Mapping Aqsa 3 dan titipan, Jumat 16 April 2021

k1b1 K1B2 K1B3 K1B4

DPJP : Dr. dr. Fauzi DPJP : Dr. dr. Azhari DPJP : Dr. dr. Azhari Gani, DPJP : dr. Hendra Zufry,
Yusuf, Sp.PD-KGEH Gani, SpPD, KKV Sp.PD-KKV Sp.Pd-KEMD
Cow: dr. Saddam COW : dr. Malahayati COW : dr. Malahayati COW : dr. Rizqi Aulia
Ruangan: dr. Bayu Ruangan : dr. Ruangan : dr. Rahmat Ruangan : dr. iqbal
Rahmat Zuaidi Zuaidi
Raber : Raber :
Nama :Ainsyah Ismail Nama : Mariana A Nama: Faridah Hanafiah Nama : Lisnamufida
TTL :01/07/1970 Rasyid TTL: 16/02/1958 (63) TTL : 28/10/1972
CM : 1269178 TTL : 10/8/1970 CM: 1116184 CM : 1270688
Tgl Masuk : (50) Tgl masuk: 09/04/2021 JK: Perempuan
14/04/2021 CM : 0967442 Tgl Masuk : 03/4/2021
Tanggal masuk :
30/3/2021
Ass/ Ass/ Ass/ Ass/
1.Asites grade III ec 1.CKD stage 5 dengan 1.Sepsis ec dd/
sirosis hepatis uremic sindrom ec dd a.pneumonia 1. Syok Kardiogenik
dekompensata related 1) PGOI 2) HN 3) PNC b.Urosepsis 2. Acute decompensated
hepatitis B 2.Efusi pleura sinistra 2.Grave disease Heart Failure type wet and
ec dd/ 3.Stroke iskemik dengan warm ec VHD (MR severe,
Th/ a.related HD hemiparese sinistra AR severe)
-Bedresr b.CHF 4.DM tipe 2 Normoweight 3.SLE derajat berat dengan
-Diet hati M II c.Hipoalbuminemia 5. ulkus dekubitus grade II keterlibatan mukokutan,
1200/kal 3.HHD ar gluteal serositis, hematologi,
-IVFD Aminofusin 4.OMI septal musculoskleletal.
hepar 1fls/hr 5.CHF FC NYHA III-IV Th/ 4.Possible Infective
-IV lansoprazole 30 mg ec –IHD –HHD -Bedrest Endocarditis
/ 24 jam 6.Hipoalbuminemia -Diet MB 1700 kkal/hari 5.Pneumonia
-IV furosemide 1 7.ISK -IVFD NaCl 0,9% 20 tpm 6. Efusi pleura sinistra
amp/8 jam 8.Dislipidemia -IV meropenem 1 gr/8 jam minimal dd 1.
-Domperidon 3x10mg 9.CAD -drip furosemide 200 gr/24 Pleuropneumonia 2. Pleuritis
-Spironolacton jam TB 3.Serosepsis
2x200mg Th/ - insulin lantos 0-0-0-12
-Bedrest (pukul 22.00) Th/
-Bedrest semifowler
-O2 nasal kanul 2-4 -IV Omprazole 40 mg/12
-O2 2-4 lpm
lpm jam
-Diet Jantung II 1700
-Diet ginjal 1700 -Proponolol 2 x 10 mg
kkal/hari
kkal / hari, protein 30 -SC Apidra 6-6-6 IU
- IVFD Nacl 0,9 % 10 gtt/i
gr / hari -Burnazin zalf 4 x 1 oles
- IV Ampicilin Sulbactam
-Threeway -paracetamol vial 1 gr
1gr/8 jam (H8)
-IV Easprimer 1 fls / -Dipenhidramin 1 sup IV - IV Gentamicin 80 mg/12
24 jam -Bicnat 500 mg/8 jam jam (H8)
-IV Cefuroxime 750 -Atorvastatin 40 mg/24 jam - IV Lansoprazole 30 mg/24
mg/24 jam -lactulac syr jam
-IV Furosemide 20 -fluconazole 20 mg/24jam - IV Furosemid 20 mg/12 jam
mg/8 jam - Drip norepinefrin mulai
-IV Lansoprazole 30 Lab 12/04/2021 dosis 0,05meq/kgBB titrasi
mg/12 jam Hb/Ht/L/T : Dosis, target MAP ≥ 65
-IV Ondancetron 4 9,5/28/409/15,5 mmHg atau TDS ≥100 mmHg
mg/8 jam MCV/MCH/MCHC : -Asam Folat 2 x 1 tab 0,4mg
-IV Albuminar 25 % 72/25/34 -Lenal Ace 2 x 169 mg
100 cc / 24 jam Diftel : 2/0/1/65/24/8 -Ostriol 2 x 1 tab
-Ciprofloxacin 2 x 500 T4: 44,53 -Methylprednisolon 8mg/12
-CPG 1 x 75 mg TSHs 0,005 jam
-ISDN 3 x 5 mg Na/K/Cl : 141/2,90/104 - myfortic 360 mg/ 12 jam
-Herbesser CD 1 x 100 Ur/Cr 19/0,30 - HCQ 200 mg/24 jam
mg - Spironolakton 25 mg/ 24
-Valsartan 1 x 160 mg Urinalisis (14/04/2021) jam PO
-Bisoprolol 1 x 5 mg Leukosit positif - Simarc 2 mg/ 24 jam Pao
-Flukonazole 1 x 150 Protein +1 - Curcuma 1 tab/ 8 jam PO
mg Glukosa +1 - Lovadin CII/ 8 jam
-Bicnat 3 x 500 mg Nitrit positif - Fosen enem supp ekstra
-Atorvastatin 1 x 20 Darah positif
mg Leukosit 400-500 P/
Eritrosit 80-100
Sel ragi positif - USG Thoraks (Kesan efusi
Echocardiography Bakteri positif pleuraa minilmal)
(07/04/2021) - Kultur darah (tunggu hasil)
-MR mild, AR Biakan urin - Gen Expert (tidak ada
moderate, TR mild (13/04/2021) sputum)
-EF menurun 48% Hasil tidak ada - Balance Cairan
-Disfungsi diastolik, pertumbuhan bakteri - Konsul ICCU
LVH konsentrik
-Hipokinetik dari Lab 12/04/2021 Lab 12/4/2021
apeks-mild lateral Hb/Ht/L/T : Hb/Ht/E/T/L
10/29/147/16,3 9/28/3,2/464/6,7
Lab 07/04/2021 MCV/MCH/MCHC : MCV/MCH/MCHC/RDW/P
Hb/Ht/L/T : 72/25/35 DW
8,3/26/5,8/344 Diftel : 0/0/0/74/18/8 87/28/32/18,4/9,9/9,9
MCV/MCH/MCHC : T4: 40,87 LED: 114
Difftell : 0/0/0/93/43/3
83/26/32 TSHs 0,005
Diftel : Na/K/Cl : 137/3,3/104 Ur/ Cr : 44/0,57
1/1/0/72/11/14 Na/K/Cl : 136/4,3/97
Ca : 7,9 URINALISIS
Ur/Cr : 47/3,6 protein positif 1 Lab 9/4/2021
Na/K/Cl : glukosa positif 2 Bilirubin total : 0,38
135/3,3/102 leukosit positif (100-150 Bilirubin direct : 0,10
LPB) Bilirubin indirect : 0,28
Lab 06/04/2021 darah positif (25-50 LPK) SGOT : 107
Hb/Ht/L/T : sel ragi positif SGPT : 102
8,8/28/6,6/342 bakteri positif
MCV/MCH/MCHC : Lab 3/4/2021
83/26/32 H/Ht/E /L/T
Diftel : Lab 09/04/2021 9,9/30/3,4/5,9/376
1/1/0/77/10/11 Hb/Ht/L/T : MCV/MCH/MCHC 89/29/33
Albumin 2,3 11,8/34/21,4/485 RDW/MPV/PDW
Ca 8,0 MCV/MCH/MCHC : 18,7/9,2/9,7
GDS 204 73/25/35 Diftell 0/1/0/90/7/2
Ur/Cr : 54/3,7 Diftel : 0/0/0/84/10/6
Na/K/Cl : Ca : 9,1 SGOT/SGPT/Abumin
136/3,8/103 GDS : 513 50/57/2,90
Ca : 8,7
Ur/Cr : 34/0,40
Lab 03/04/2021 Na/K/Cl : 130/5,0/91
GDS : 62
Hb/Ht/L/T :
U/K : 37/0,50
8,8/28/8,7/362
Na/K/Cl : 143/4,60/109
MCV/MCH/MCHC :
83/27/32
Diftel :
0/1/0/78/9/12
Ur/Cr : 62/3,5
Na/K/Cl :
140/3,8/108

