEH - 0

5. dr. Hendra Zufry SpPD KEMD K3B$, K3B1 2

6. dr. Desi Salwani, SpPD-KGH Zamzam 3 K02, , Zamzam 3K12 2

7. Dr. dr. Azhari gani, Sp. PD, KKV K1B4, K1B1, K4B2f 3

8. dr. M. Fuad, Sp.PD KHOM K4B4, Zamzam 3 2

9. dr. Alfi Syahrin, Sp.PD K2B5, 2

10. dr. Islamudin, Sp.PD Zamzam 3K11 Zamzam 3K20A 1

11. dr. Azzaki Abubakar, Sp.PD KGEH Zam zam K10 1

 K1B1 K1B2 K1B3 K1B4
DPJP : dr. Azhari Gani, Kosong Kosong DPJP Dr. dr. Azhari Gani, Sp.PD
Sp.PD-KKV KKV
COW : dr. Irhash/ dr. COW : dr. Irhash/ dr. Eko
Eko Ruangan : dr. Jupri/dr. Julia/ dr.
Ruangan : dr. Jupri/dr.
Rossyta/ dr. Rina
Julia/ dr. Rossyta/ dr.
Rina
Nama: Irma Suryani Nama: Fatimah Syam
CM: 1-20-04-15 TTL: 10/07/1959
TL: 20-04-1991 CM: 1277095
TM : 13/07/2021
TM: 12/07/2021
Ass Ass/
1. GAD 1. Anemia sedang NN ec dd 1)
2. Psmbb ec hemorroid perdarahan 2) penyakit kronis
interna 2. malfungsi AV shunt
3. CKD stage V on HD regular ec dd: 1)
Th/ DN 2) HN 3)PNC
- Tirah baring 4. DM tipe II NW
- Diet MB 5. Hipoalbuminemia sedang
1700kkal 6. Hipokalemia sedang
- Ivfd nacl 0,9% 7. Syok hipovolemik (perbaikan)
20 gtt
- iv lansoprazole Th/
30 mg/12 jam Tirah baring
- Asam O2 nasal kanul 4lpm
tranexamat Diet ginjal 1700kkal/hari + 1,2 gr
3x500mg protein/kgBB/hari
- IV Lansoprazole IV Meropenem 500 mg/24 jam
30mg/12jam IV Ca glukonas 2 ampul/12 jam
- Anti Hemoroid Transfusi FFP 500 cc
supp/12jam Vitamin K 1 ampul/12 jam
- PO Bisoprolol Iv omeprazole 40mg/12jam
2,5mg/24 jam Asam folat 2x400mg
- PO Alprazolam Lenal ace 1x 169 mg
0,5mg/12jam Amlodipine 1x5mg
- Paracetamol Valsartan 1x160mg
1000gr/12jam IV asam traneksamat 500 mg extra
- Laxadyn KSR Tab 600 mg/12 jam
IIIc/8jam
P/
  Pantau hemodinamik
P/ KGDP/hari
- HD hari ini
Cek elektrolit, ur/Cr, albumin
Lab 14/07/2021
Free T4 : 20,06 Lab 17/7/2021
  Hb/Ht/Eri/Leu/Tr
Lab 13/07/2021 7,1/20/2,4/22/72
Hb/l/t: 12,4/10,4/324 MCV/MCH/MCHC
Mcv/mch/mchc: 73/24/32 82/30/36
Diftel: 3/0/0/70/20/7 RDW/PDW
CK-MB: 20 19,3//14
UR/Cr: 18/0,50 Diftel 7/1/0/84/5/3
PT :1,08
APTT :35,50

Lab 15/07/2021
Hb/Ht/Eri/Leu/Tr
6,2/18/2,2/33,1/99
MCV/MCH/MCHC
82/28/34
RDW/MPV/PDW
18,2/10,3/10,6
LED: 1
Diftel 0/0/0/97/2/1
PT :1,28
APTT :1,3

Lab 14/07/2021
Hb/Ht/Eri/Leu/Tr
8,2/23/3,0/19,4/91
MCV/MCH/MCHC/RDW
78/28/35/17,7
Diftel 2/1/0/92/3/2
 PT/APTT : 1,74/4,69
Albumin 2,80
Ca : 7,5
Ur/Cr : 65/3,60
Na/K/Cl : 135/2,90/105

Lab 12/07/2021
Hb/l/t: 2,7/12,9/116
Mcv/mch/mchc: 78/26/33
Pt/aptt: 1,43/1,12
Hiv: non reaktif
Hbsag/anti hcv:-/-
Albmin 3,2
GDS: 73
Ur/cr: 60/3,8
Na/k/cl/ca: 135/3,7/103/8,1