USG Thorax
02/04/21
-Efusi plura bilateral

Lab 1/4/2021
Kolesterol
Total/HDL/LDL/
Trigliserida:
134/50/67/108

Urinalisa 1/4/2021
MAK
-Leukosit : (+)
-Protein : (+1)
-Darah : (+)
MIK
-Leukosit : 200-250
-Eritrosit : 25-50
-Epitel : 0-1
-Sel ragi : (+)

Ro Thorax AP
(31/12/21)
-Cardiomegaly
-Efusi Pleura kiri
masif

AGDA 31/3/2021
pH : 7,434
pCO2 : 27,80
pO2 : 107
HCO3 : 17,9
Total CO2 : 18,7
BE : -4,6
SaO2 : 78,3

Lab 30/3/2021
Hb/Ht/L/T :
11,4/35/9,6/463
MCV/MCH/MCHC :
80/26/33
Diftel : 0/0/1/83/8/8
HIV : Non Reaktif
Anti HCV/HbsAg :
Negatif /Non Reaktif
SGOT/SGPT : 21/17
Albumin : 2,3
GDS : 110
Ur/Cr : 124/4,0
Na/K/Cl :
134/5,4/107
 K2B1 K2b2 K2b3 K2B4 K2B5
DPJP : dr.M Riswan SPPD DPJP : Prof. Dr. dr. DPJP : dr. Hendra Zufri, Sp.P DPJP: dr. M. Riswan, DPJP : Dr. dr. Azhari Gani,
KHOM Maimun Syukri, Sp. Pd D KEMD SpPD-KHOM Sp.PD-KKV
COW : dr. Saddam KGH- FINASIM COW : dr. Rizqi COW dr. Saddam COW : dr. Malahayati
Ruangan : dr. marcel COW : dr. Ricky Virnando Ruangan : dr. iqbal Ruangan: dr. Marcel Ruangan : dr. Rahmat
Ruangan : Zuaidi
Raber : Raber :
Nama :Wasiyah binti Nama: Yusallia Harun Nama : Fatimah zuhra Nama : Nurbaiti binti Nama: Yuslina Hasan
Thahirin TTL: 05/07/1983 (37 th) TTL : 01-07-1964 (56 th) hasbillah TTL: 04/12/1973 (47)
TTL: 20/07/1980 CM: 1193670 CM : 1057727 TTL : 12/7/1985 CM: 1181280
CM : 1270890 Tgl masuk: 30/03/2021 CM : 1267679 Tgl masuk: 03/04/2021
Tgl masuk : 05/04/2021
Tg masuk : 15-04-2021
Tgl masuk : 07/04/2021