K2B1 K2B2 K2B3 K2B4 K2B5

 DPJP dr. T. Mamfaluti, DPJP dr. M. Riswan DPJP dr. Alfi Syahrin,
SpPD SpPD KHOM Sp.PD
COW : dr. Irhash/dr.Eko COW : dr. Irhash/ COW : dr. Irhash/dr.
dr. Eko Eko
Ruangan : dr. Rossyta/ dr.
Ruangan : dr. Ruangan : dr.
Rina/dr.julia/dr.Jupri Jupri/dr. Julia/dr.
Jupri/dr. Julia/ dr.
Rossyta/ dr. Rina Rossyta/ dr. Rina
Nama :Atina binti Zainal Nama : Mayasari Nama : Cut Badri
Abidin Binti Nurdin Yunus TTL : 17/08/1967
TTL : 18/05/1976 TTL : 16/1/1992 CM : 1070771
Tgl masuk: 14/07/2021
CM: 1279771 CM 1279281
Tgl masuk : 16/7/2021 Tgl masuk : 13/7/2021
Ass/ Ass/
1. Ass/ 1. Massa intra Abdomen 1. AKI stage III dd
1. dd/ e.c dd: acute on CKD
-parotitis supuratif - Ca Colorectal 2. Diabetic nefropati
-parotitis viral - Ca colon 3. ISK dd BSK
-mastoiditis - Metastase proses 4. Hiponatremia
2.AKI stage III dd/ diabetik 2. Metastase proses hipoosmolar
nefropati 3. Candidiasis oral hipovolemik
3.Severe Headache   5. CHF NYHA II ec dd
4.DM Tipe 2 NW Th/ -HHD
5.Hipertensi stg 1 Bedrest -IHD
Diet lunak 1700 -DCM
Th/ kkal/hari 6. PSMBA (perbaikan)
Bed rest IV lansoprazole 40mg / ec dd:
Diet DM 1700 kkal/hari 12 jam - stress ulcer
IVFD Nacl 0,9% 20 gtt/i IV ondancentron 4 mg/8 - uremic bleeding
IV ceftriaxone 2 gr/ 24 jam jam
Drip paracetamol 1 g/8 jam Attalpulgite 1 tab/ Th/
SC lantus 0-0-0-14 IU mencret max 10 tab k/p Bedrest
SC apidra 8-8-8 IU Sucralfat syr 3xCI O2 nask Kanul 4 l/i
IV lansoprazole 30 mg/12 Zink 1x20 mg Diet sonde ginjal 6x200
jam Lacbon 1 tab/12 jam CC via NGT
Azitromicin 1x500 mg Nystatin drop 4x2cc IVFD NaCl 0,9% 500
Amlodipine 1x10 mg Kaltropen supp 100 mg CC/12 jam
Flumucyl 3x200 mg (k/p) IV Ceftriaxone 2 g/24
IV Citicolin 500mg Drip Paracetamol 1g/8 jam (14/07/2021)
Kaltrofen supp k/p jam Fluimucyl 200 mg/8 jam
Laxadine syr 3xCII Transfusi PRC Target Bicnat 500 mg/ 8 jam
Fosen enema supp k/p Hb>=10g/dL Ondancetron 4 mg/8
  jam
P/ P/ IV furosemid 25 ampul
Evaluasi NRS susul hasil Ro Thorax +50 cc NaCl 0,9%
Susul hasil head CT scan, Colonoskopi + EGD IV ondansetron 4 mg/8
Ro Thorax, Ro cervical lat CT- scan abdomen dan jam
Cek KGDP/hari Thorax kontras (hasil) Lenal Ace 169 mg/12
Cek lipid profile, HbA1C, jam
PT APTT, D-Dimer,   Drip lansoprazole 60mg
elektrolit, DR, Ur/Cr Analisa Gas Darah + 50 CC NaCl 0,9% 5
Kultur darah 18/7/2021 CC/jam
Ecaluasi DR/3 hari pH : 7,522 Drip furosemide
Urinalisa pCO2 : 33,20 10mg/jam
pO2 : 69  
Radiologi 17/07/2021 Bikarbonat (HCO3) : P/
Cervical AP/Lat : 27,5 Pantau hemodinamik
spondylosis cervical, soft Total CO2 : 28,5 Pantau UO
tissue swelling sisi Kelebihan basa (BE) : Echocardiografi
interoposterior kanan 5,5 USG urologi
Saturasi O2 : 94,5
Lab 16/07/2021 Lab 17/7/2021
Hb/Ht/Eri/L/Tr: Lab 16/7/2021 Hb/Ht/Eri/Leu/Tr :
10,0/29/3,5/23,4/394 Hb/Ht/Eri/L/Tr: 9,8/27/3,6/7,8/67
MCV/MCH/MCHC: 9,4/31/3,8/9,9/580 MCV/MCH/MCHC :
82/28/35 MCV/MCH/MCHC: 75/27/36
RDW/MPV/PDW:13,3/10,6 80/25/31 RDW: 19,1
/13,1 RDW/MPV/PDW: Diftel 2/1/0/78/13/6
Diftel: 0/1/0/86/8/5 18,1/8,5/7,7 K/Ca/Cl/Na :
GDS: 578 LED: 129 3,60/9,1/94/124
Ur/Cr: 73/ 3,00 Diftel: 2/0/0/73/16/9 Ur/Cr : 73/3,40
Na/K/Cl: 138/4,20/103 Ur/Cr: 5/0,24  
Lab 15/07/2021
Analisa Gas Darah Hb/Ht/Eri/Leu/Trombo:
16/7/2021 9,6/27/3,5/8,6/61
pH : 7,491 MCV/MCH/MCHC:
pCO2 : 33,60 77/27/35
 pO2 : 34 Diftel: 0/0/0/84/9/7
Bikarbonat (HCO3) : Ur/cr: 61/2,7
25,9 Na/K/Cl: 123/3,7/94
Total CO2 : 26,9  
Kelebihan basa (BE) : Lab 14/07/2021
3,4 Hb/HT/Eri/Leu/Trom:
Saturasi O2 : 68,8 10,3/28/3,8/4,0/110
  MCV/MCH/MCHC:
Lab 15/7/2021 75/27/36
PT:1,01 Diftel: 2/0/0/70/21/7
APTT:1,06 Albumin: 3,00
AFP:1,18 Ca 9,1
CA125:5,4 Na/K/Cl: 122/4,6/90
Anti HCV:Negatif GDS : 143
HBsAg:Non Reaktif Ur/Cr: 56/2,1
Albumin:2,86
GDP:75