Ass/ Ass/ Ass/ Ass/

1. Sindroma nefrotik Ass/ 1. ITP 1.Penurunan kesadaran
2. Hipokalemia induced by 1. krisis hipoglikemia ec dd (perbaikan) ec dd/
furosemid Th/ a.Uremic encefalophaty
1. Penurunan kesadaran ec -KAD -HHS
3. CHF NYHA III-IV - IVFD NaCL 0,9% 10 gtt b.Sepsis
dd/ 2. DM tipe 2 critical ill
4. Efusi pleura sinistrra ec - diet MB 1700 kkal/hari 2.Sepsis ec dd/
- Lupus serebral 3. aki stg 3 prerenal
dd/-hipoalbuminae, - IV metilprednisolon 125 a.Pneumonia
- Uremic Ensefalopathy
-pleuropneumonia 4. efusi pleura sinstra ec dd mg/12jam b.Urosepsis
2. SLE derifat Berat
5. anemia sedang ec -pleuropneumonia - IV omeprazol 40 mg/12 3.CKD stage 5 on HD ec dd/-
3. HT stage 1
dd/penyakit kronis -pleuritis tb jam HN -PNC
4. Nefritis lupus ec syndrom
nefrotik 5. chf fc nyha 2-3 ec dd - Betahistin 2x1 4. Hipertensi stage 2
Th/ - Calporosis-D 1 tab/12 jam (terkontrol)
-Diet ginjal 1700 kklal + -IHD -HHD -DCM
5. Anemia sedang NN ec PGK
ekstra putih telur 6. hiperkalemia ringan
- drip NTG 3 cc/jam (10 Th/ 7. iskemik lateral
-Bedrest Lab 07/04/21 Th/
mcg/menit) -Bedrest
- drip furosemid 2 cc/jam (20 -02 2-4 L/I via nasal canul Hb/Ht/L/Tr :
-Diet MD 1750 kkal / hari
Th/ -Diet ginjal 1700 kkal/ hari
mg/jam) 12,1/38/13,1/13
- iv ceftriaxone 2 gr/ 24 jam -tirah baring Mcv/Mch/Mchc : 67/22/32 & 1,9 gr protein / kg BB /
- KSR 3x600mg
- iv omeprazole 40 mg / 12 -diet dm mb 1700kkal/hari Diftel ; 4/1/0/69/20/6 hari
- Valsartan 1x160 mg -Threeway
- Spironolactone 1 x 25mg jam + 0,6-0,8 protein/kg/hari LED : 45
- iv ondensetron 8 mg / 24 -02 2-3 l/I nasal kanul PT/APTT : 14,4/35,3 -Drip Furosemid 2cc/jam
- bisoprolol 1 x 5 mg
jam -IV Ceftriaxone 2 gr/24 jam
- Lactulac syr/8 jam -drip novorapid 50 unit
- Valsartan 8 mg / 24 jam -IV Vancomycin 1 gr /12 jam
- Natrium bicarbonat 500mg/8 dilarutkan 49,5cc nacl
jam - iv furosemid 40 mg / 8 jam -SC Heparin 500 mg/12 jam
- fenitoin 100 mg / 8 jam 0,9% dengan dosis 2 -IV Omeprazole 40 mg/12
- IV metilprednisolon unit/jam, titrasi dosis,
125mg/24jam - methyl prednisolon drip 50 jam
cc -iv lansoprazole - omeprzaole drip 80 mg +
-IV ceftriaxone 2g/24 jam - valsartan 16 mg / 24 jam 30mg/24jam NaCl0,5%
-Drip Furosemid 2cc/jam -iv furosemide - drip herbeser 1 amp 50cc
-Omeprazole 40g/12 jam Lab 07/04/2021 20mg/12jam - NTG drip 1 amp + 80 cc
-Albumin 25 100cc/24 jam CRP kualitatif (+) NaCl
-Lactulac syr/8 jam Faktor rheumatoid (-) -Amlodipin 1 x 10 mg
Ureum 277 Lab 15-04-2021
-Tanapres 2,5g/24 jam -Valsartan 1 x 160 mg
Creatinin 4,56 Hb/ht/T/L:10/30/336/9,9 -Flumucyl 3 x 200 mg
-Valsartan 160mg/24 jam
Mcv/mcvh/mchc : - IV meropenem 1 gr/8 jam
- Codein /8 jam
-Drip NTG dosis 5mcg/kgBB Lab 06/04/2021 82/28/34 - Clindamycin 300 mg/8 jam
( kecepatan 3cc/jam ) LED 30 Diftel : 3/0/1/61/29/6 - paracetamol 1000 mg KP
-Bila TDS <100 , drip Albumin/gds: 3,6/642
dobutamin 1vial dalam NaCl Urinalisis Lab 14/04/2021
Ur/cr:113/3,3
0,9% 50cc Kecepatan Warna kuning PT/APTT 1,27/1,03
Keruh Ca : 9,3
3,6cc/jam l Na/k : 136/5,7
-Flumicyl 200mg/8 jam Leukosit (+) Lab 14/04/2021
- Newdiatab/curcuma 2 tab pH 5 AGDA PT/APTT 1,12/0,99
setiap diare protein +2 Ph/pco2/po2 :
-Bicnat 500mg/8 jam darah (+) 7,501/29,10/42 Lab 09 /04/2021
Hco3/total co2 : 25,2/26,2 Hb/Ht/L/T :
P/ Lab 04/04/2021 7,3/21/18,1/216
Hb/Ht/L/T : 7,5 / 20/ 7,6 / 58
BE/saturasi o2 : 3,0/77
- Susul hasil : HbsAg, MCV/MCH/MCHC :
AntiHCV, SGOT/SGPT, MCV/MCH/MCHC : 69 / 25 /
81/29/35
bilirubin total direct indirect, 37
Diftel : 3/1/0/86/5/5
profil lipid , elektrolit, Diftel : 0/0/0/87/4/9
Cr : 7,4
albumin Albumin : 2,5
K/Cl : 4,2/105
- Cek anti DS DNA Ur/Cr : 332/ 4,9
- Echocardiography Na/K/Cl : 132 / 3,7 / 106
Lab 06 /04/2021
- Timbang BB Hb/Ht/L/T : 7,1 / 20 /
- Pantau tensi 12,9 / 104
MCV/MCH/MCHC : 79 / 29 /
Lab 12/04/21 36
LED : 110 Diftel : 6 /1 / 0 / 7 7 / 9 / 7
PT/APTT : 13,7/35,8 Ur/Cr : 349 / 16, 00
RF : positif Na/K/Cl : 140 / 4, 50 / 106
Bilirubin total: 0,05
Protein total : 4,37 Lab 04 /04/2021
Albumin : 1,39 Hb/Ht/L/T : 6,2 / 17 / 11,
Kolesterol total : 450 1 / 116
Kolesterol HDL : 13 MCV/MCH/MCHC : 76 / 28 /
Kolesterol LDL : 328 37
Trigliserida : 426 Diftel : 1 / 1 / 0 / 84 / 8 / 6
Ca : 8,1 Ur/Cr : 311 / 14,60
Na/K/Cl : 143/2,7/107 Na/K/Cl : 144 / 4,60 / 111
Lab 09/04/21
Hb/Ht/E/T/L :
7,6/22/2,6/208/12,2
MCV/MCH/MCHC:
85/29/34
Diftel : 11/1/0/50/36/2
Albumin : 1,70
Ur/Cr : 70/1,70
Ca/Na/K/Cl :
8,5/142/2,90/113