Lab 14/7/2021
Hb/Ht/L/T
8,8/27/10,8/540
MCV/MCH/MCHC
78/25/32
Diftell 2/1/0/70/17/10

K3B1 K3B2 K3B3 K3B4 K3B5

DPJP dr.Hendra DPJP dr. r Abdullah, DPJP dr.Hendra DPJP: dr. dr. M.
Zufry,SpPD-KEMD SpPD Zufry,SpPD-KEMD Riswan SpPD KHOM
COW:dr.Irhash/ dr. Eko COW:dr.Irhash/ dr. COW : dr. Irhash/ dr.
Ruangan: Eko Eko
dr.Rossyta/dr.Jupri/dr.Ri Ruangan: Ruangan : dr.
na/dr.julia dr.Rossyta/dr.Jupri/dr. Rossyta/dr. Jupri/ dr.
Rina/dr.julia Julia / dr Rina

Nama:Sumiati Sulaiman
TTL: 01/07/1966
CM:1171102
Tgl masuk:15/07/2021
Ass/
1. Sepsis ec dd/
-pneumoni
-urosepsis
2. Pneumoni HAP dd infeksi
paru spesifik
3. Efusi pleura dextra ec dd/
-pneumoni pleura
-TB pleura
4. DM tipe 2 NW
5. Anemia berat NN ec dd/
- penyakit kronis
- perdarahan
Th/
Bedrest
O2 nasal kanul 3-4 lpm
Diet MII 1700 kkal/hari
IVFD NaCl 0,9% 10gtt/i
paracetamol 500mg 3x1
IV meropenem 1gr/8jam
IV lansoprazole 30mg/12jam
Transfusi PRC s/d HB >
10g/dl
SC Lantus 0-0-0-8 IU
IV Albumin 1fls/hari
P/
Ro thorax PA susul hasil
Urinalisa
Kultur urin + STAB
Kultur darah + STAB
Cek D-dimer, MDT,
Prokalsitonin, retikulosit
Sputum BTA jika ada dahak
Gen expert
USG thorax didivisi pulmo
Pungsi cairan pleura sudah
200cc
Cek KGDP/hari
Pantau hemodinamik
Rivalta test
Nama : Syarifah Tauhida Nama : Hasimah Nama : Irma Dewi
TTL: 7/10/1977 TTL : 01/07/1959 Kusuma Nengsih
CM : 1279880 CM : 1279682 CM : 1261455
Tgl Lahir : 05/07/1975
Tgl Masuk : 17/7/2021 TM : 17/7/2021
Tgl masuk : 16-7-2021
Ass/ Ass/ Ass/
1. Pansitopenia ec dd/ 1.Dyspepsia tipe like 1. ca mamae post
- anemia aplastic ulcer dd tipe mixed kemoterapi siklus ke 3
- Leukimia 2. Pneumonia CAP dd dengan regimen TAC
- MDS infeksi paru spesifik 2. Neutropenia ec
2. Menoraghia 3. Hipokalemia ringan kemoterapi induced
3. Hipernatremia ringan (3,5)
4. Hiperchlorida Th/
Th/ Bedrest
Th/ - Diet MB 1700 kkal/hari Diet MB 1700 kkal/hari
Diet MB 1700 kkal/hari - IV Ceftriaxone 2 IVFD NaCl 0.9% 20 tpm
IVFD NaCl 0,9% 20 tpm g/24jam IV omeprazole 40 mg/ 12
IV. Omeprazole 40 - IV Omeprazole jam
mg/12 jam 40mg/8jam IV ondansentron 4 mg/8
Domperidone 3x10 mg - IVFD Nacl 0,9% 20 jam
Transfusi Trombosit Jika gtt/i Curcuma 2x1
-trombosit < 20.000 - Domperidone 3x10mg Sc leucoge 1 vial/hari s/d
terjadi perdarhan - Sukralfat syr 3XC1 ANC > 1500
- trombosit < 10.000 - Vit D 2x400mg Transfusi PRC s/d 10 gr/dl
- Vit C 2x1000mg
- Paracetamol 3x500mg
- Sc Heparin 5000Iu/12
P/
Jam Evaluasi klinis +
hemodinamik
Lab 17/07/2021 DR/ hari
Hb/L/T : 13,6/13,4/182
Monitoring ANC
Diftel 0/1/0/92/3/4
PT/APTT : 1,0/1,5 Lab 17/07/2021
Fibrinogen 1152 Hb/Ht/Eri/Leu/Tr
Ddimer 8210 7,4/22/3,2/0,7/62
GDS 203 MCV/MCH/MCHC
UR/CR 45/0,9 69/23/34
Na/K/Cl : 137/3,5/106 RDW
Troponin T <0,04 25,8
CK MB 27 Diftel 0/1/0/12/48/39
Lab 14/07/21
Hb/Ht/E/L/trom
9,2/28/4,0/0,8/194
MCV/MCH/MCHC
70/23/33
RDW: 26,8
Diftell : 0/3/0/19/74/4

Lab 17/7/2021
Analisa Cairan Otak/Tubuh :
Protein Tot : 5,60

Protein Total :
Albumin : 2,50
Globulin : 3,10

Lab 16/07/2021
Hb/Ht/Eri/L/Tr:
7,0/22/2,3/17,8/343
MCV/MCH/MCHC:
95/30/32
RDW/MPV/PDW:
14,7/10,6/11,7
LED: 130
Diftel:1/0/0/86/9/4
Retikulosit: 3,4
Morfologi darah tepi;
Eritrosit: normokrom
normositer
Leukosit: jumlah meningkat,
bentuk normal, neutrofilia (+)
Trombosit: jumlah cukup
bentuk normal, tersebar (+)
Kesimpulan: anemia
normokrom normositer,
leukositosis
D-dimer: 2050
HbA1c: 8,4
Procalsitonin: 1,26

Lab 15/07/2021
Hb/Ht/Eri/L/Tr:
6,7/21/2,2/321/19,9
MCV/MCH/MCHC:
92/30/33
RDW/MPV/PDW:
15,0/10,1,12,1
Diftel:0/0/0/87/8/5
Analisa Gas Darah
-PH:7,492
-pCO2:41,00
-pO2:127
-HCO3:31,6
-Total CO2:32,9
-BE:8,3
-Sat.02:97,2
Albumin:2,5
Ca:8,2
GDS:94
Ureum:36
Kreatinin:0,6
Na:143
K:4

K4B1 K4B2 K4B3 K4B4 K4B5

DPJP : dr.Vera DPJP : dr. Azhari DPJP: dr. T. Mamfaluti, DPJP : dr. M. Fuad, DPJP: dr. M. Riswan, SpPD
Abdullah, Sp.PD, Gani, Sp.PD-KKV Sp.PD SpPD-KHOM KHOM
K.Psi COW : dr. Irhash/ dr.
COW : dr. Irhash/ dr. Eko COW : dr. Irhash/ dr.Eko COW : dr. Irhash/ dr.Eko COW : dr. Irhash/ dr.Eko
Eko Ruangan : dr. Ruangan : dr. Rossyta/dr. Ruangan : dr. Rossyta/dr. Ruangan : dr. Rossyta/dr.
Ruangan : dr. Jupri/dr. Julia/ dr. Jupri/ dr. Julia / dr Rina Jupri/ dr. Julia / dr Rina Jupri/ dr. Julia / dr Rina
Jupri/dr. Julia/ dr. Rossyta/ dr. Rina
Rossyta/ dr. Rina

Nama : :Tjut Abadi Nama : Hasanah binti Nama : Murni Jalidin (HD)
Hanum Yahya CM : 1279329 Nama : Nurmala Nama : Marlina binti usman
CM : 082948 CM : 0972946 TTL : 16/11/1987 CM : 1274982 CM : 1279846
Tgl Lahir : 11/12/1951 Tgl Lahir : 01/07/1956 TTL : 06-07-1976 (45) TTL : 16/06/1980
Tgl masuk : 16 Juli 2021 Tgl masuk: 17/ 07/ 2021
Tgl masuk : 19/07/2021 Tgl masuk : 13/07/2021