Lab 07/04/21
Hb/Ht/E/T/L :
9,8/29/3,4/595/11,4
MCV/MCH/MCHC/RDW:
86/29/34/16,3
Diftel :
12/1/1/51/33/2

Lab 05/04/21
Hb/Ht/E/T/L :
9,2/27/3,2/500/11,0
Protein tot/albumin :
5,40/1,30
Ca : 8,4
Ur/Cr : 79/1,80
Na/K/Cl : 142/3,50/118
 K3B1 K3b2 K3B4
DPJP : Dr. dr. Fauzi DPJP : dr. M. diah DPJP : dr.T.
Yusuf, Sp.PD-KGEH sp.pd kkv Mamfaluti, Sp.PD
Cow: dr. Saddam Cow : dr. t mirzal COW : dr. Rizqi Aula
Ruangan: dr. Bayu Ruangan : dr. fahri Ruangan : dr. Aidil
Nama : Hamdiah Nama: yusni binti yusuf Nama : Zubaidah binti
binti AhmadTTL : Ttl: 01-07-1961 (59 th) Abdullah
10/12/1962 (58 thn) Cm : 1271984 TTL : 6/08/1997
CM : 1250563 Masuk : 15-04-2021 CM : 1271848
Tgl masuk : 15/04/2021
Ass/ Ass/ Ass/
1. Efusi Pleura Dextra 1. chf fc nyha III ec dd- 1. SLE derajat berat
post wsd ec dd 1. K4B1
IHD -CAD -DCM K4B2 K4b3keterlibatan
dengan K4B4 K4B5
Related Cirrhocis, 2. 2. pneumonia dd inf paru
DPJP : dr.Vera DPJP : dr.T. DPJP :ginjal
Dr. dr. danFauzi
hematologiDPJP : dr. T. DPJP : dr. Hendra
Pleuritis TB Abdullah,spesifik
Sp.PD KPSi Mamfaluti, Sp.PD Yusuf, 2. AKI stage II dd Mamfaluti Sp.PD
Sp.PD-KGEH Zufry, Sp.Pd-KEMD
2. Sirosis Hepatis std
COW : dr. Saddam Emir COW : dr. Rizqi Aula Cow: dr.nefritis
Saddam lupus COW : dr. Rizqi COW : dr. Rizqi
DC Child Pugh B RuanganTh/ : dr. Santun Ruangan : dr. Aidil Ruangan:3. Asites ec DD :
dr. Bayu Ruangan : dr. iqbal Aulia
dengan asites -bedrest - Hipoalbumin Ruangan : dr. iqbal
3. Anemia sedang Nama : Ainsyah -02 2-4li/i
Yusuf Nama : Kasmawati -Sirosis Hepatis
Nama:Mehram Abdul Nama : Nur binti Nama : Kasmiah
(perbaikan) HM ec TTL dd 1. : 31/12/1938
-threeway TTL : 01/07/1969 rani -TB Peritoneal Sulaiman binti tgk ccut ahmad
Penyakit kronik 2. CM : 1268370 -iv ceftriaxone CM : 1270896 -CHF
TTL:01/07/1940 No. RM : 1-05-27- TTL : 12-12-1962(58
Perdarahan Tgl masuk 2gr/24jam
: 02/04/2021 Tgl masuk : 06/04/2021 4. HT stage 2
Tgl msk:15/04/2021 36 th)
4. DM Tipe 2 -iv furosemide 5.Hiperkalemia TTL : 03-01-1959 CM : 0964302
20mg/8jam Tgl masuk : 10-04- Tgl Masuk :
Th/ -iv lansoprazole 30 Th/ 2021 15/04/2021
- Bedrest Ass/ mg.12jam Ass/ Ass/ - Bed rest Ass/ Ass/
- Diet Hati II 1700 1. Post covid -Atorvastatin
19 1x40mg1. Pneumonia -O2 2-4ec dd
1.leukositosis
kkal/hari 2. Sepsis -spironolakton
ec dd 1x25mg
2. PSMBA ec dd: - CML - Diet MB 1700 1. penurunan kesadaran 1. obs febris ec dd
- IVFD NaCl 0,9% 10- Pneumonia -n asetilsistein3x200mg - Ulcus gaster -CLL kkal/hari ec. Dd. -ulkus dm pedis -isk
gtt/i -cpg 1x75mg
- Urosepsis - Gastritis Erosif 2.Anemia- Threeway
berat 1)SDA, -pneumonia
- IVFD Aminofusin3. CKD stage -nebule Ventolin 1
V ecdd - Stress ulcernemia - IV ec
Makrositer ceftriaxon
dd 2) Stroke, 2. ulkus dm pedis
Hepar 1 fls/hari - HN rep/8jam 3. Anemia sedang ec 2gr/24jam
-As folat 3) sepsis sinistra
- IV Lansoprazole 30 - PNC dd: - IVkronik
-penyakit Omeprazole 40 mg /
2. SDA dengan pencetus 3. seulitis pedis
mg/24 jam 4. AnemiaLab 15/04/2021
sedangec PGK - Perdarahan 12 jam infeksi sinistra dd dvt
- IV Furosemide 5. Efusi Pleura Hb/ht/L/T :
Bilateral - Penyakit kronis Th/ - Drip Metilprednisolon 3. dd/ Pneumonia 4. dm tipe 2 obese gr 1
20mg/12 jam 6. Pneumonia 14,6/43/12,9/183
dd infeksi 4. OA genue bilateral 250mg/12jam
-lansoprazole 4. LBP dengan radikular 5. hipertensi stg 1
- Lactulate syr 3xCIIparu spesifikMcv/mch/mchc : 5. DM tipe 2 - Kalitake 3x1
30mg/12jam pain ec spinal stenosis 6. dd -hhs -kad
- Spironolakton 2x1007. 95/32/34 -curcuma- Nebul
3x1 Venitoin 5. Autosomal functional
mg Diftell : 0/1/0/78/13/8Th/
Hipoalbuminemia(perbaika (Ekstra) thyroid dd/ grave disease Th/
- Paracetamol 3x1000 n) Alb/gds: 2,8/130 - Bed rest Lab 15/04/2021 6. Trombositopenia ec. -bedrest
mg Ur/cr : 42/0,90 - Diet DM 1700 Hb/L/T Dd/ 1) viral infection -iv ceftriaxone 2gr
- IV Ondansetron 4Th/ mg/8 Na/k/cl : 138/4,1/107 kkal/hari Lab 15/4/2021
4,7/289,9/60 2) gangguan koagulasi /24jam
jam -Bedrest - IV meropenem 2 gr/8 Hb/Ht/L/T/E :