Ass/ Ass/ Ass/

1. Vertigo Perifer dd 1. AKI stage III dd acute 1.CKD stage V dengan uremic Ass/ Ass/
meniere disease on CKD syndrome ec dd 1.Multiple limfadenopati ec 1. PSMBA ec dd/
2. Ca Colon 2.Anemia sedang HM ec -DN dd 1. Limfoma maligna 2. -Ulkus gaster
dd -GNC Malignancy - ulkus duodenum
Th/ 1). def. besi 2. DM tipe 2 normoweight 2, Bisitopenia ec dd 1. AML 2. Anemia berat makrositer ec
Bedrest 2).Penyakit Kronis 3. Ulcus diabeticum ar plantar 2. CML 3. MDS dd/ -perdarahan
O2 nasal canul 4 lpm 3.Hipoalbuminemia pedis dextra 3.Tumor Paru T2N3M1 - autoimun
Diet MII 1700kkal/hari sedang ringan 4. Hipoalbuminemia ringan stadium IV A  
IVFD NaCl 0,9% 20 4.Geriatri problem 5. Hipocalsemia ringan 4. Pneumonia Th/
gtt/i (inanisi, instabilitas dan 6. Anemia ringan HM ec 5. Sindroma obstruksi Bed rest
IV omeprazole 40 jatuh, impaired of penyakit ginjal kronik   O2 nasal 4 lpm
mg/12 jam hearing and vision) 7. Hipokalemia ringan Th/ Diet lunak 1700 kkal/hari
IV Ondacetron 4mg/12 5.DM tipe II -bedrest IVFD NaCl 0,9% 20 gtt/i
jam 6.Hipertensi stage II Th/ -IVFD Nacl 0,9% 20 gtt/i IV Omeprazole 40 mg/12 jam
Betahistine 3x6 mg PO   - Tirah baring -IV Omeprazole 40mg/12 IV Cefotaxime 1 gr/8 jam
Flunarizine 2x5mg PO Th/ - O2 nasal kanul 4 lpm jam Transfusi PRC s/d Hb > 1 g/dl
Mecobalamine Tirah baring - Diet Ginjal 1700kkal/hari - Ventolin 4x1 respul dengan bloodset khusus,
2x500mg Po Diet Ginjal - Threeway - Fluxotide 1respu/12 jam premedikasi diberikan IV
Lactulac syr 2xCI 1700kkal/hari+protein - IV Ceftriaxone 2g/24jam Asam folat 3x400mg dexametason 1 amp
0,6-0,8 g/kgbb/hari - IV Omeprazole 40 mg/12 jam -SF 3X1 IV metilprednisolone
P/ O2 nasal canul 4 lpm -Lenal ace 2x169mg Kaltrofen sup 125mg/12 jam
Pantau hemodinamik Catheter -Asam folat 2x0,4mg Ciprofloxacin  200mg/12  
Konsul THT Threeway -Bicnat 3x500mg jam P/
Konsul Kulit Iv ceftriaxone 2 g/24 -Albuminar 20 % Methlprednisolon 125mg/12 Transfusi PRC sampai Hb > 10
jam -IV Ca gluconas 3x1ampul jam g/dl dengan bloodset khusus
Lab 19/07/2021 Iv Lansoprazoe - Valsartan 160 mg/24j -Ostriol 2x0,25mg Premedikasi 1 amp
30mg/12jam - domperidone 10 mg/8jam -Drip Resfar 8-8-9 Dexametason
Hb/Ht/Erit/leu/trombo: Fluimucyl 3x200mg - Amlodipin 10mg/24jam -Flumicort 2x1respul  
12,3/37/4,4/10,6/435 Valsartan 1x80mg -Paracetamol 3x500mg -Duralgesic patch Lab 17/7/2021
MCV/MCH/MCHC:84 Transfusi PRC s/d Hb > -calsium lactat 2x500mg Hb/Ht/Erit/leu/trombo:
28/34 9 P/ -transfusi tc 10 kolf premed 2,1/5/0,4/13,3/261
RDW/MVP: 14,1/8,5 Asam folat 1x0,4 mg Cek KGDP/hari furosemid 1 amp MCV/MCH/MCHC:127/57/45
Diftel: 4/1/0/48/38/9 IV Furosemide 2x1 amp Cek DR,Ur, Cr, Elektrolit/   PDW/MVP: 11,9/15,2
SGOT/SGPT: 26/25 Amlodipin 1x10 mg 3hari P/ Diftel: 0/0/0/73/19/8
Albumin : 4,00 AV Shunt: jadwal konfirmasi Transfusi cek DT, post PT/ APTT: 1,42/ 0,81
Troponin T/CK-MB : P/ HD selanjurnya senin (19 Juli transfusi tc Anti HCV: negative
<0,04/16 Pantau hemodinamik 2021) HBsAg: non reaktif
Ca/Na/K/Cl: Cek KGDP/hari Lab 18/07/2021 Bilirubin total 3,17
10,3/143/3,4/103 USG urologi Lab 17/07/2021 Analisa gas darah Bilirubin direct 1,21
Ur/Cr: 33/0,6 Cek ur/cr per 3 hari PH : 7,493 Bilirubin indirect 1,96
GDS 185 Hb/Ht/Eri/Leu/Tr pCO2 :34,6 Foto thorax AP : cardiomegaly
Lab 18/7/2021 11,8/33/4,4/11,7/98 pO2: 33 Pneumonia
Hb/ht/E/T/L: MCV/MCH/MCHC Total CO2 : 27,8 SGOT: 113
8,1/24/3,1/256/6,6 76/27/35 Saturasi O2: 64,7 SGPT: 65
MCV/MCH/MCHC : RDW: 14,6 Protein total: 6,10
78/26/34 Diftel 4/1/0/72/16/7 Lab 13/07/2021 Albumin 3,60
Diftel: 5/1/0/69/16/9 K/Ca/Cl/Na : 2,90/7,1/109/138 Hb/L/T : 6,0/9,3/6 Globulin 2,50
K/Ca/Cl/Na: Albumin : 2,40 Diftel : 1/1/0/69/22/1 Kalsium 8,7
4,8/8,3/107/132 Ur/Cr : 66/6,70 MDT : Hipokrom mikrositer Ur/ cr: 32/ 0,70
Ur/Cr: 4,70/102 Anisopoikilositosis, Na/k/cl: 142/4,6/112
Lab 14/07/2021 hipersigmentasi,
Lab 16/7/2021 Hb/Ht/E anisopoikilositos, ovalosit,
Hb/Ht/Eri/Leu/Tr 9,5/27/3,7 sel target
7,3/22/2,8/6,5/239 MCV/MCH/MPV Ddimer 2580
MCV/MCH/MCHC 74/26/12,9 LDH 1785
78/26/34 Diftell: 3/1/0/67/20/9
RDW/ PDW Albumin : 3,3 Lab 08/07/2021
15,7/14,2 K/Cl/Ca 1.
Diftel 7/1/0/69/16/7 3,4/107/6,7
PT :1,17
APTT :34,20
Ur/Cr : 105/4,6 Urinalisa 14/07/2021
Lab 15/7/2021 Makroskopis/
HbA1c:4,8 Keruh
Ferritin:271,50 Leukosit : positif
Besi:28 Protrin : positif +2
TIBC:207 Keton: positif
Lab 13/07/2021 Darah: positif
Hb/Ht/L/E/Tr: Mikroskopis/
7,1/20/8,5/2,6/275 Leukosit: 5-10
Diftel: 2/1/0/60/28/9 Eritrosit: 2-5
MCV/MCH: 77/27 Epitel: 1-3
Albumin 3,2 Hyalin cast: positif
GDS : 127 Ca oksalat: positif
Ur/Cr: 114/4,5 Sel ragi: positif
Na/K/Cl/Ca:
136/4,6/109/8,6 Lab10/07/2021
HbsAg/AntiHCV/HIV: Hb/L/T : 6,8/6,2/190
negtif MCV/MCH/MCHC : 75/27/36
Diftel : 1/0/1/76/16/6
Swab PCR : negatif HIV : non reaktif
AntiHCV : negative
HbsAg : non reaktif