MCV/MCH/MCHC 3) Consumption -iv lansoprazole
- Cetirizine 10mg/12 -DietjamGinjal 1500 kkal/hari jam 7,4/21/2,6/143/2,6 Coagulophaty
144/36/25 30mg/24jam
- Novorapid 10-10-10 - IV levofloxacin 750 - IV Pantoprazole 40 mg Diftel MCV/MCH/MCHC : 7. Geriatri problem -iv parasetamol
unit mg/24 jam / 24 jam 80/28/35
0/0/01/97/2 (immobilisasi, 1gr/8jam
- HD rabu dan sabtu - Drip prosogan Ur/cr RDW/PDW: instabilitas dan jatuh, -drip novorapid 50 unit
- IV Lansoprazole 30 - paracetamol 2 x 1000 39/0,7015,7/10,2 infeksi, inanfagi) + 50cc nacl 0,9%via
Lab 15/04/2021 mg/12 jam mg Diftel : 2/0/0/66/19/13
Na/K/cl/Ca syring pump 3cc/jam
Hb/Ht/E/L/T -Lenal ace 169 mg/12 jam - Sucralfat syr 3 xCII Albumin : 2,10
145/4,10/112 Th/ -clindamisin 3x300mg
10,2/30/4,0/4,4/136-LactulacSyr 3Xci - Lactulosa syr 3x CII Albumin Ca4,2: 7,2 - Bedrest -valsartan 1x80mg
MCV/MCH/MCHC- AsamFolat 0,4 mg / 12 -fossen enema (k/p) Na/K/Cl : 145/5,80/124
SGOT/SGPT - O2 2-4 lpm
74/26/35 jam 12/12 Ur/Cr: 162/2,70 - IVFD Dextrose 5% 20 Lab 15/04/2021
RDW/MPV/PDW - Flumuycil 3 x 200 mg Lab 13/4/2021 GDS
Bil tot/bil : 114
dir/indire gtt/i Hb/ht/L/T :
18/9,2/9,9 - Levofloxacin 750 mg/24 Hb/Ht/L/T/E : 1,11/0,34/0,77 - NGT kateter 11,9/34/22,0/400
jam
Diftel : E/B/NB/NS/L/M 6,7/20/12,8/167/2,6 - Diet Sonde 6x200 cc Mcv/mch/mchc :
2/1/0/58/25/14 -IV Albumin 25% MCV/MCH/MCHC : via NGT 79/28/35
Albumin : 2,90 100cc/24 jam 77/26/34 - Na Diklofenak Diftel : 0/1/0/78/14/7
-Cetirizine 10 mg/12 jam RDW/PDW: 50mg/12 jam Alb/gds : 3,8/637
Lab 12/04/2021 -Fosen enema 1 supp 18,5/12,1 - Omeprazole 20 mg/12 Ur/cr : 31/1,2
Hb/Ht/E/T/L -Eparison 3x50 mg Diftel : 2/1/0/67/22/8 jam Ca : 9,3
8,1/25/3,4/155/4,6 - Paracetamol 3x500 mg - KSR 600mg/12 jam Na/k/cl : 134/4,0/96
MCV/MCH/MCHC Lab 10/4/2021 - Mekobalamin
74/24/33 P/ Hb/Ht/L/T/E : 500mg/12 jam
Pantau hemodinamik
Diftel : 6/1/0/57/24/12 7,0/22/24,1/261/3,0 - Gabapentin 300mg/12
Albumin : 2,27 - Balance cairan MCV/MCH/MCHC : jam
Kalsium : 7,8 73/23/32 - Paracetamol 1gr/ 8 jam
Ur/Cr Lab 09/04/2021 RDW/PDW: - meropenem 1gr/12 jam
78/1,46 Hb/L/T: 7,7/7,3/139 19,4/11,8
Na/K/Cl MCV/MCH/MCHC : Diftel : 5/0/0/82/10/8 P/
128/5,5/96 78/26/34 Albumin : 3,00 - KGDP/hari
Diftel : 0/1/0/70/14/15 Ca : 7,7 - KGDs/ 2 jam
INR/APTT: 1,14/1,29
Analisis cairan pleura Na/K/Cl : 133/4,0/106 - urinalisa
06/04/2021 Albumin : 2,78 Ur/Cr : 50/0,70 - kultur urin+STAB
Warna : kuning Ur/Cr : 102/4,27 INR : 1.05 - DR/ 3 hari
Jernih Ca : 8,7 APTT : 26,20 - kultur darah + STAB
Bekuan (-) Na/K/Cl : 137/3,8/103 - MDT
PMN 19 Lab 09/4/2021
MN 81 Lab 04/04/2021 Tinja Rutin Lab 14/4/2021
Leukosit 99 Hb/Ht/E/L/T : Warna: coklat kehitaman Imunoserologi
Total protein1,7 7,3/22/2,8/198 Mikroskopik : Tiroid
Albumin 0,7 MCV/MCH/MCHC : Eritrosit : Negatif FT4: 14,31
Glukosa 345 80/26/33 Leukosit : Negatif Sepsis
Lab 03/04/2021 Difel : 0/0/0/66/19/15 Telur Cacing : Negatif Prokalsitonin: 15,64
Hb/Ht/L/T : PT/APTT: 16,10/71,20 Parasit : Negatif
9,3/29/4,5/130 Albumin : 2,60 Konsistensi : Lunak Lab 13/4/2021
MCV/MCH/MCHCUr/Cr : : 114/4,30 Hb/Ht/E/L/T
75/24/33 Ca : 8,4 Lab 07/4/2021 10,3/29/3,5/17,6/96
Bilirubin
total/direct/indirect :
0,89/0,34/0,55
Na/K/Cl : 135/3,80/103 Urinalisis MCV/MCH/MCHC/RD
Warna:kuning W/PDW/MPV
Lab 01/04/2021 keruh 85/30/35/14,3/14,1/11,4
Hb/Ht/E/T/L : Berat jenis: 1,019 Difftell : 0/0/0/95/2/3
8,2/25/3,1/237/4,5 pH: 6,0
MCV/MCH/MCHC : Leukosit:+ Lab 12/4/2021
80/27/33 Protein: - Imunoserologi
Difel: 1/1/0/62/22/14 Glukosa: +2 Tiroid
Ca/Mg : 8,0/1,5 Keton, nitrit: - T3 total: 2,20
Ur/Cr : 109/4,20 Urobilinogen: + T4 total: 88,44
Na/K/Cl: 135/3,70/103 Bilirubin - TSHs: 0,084
Darah:+
Leukosit: 10-25 Na/K/Cl: 134/4,00/103
Eritrosit: 5-10
Epitel: 0-1 Lab 09/4/2021
Hb/Ht/E/L/T
Lab 06/04/2021 11,6/34/3,9/21,6/163
Hb/Ht/L/T : MCV/MCH/MCHC/RD
5,8/18/36,9/260 W/PDW/MPV
MCV/MCH/MCHC : 87/30/35/13,8/9,4/10,3
73/24/33 Difftell : 0/1/0/93/2/4
Diftel : 0/0/1/85/5/9 GDS: 166
PT/APTT: 14,80/26,00 Ur/Cr: 64/0,9
Na/K/Cl: 137/3,2/106

Lab 05/04/2021
Hb/Ht/L/T :
6,4/20/41,1/295
MCV/MCH/MCHC :
73/24/33
Diftel : 0/0/1/85/6/8
Anti HCV: -
HBsAg: non reaktif
Albumin : 3,10
Ca: 8,4
GDS: 242
Ur/Cr: 44/0,60
Na/K/Cl : 133/3,90/104

Lab 06/04/2021
Hb/Ht/L/T :
5,8/18/36,9/260
MCV/MCH/MCHC :
73/24/33
Diftel : 0/0/1/85/5/9
PT: 14,80
INR: 1,05
APTT: 26,00
 K5B1 K5B2 K5B3 K5B4 K5B5
DPJP : dr.Vera Abdullah, DPJP : Dr. dr. Azhari Gani, DPJP : Dr. dr. Azhari Gani, DPJP : dr.T. Mamfaluti, DPJP : dr.T. Mamfaluti,
Sp.PD KPSi Sp.PD-KKV Sp.PD-KKV Sp.PD Sp.PD
COW : dr. Saddam Emir COW : dr. Malahayati COW : dr. Malahayati COW : dr. Rizqi Aula COW : dr. Rizqi Aula
Ruangan : dr. Santun Ruangan : dr. Rahmat Ruangan : dr. Rahmat Ruangan : dr. Aidil Ruangan : dr. Aidil
Zuaidi Zuaidi
Raber : Raber :

Nama : Nova Mastura Nama: Yuslavia binti
TTL : 17/11/1991 Sahyanuddin
CM : 0991298 TTL: 05-05-1976
Tgl masuk : 16/04/2021 CM: 1271563
Tgl masuk: 11/04/2021
Nama: Cut Ritazahrafona Nama : Maulina Nama : Nurbaiti Jamil
TTL: 11-12-1982 TTL : 12/11/1987 TTL : 01/07/1969
CM: 1271586 CM : 0978728 CM : 1218639
Tgl masuk: 12/04/2021 Tgl masuk : 12/04/2021 Tgl masuk : 12/04/2021