AGDA
Ph 7,3
Pco2 20,80
PO2 74
HCO3 11,2
Total CO2 11,8
BE -12,6
Saturasi 90,7
Albumin 2,4
Na/K/Cl/Ca : 127/4,2/103/4,2
GDS 103
UR/CR : 156/11,9
2.

3.
4.

5.
 K5B1 K5B2 K5B3 K5B4 K5B5

UROLOGI DPJP SPOT

Zamzam 3 K10 Zamzam 3 K 15 Zamzam 3 kamar 18 Zamzam 3 K20
DPJP:dr.Azzaki Abubakar DPJP : dr. M. Riswan, Sp. PD, DPJP : dr. M. Fuad, Sp.PD DPJP : dr. Islamuddin, SpPD
SpPD-KGEH KHOM KHOM
 Nama: Siti Kaila Nama : Nurtanty Jambak
TTL: 29-05-2001 TTL : 10/ 08/ 1961
CM: 1228088 CM : 98-81-76
Tgl Masuk: 18-07-2021 Tgl Masuk : 08/ 07/ 2021
Ass/ Ass/
Dyspepsia tipe like ulcer dd tipe 1. Cystitis
mixed 2. Anemia Ringan NN ec dd
- penyakit Kronis
TH/ - Occult Bleeding
-Bedrest 3. LBP
- IVFD NaCl 0,9% 20 tpm 4. Dyspepsia tipe like ulcer dd
- IV Lansoprazole 30 mg/12 jam tipe mixed
- Sukralfat syr 3XCI
- Domperidon 3x10mg
Th/
Lab : - Tirah Baring
Hb/L/T : 13,6/9,6/297 - Diet Lunak 1700kkal/ hari
MCV/MCH/MCHC : 88/29/33 - IVFD NaCl 0,9 % 20 gtt/i
Diftel : 4/0/0/55/33/8 - IV Ceftriaxone 2 gram / 24jam
PT/APTT : 1/1,09 - Drip Tramadol 1 amp/ 8jam
UR/CR : 17/0,62 - IV Lansoprazole 30mg/ 12 jam
- IV Ondansetron 4mg/ 8jam
- IV mecobalamin 1 amp/ 8jam
- Paracetamol 3x 500mg
- Lactulac syr 3x 2C
- gabapentin 1x 300mg
- Kaltropen supp 2x1 supp
Lab 08/ 07/ 2021
Hb/ L/ Tr : 11/ 14,5/ 390
MCV/ MCH/ MCHC : 81/ 28/ 34
Diftel : 0/0/0/78/15/7
Alb : 4
Ca: 12,5
GDS: 103
Ur/ cr : 98/ 2
Na/ K/ cl : 129/ 4/
Zamzam 3 K01 Zamzam 3 K02 Zamzam 3 K11
DPJP: dr. Islamuddin, DPJP dr. Desi Salwani DPJP dr. Desi Salwani,
Sp. PD SpPD KGH SpPD KGH
Nama: Meliana Budiman Nama: Teuku Cut Din Nama : Nana Diana
TTL: 01/07/1984 Muska TTl : 05/02/1973
Nama : Nurhayati Binti Ismail
TTL : 11/5/1983 38 thn
CM : 0842865
Tgl Masuk : 13/ 07/ 2021
Ass/
1.Anemia sedang HM ec dd 1.
Penyakit kronik 2. Def fe
Th/
bedrest
Diet MB 1500 kkal/hari
IVFD nacl 0,9% 20 gtt/I
IV omeprazole 40 mg/12 jam
Transfusi PRC
Lab 12/7/2021
Hb/Ht/L/T 7,7/28/5,7/609
MCv/MCH/MCHC 59/16/28
Diftell 2/1/0/55/36/6
MDT anemia Hipokrom
mikrositer, trombositosis
Feritin 13,78
Ur/Cr 18/0,68
Zamzam 3 K12
Dpjp : dr. Desi Salwani,
SpPD-KGH
Nama : M. Hasan AR
CM: 1227027
Nama : Raimah
TTL : 03-8-1966 (54)
CM : 1270803
TM : 17-07-2021
1. Diare kronik ec dd 1. Chron
disease 2. Colitis ulseratif 3. Ca
colorectal 4. Ca rectosigmoid
2. Pneumonia HAP dd infeksi
paru spesifik
3. Hipoalbuminemia berat
4. AKI stage II prerenal
5. Anemia sedang HM ec ss 1.
Penyakit kronis 2. Defisiensi Fe
6. Partial MBO
Th/
Bedrest
Diet sonde 6x200cc
IV Cefepime 1g/8jam
IV Omeprazole 40mg/12 jam
IV Metoclopramid 1
ampul/8jam
Albuminar 25% 100cc/24 jam
Attapulgite
Synbio 2x1
Sucralfat 3XC1
Lab 17-07-2021
Hb/L/T : 8,1/12,2/310
MCV/MCH/MCHC : 68/24/35
Diftel : 1/0/0/86/7/6
PT/APTT 1,3/1,3
Anti HCV NNegatif
HbsAg non reaktif
GDS 108
UR/CR 112/2,1
Na/K/Cl : 142/4,0/122
Raudah 1 K7B2
Nama : Nurjannah
No RM : 1.27.96.70
CM: 1077299 TTL: 24/06/1964 CM : 1190072 Tgl masuk: 09/07/2021 TTL : 01/12/1968
Tgl Masuk:16/07/2021 RM: 0-76-22-57 Tgl Masuk : 16/07/2021 Tgl Masuk : 15/07/2021
Tgl masuk: 27-06-2021
Ass/ Ass/ Ass/ Ass/ Ass/
1. cancer pain ec dd MCL 1. HHD 1. Penurunan Kesadaran 1.PSMBA ec dd/ 1. Anemia sedang HM ec
2. hepatomegaly ec dd 2. APS CCS III post PCI ec.dd - gastropati NSID DD 1. Defisiansi besi 2.
 HCC (2minggu yll) 1. Syok Sepsis - ulkus gaster/ dudenum perdarahan
 Metastase proses 3. AKI stge II ec dd/ 2. Uremic 2. Anemia berat MH ec 2. AUB ec susp mioma