Ass/ Ass/ Ass/ Ass/ Ass/

1.CKD stage V on CAPD 1.Massa Intraabdomen ec 1. SLE derajat berat dengan 1. Dispepsia tipe like 1. CKD Stage V
2.Dyspepsia type like dd/ 1.Ca gaster 2.ca colon keterlibatan ginjal, ulcer dd tipe mixed dengan edem paru
2. UAP dd STEMI akut
ulcer ec dd type mixed transversa 3.ca omentum hematologi, kelainan
3. Anemia Ringan 2. DM tipe II
3.Hipertensi on terapi 4.limfoma hodgkin muskulosketal dan HM on dd 3. Hipertensi stage II
2. Asites ec dd 1. Malignancy mucokutan - Defesiensi Fe Th/
Th/ proces 2.TB peritoneal - Perdarahan - Bed rest
-bedrest 3. Efusi pleura sinistra ec 2. Efusi pleura sinistra ec dd - Threeway
-Diet ginjal 1700 dd/ 1.pleuropneumonia 1.serositis Th/ - Levofloxacin 500mg/24 jam
- Bed rest - IV ceftriaxon 2gr/24jam
kkal/hari 2.pleuritis TB 3.malignancy 2.pleuropneumonia
- Diet MB 1700 kkal/hari -Aspilet1x80mg
-lansoprazole proses 4. Limfoma hodgkin 3.pleuritis TB - IVFD NaCl 0,9% 20 gtt/i - CPG 1x75 mg
30mg/12jam 4. limfadenopati ar inguinal 4.Hipoalbuminemia - IV Ondasetron 4 mg /8 jam -Drip Insulin Novorapid 50
-ondansetron ec dd/1. Malignancy proces - IV Omeprazole 40 mg / 12 unit daam 50 cc NaCl 0,9%
4mg/12jam 2. Limfoma hodgkin 3. Nefritis lupus kelas III-IV jam - Asam Folat 2x0,4 mg
-sucralfat 3xcll 3.limfadenitis dd/sindroma nefrotik - Sucralfat syr 3 xCII - RenalAce 2x1
-lenal ace 2x169 mg - Clopidogrel 1x75 mg - Gabapentin 1x300mg
4. Hipoalbuminemia ec
- ISDN 3x5mg (malam)
As folat 0,4/12jam Th/ Renal loss -Atorvastatin 1x20mg - Drip Fluconazole
-levofloxacin 500 -Bedrest 5. Anemia NN ec dd - KSR 1x600mg 100mg/24jam
mg/24jam - O2 2-4L 1.perdarahan 2.penyakit
-paracetamol 1gr/8jam -Diet MB 1700 kkal/hari kronis Lab 14/4/2021 Lab 14/4/2021
KSR 600 mg/8jam -Threeway 6. AKI stage II prerenal Urinalisis Urinalisis
-valsartan /24jam Warna:kuning Warna:kuning
- IV Ceftriaxone 2gr/24 jam 7. ISK asimptomatis
keruh keruh
- IV lansoprazole 30 mg/12 Berat jenis: 1,028 Berat jenis: 1,015
jam Th/ pH: 5,0 pH: 5,0
Lab 16/04/2021 - Domperidon tab 3 x 10 mg -Bedrest Leukosit:- Leukosit:+
Hb/L/T - coditon tab 3x1 -Diet MB 1700 kkal/hari Protein: - Protein: +2
13,5/8,8/127 - furosemid 1 amp/12 jam -IV ceftriaxone 2 gr/24jam Glukosa: - Glukosa: +1
MCV/MCH/MCHC - spironolacton 100 gr/24 -IV Furosemid 40 mg/8jam Keton: + Keton: +
82/29/36 Urobilinogen: - Urobilinogen: -
jam PO -Valsartan 1x80 mg Bilirubin : + Bilirubin : -
Diftel - curcuma 1 tab/12 jam -Bicnat 3 x 500 mg Darah:+ Darah:-
2/1/0/76/15/6 -Flumucyl 3 x 200 mg Leukosit: 0-2 Leukosit: 5-10
Albumin:3,70 USG (14/04/2021) -attalpugit 2 tab/8jam Eritrosit: 25-50 Eritrosit: 0-2
Na/K/Cl/Ca Kesimpulan: tampak asites - albuminar 25% 100cc/24 Epitel: 0-1 Epitel: 1-3
136/2,40/96/9,6 dan efusi pleura jam Bakteri : + Sel Ragi : +
Bakteri : +
Kesan: asites non sianotik -methylprednisolone 250
mg/12 jam Lab 12/04/2021 Tinja Rutin :
FNAB (13-04-2021 - Lenal ace 169/12 jam Troponinn T : <0,04 Makroskopik :
CA 125 5876 U/mL -As.folat 0,4 mg/12 jam Kolesterol Total : 187 Warna : Kuning
-ostriol 0,25 mg/12 jam Kolesterol HDL : 67 Bau : Khas
Urinalisa 13/04/2021 - hidrochloroquin 200 Kolesterol LDL : 124
Warna kuning kemerahan Trigliserida : 52 Mikroskopik :
mg/24 jam
Eritrosit : Negatif
Leukosit positif - IV omeprazole 40 mg/12 Lab 11/04/2021 Leukosit : Negatif
Protein +1 jam Hb/Ht/E/L/T : Telur Cacing : Negatif
Darah positif 10/32/4,7/8,6/372 Parasit : Negatif
Leukosit 25-50 LPB Analisa cairan pleura MCV/MCH/MCHC : Konsistensi : Lunak
Eritrosit 300-400 LPB (13/04/2021) 67/21/32
Sel ragi positif Diftel : 3/1/0/76/14/6 Lab 13/4/2021
Warna kuning
CK-MB :6
Bakteri positif Kejernihan jernih TROPONIN T : 0,04
Bekuan negatif
Lab 11/04/2021 PMN sel 10%
Hb/Ht/L/T : MN sel 90% Lab 12/4/2021
12,1/35/522/11,7 Leukosit 32/mm3 Hb/Ht/L/T/E :
MCV/MCH/MCHC : 9,8/30/20/287/3,5
Protein total 1,2
76/26/34 MCV/MCH/MCHC : 85/28/33
Diftel : 3/1/0/69/18/9 Albumin 0,5 g/dL RDW/PDW:
PT/APTT 0,94/0,84 Glukosa 135 mg/dL 12,8/12,8
Anti HCV negatif Diftel : 0/1/0/87/7/5
HbsAg non reaktif Lab (12/04/2021) Albumin : 3,70
Bilirubin total 0,9 Hb/Ht/L/T : Ca : 9,6
Bilirubin direct 0,31 6,6/21/8,7/311 Na/K/Cl : 139/5,5/
Bilirubin indirect 0,59 MCV/MCH/MCHC : Ur/Cr : 152/7,5
SGOT/SGPT38/9 83/27/32 GDS : 399
Protein total 7,3 Diftel : 0/0/0/76/19/5
Albumin 3,5 Anti HCV negatif pH : 7,444
Globulin 3,8 HbsAg non reaktif pCO2: 31,20
Ca 9,7 SGOT/SGPT 47/26 pO2 : 67
GDS 109 Protein total 4,70 HCO3 : 21,6
Ur/Cr 38/1,0 Albumin 1,4 Total CO2 : 22,5
Na/K/Cl 141/3,7/92 Globulin 3,3 BE : -0,9
Ca 7,4 SpO2 : 92,8%
GDS 102
Ur/Cr 116/2,80 Lab 07/4/2021
Na/K/Cl 145/4,4/125 Urinalisis
Warna:kuning
URINALISIS 12/04/2021 keruh
Leukosit postif (100-150 Berat jenis: 1,019
LPB) pH: 6,0
Nitrit positif Leukosit:+
Darah positif (50-60 LPB) Protein: -
Hyalin cast positif Glukosa: +2
bakteri positif Keton, nitrit: -
Urobilinogen: +
Bilirubin -
Darah:+
Leukosit: 10-25
Eritrosit: 5-10
Epitel: 0-1

Lab 07/04/2021
Hb/Ht/E/L/T :
9,8/30/3,6/8,4/248
MCV/MCH/MCHC : 85/28/33
Diftel : 10/1/0/55/27/7
Albumin : 3,2
Ca: 8,9
Ur/Cr: 122/6,2
Na/K/Cl : 145/4,3/108