3. ca mammae dextra post contrast induce nefropati enchepalopati dd/ uteri
mastektomi dan 4. gangguan psikotik 3. Stroke - penyakit kronik 3. Hipertensi Stage I
kemoterapi organik 2. Sepsis ec Pneumonia dd - defisiensi besi
4. hipokalemia ringan probable covid 19 3. Bradiaritmia ec AV Th/
Th/ 3. CKD stage V on HD block derajat 2 mobitz 2 -Tirah Baring
Th/ - bedrest regular ec DN 4. CHF NYHA II ec dd/ -diet MII 1700kkal/hari
IV Ceftriaxone 2 gr/24 jam - IVFD NaCl 15gtt 4. Anemia ringan HM ec - HHD - TVFD Nacl 0,9% 20 gtt
IV lansoprazole 30 mg/ 12 - Diet jantung dd - IHD - drip Levofloksasin 750
jam 1700kkal/hari 1. Def. Besi 5. Hipertensi on therapy mg/24 jam
MST 2x10 mg - IVFD clinimix 1 fls/hari 2. PGK 6. AKI stage 3 prerenal - IV Lansoprazole 30,g/24
N. acetilsistein 3x200 mg - Levofloxacin 750/24 4. DM tipe 2 Overweight 7. Hiperkalemia ringan (K jam
Bicnat 3x500 mg - IV meropenem 1 g/8 jam 5,9) - fluimucyl 3x200 mg
KSR 2x600 mg - Drp PCT 1g/8 jam Th -Valsartan 1x80mg
- IV lansoprazole 30mg/12 Bedrest, NGT, Folley Th/ -IV Kalnex 500mg/8 jam
P/ - IV ondansentron 4mg/8j cateter urine - Bedrest -Transfusi PRC s/d Hb >
- Fluimucyl 1x200mg 02 2-4 liter/menit (canule - NGT 10 g/dl
Lab 15/07/2021 - ramipril 1x5 nasal) - IVFD NaCl 0,9%
Hb/Ht/Eri/L/Tr: - atorvastatin 1x40 Diet ginjal 1700 kkal/hari - IV omeprazole 40 mg/12 Lab 15/7/21
12,8/36/4,3/13,7/269 - ISDN k/p (Protein 70g/hari) jam Hb/L/T : 8,2/10,6/409
MCV/MCH/MCHC: - CPG 1x75 IV Ceftriaxone 2g/24jam - IV ondansentron Ht :26
84/30/36 - Risperidon 0,5 (H1) 4mg/8jam MCV/MCH/MCHV:74/23
RDW/MPV:15,9/11,1 - Kalitake 3x1 Drip NE 1amp dalam 50cc - IV Furosemide 20mg/12 /32
Diftel:2/0/0/81/14/3 NaCL 0.9% dengan Dosis jam Diftel : 1/1/0/71/22/5
PT/APTT: 1,13/ 1,26 Lab 16/7/2021 0.03 mEq/KgBB/menit - IV Sulfas atropin 12mg / PT/APTT : 0,9/0,7
Albumin: 3,40 Na/K/Cl : 133/6,6/106 (titrasi dosis) 6jam SGOT/SGPT : 65/69
Kalsium: 18,5 IV lansoprazole - Aminofilin 2x200mg Gds : 118
Natrium: 131 Lab 15/7/2021 30mg/12jam - Cilostazol 1x100mg Ur/Cr : 17/0,80
Kalium: 2,90 Hb/L/Tr : 15/7/210 As. Folat 2x0.4mg - Salbutamol 3x4mg Na/K/Cl : 146/4,20/110
Klorida: 91 Alb : 2,7 Lenal ace 2x169 mg - Kalitake 3x 1sach
GDS: 75 Ur/Cr : 74/2,3 N asetil sistein 3x200mg - Transfusi PRC s/d hb
Ur/ Cr: 59/ 3,40 SC Apidra 3-3-3-3-3-3 10g/dl
Lab 11/7/2021 unit - Balans cairan seimbang
Hb/L/Tr : 8,3/8,1/355 HD regular
NS 74
Malaria – Lab 16/07/2021 Lab 09/07/2021
Tubex 6 Hb/L/T : 10.1/11.7/218 Hb/Ht/E/L/T :
Procalcitonn 10,55 MCV/MCH/MCHC : 6,1/20/4/9,1/323
SGOT/SGPT : 89/59 77/27/38 MCV/MCH/MCHC :
ALP 158 Diftel : 1/1/0/90/6/2 50/15/30
Lab 8/7/2021 SGOT/SGPT : 17/9 Diftel : 6/1/0/68/17/8
Hb/L/Tr : 9,3/7,7/279 Albumin : 3.7 MDT :
NS 79 Ur/Cr: 83/6.3 - eritrosit : hipokrom
Ur/Cr : 100/3,2 Na/K/Cl/Ca: anisopikilositosis, target
Alb 2,5 Ca : 7,3 145/4.1/107/9.5 cell, pencil cell,
Na/K/Cl : 127/4,9/102 fragmentosit, teardrop
Lab 3/7/2021 AGDA - kesimpulan : anemia
Hb/L/Tr : 9,3/7,4/240 PH : 7.4 MH
Mcv/mch/mchc : 75/26/35 PcO2 : 34.8 PT/APTT: 1,07/ 1.0
Diftel : 0/0/0/84/11/5 HCO3 : 24.1 Hbsag/ antiHCV : negatif
Lab 2/7/2021 BE : 0.9 SGOT/SGPT : 17/18
Na/k/cl/ca : Sp02 : 97 % Albumin 3,60
144/5,6/113/8,6 Ur/cr : 125/3,3
Na/K/Cl/Ca:
Lab 29/6/2021 139/5,9/114/8,5
Ur/cr : 92/3,1 GDS 138
Lab 27/06/2021
Hb/L/Tr: 15/15,1/270
Diftel: 0/0/0/77/11/12
GDS 144
Ur/Cr: 64/24
Na/K/Cl: 137/5,2,109