Lab 04/04/2021
Hb/Ht/E/L/T :
10/31/3,6/8,0/240
MCV/MCH/MCHC : 86/28/32
Diftel : 12/1/0/48/32/7
Albumin : 3,2
Ca: 9
Ur/Cr: 166/8,7
Na/K/Cl : 144/4,70/107

Lab 24/03/2021
Urinalisis
Warna:kuning muda
Kejernihan : keruh
Berat jenis: 1,013
pH: 5,0
Leukosit:+
Protein: +2
Glukosa: -
Keton, nitrit: -
Urobilinogen: -
Bilirubin -
Darah:+
Leukosit: 25-50
Eritrosit: 25-50
Sel Rag : +
Bakteri : +
 Aqsa 1 K4B2 Aqsa 1 k7b2 Aqsa 2 K4B1 AQSA 2 K2B5 Nabawi K4B1
DPJP : Dr. dr. Fauzi Yusuf, DPJP : Dr. dr. Fauzi Yusuf, DPJP : dr. Hendra Zufri, S DPJP: dr. M. Riswan, DPJP : dr. Hendra Zufry,
Sp.PD-KGEH Sp.PD-KGEH p.PD KEMD SpPD-KHOM Sp.Pd-KEMD
Cow: dr. Saddam Cow: dr. Saddam COW : dr. Rizqi COW dr. Saddam COW : dr. Rizqi Aulia
Ruangan: dr. Bayu Ruangan: dr. Bayu Ruangan : dr. iqbal Ruangan: dr. Marcel Ruangan : dr. iqbal

Nama: Azhari bin A Nama : Julhanip Nama : Hasan Basri Nama : Qadri Muhammad Nama : Tursina binti Rusli
Rahman TTL : 15/07/1960 No. RM : 1-27-12-94 TTL : 17/02/1996 No. Rm 1-27-10-42
TTL: 6/2/1962 (59 thn) CM : 1103023 TTL : 28-08-1970 CM : 1270310 Jk : perempuan
CM: 1269393 Tgl masuk : 08-04-2021 Tgl masuk : 14/04/2021 TL : 17-04-1975
Tgl masuk: Umur : 45 th 11 bln

Ass/ Ass/ Ass/ Ass/ Ass/

1. Adenocarsinoma paru 1.Kolelitiasis dengan
kanan metastase hepar 1.Cholelithiasis dengan 1. Abses a/r femur dextra kolesisitis 1. CKD Stage V ec PNC on HD
2.Cancer Pain cholesistitis 2. DM tipe 2 2. Dyspepsia tipe like ulcer reguler
3.Sindroma vena cava 2.Kista hepar 3. Hiperkalemia ringan 2. ISK
superior (5,5 Th/ 3. Hipertensi terkontrol
4.Pneumonia dd TB paru Th/ 4. Hipoalbumin ec. Dd 1) -Diet rendah lemak 4. DM tipe II Normoweight
5.Hepatomegali ec metastase -Bedrest Renal loss, 2) GI loss - IVFD RL 20 gtt 5. Hiperkalemia ringan
proses -Diethati II 1700kkal/hr 5. AKI Stage II prerenal - IV Cefoperazime sulbactam
6.konstipasi rendah lemak 4 gr/12 jam Th/
-IVFD NaCl 0,9% 20tpm Th/ - IV ondansentron 4 mg/8 - Bedrest
Th/ -IV prosogan 30mg/24 jam - Bedrest jam - Three way
1. Bedrest -iV cefoperazin 1g/12jam - Diet DM 1700 kkal/hari - IV lansoprazole 20mg/12 - Diet Ginjal 1700 kkal/ hari
2. Diet hati M II 1700 -UDCA 2x250ng - IVFD Nacl 0,9% 20 gtt/i jam - IV ceftriaxone 2 g/ 24 jam
kkal/hari -curcuma 3x1 - Drip Novorapid 50 ml - Sucralfat syr 3 x CII (H9)
3. IVFD Aminofusin Hepar 1 dalam 50 cc NaCl 0,9m% - sistenol 3x1 - IV Furosemid 20 mg/ 24 jam
fls/hari Lab 09/04/2021 3 cc/jam - UDCA 3 x 500 mg - IV Omeprazole 40 mg/ 12 jam
4. IVFD NaCl 0,9% 30 tpm Hb/Ht/E/T/L - Target KGS < 200 mg/dL - Atapulgit - Lenal ace 2x169 mg
5. IV Cefoperazine Sulbactam 12,7/37/5,1/385/16,1 - Kalitake 2 csht/ 8 jam - Kaltrofen Supp k/p - Asam folat 2x1 tab
1gr/8jam MCV/MCH/MCHC - Paracetamol 500 mg/ 8 - Valsartan 80 mg/ 24 jam PO
6. IV Lansoprazole 30mg/12 72/25/34 jam - Amlodipin 1x10 mg
P/
jam RDW/MPV/PEW/LED - N. Asetylcystein 3x - Paracetamol 1gr/ 12 jam PO
- MRCP tgl 22/04/2021
7. Lactulosa syr 3xCII 15,5/8,5/8,7/42 200mg - Domperidon 10 mg/8 jam
- Amilase, lipase
8. Kaltropen supp /6jam Diftel : E/B/NB/NS/L/M
- Alkali fosfatase
9. Metilprednisolon 3 x 16 mg 7/0/0/70/17/6 P/
- Cek ulang DR , SGOT/SGPT,
10. IV Furosemid 20 mg/12 PT/APTT : 0,98/0,97 - KGDP/Jam P/
bilirubin total, direct, dan
jam Anti HCV negatif - Balance cairan Kultur urin (susul hasil)
11. IV Ondansentron 4 HBsAG non reaktif indirect
mg/8jam Bil.total/bil.direvct/bil.indirect Lab 14/4/2021 Lab 13/4/2021
12. MST 2x15 mg 2,01/1,76/0,25 Hb/Ht/E/L/T Asam Urat: 5,2
13.SC heparin 3000mg/12jam SGOT/SGPT 9,7/28/3,5/500/7,9 Lab 05/04/2021
13. Drip Nacl 3% lfs extra 42/41 MCV/MCH/MCHC/RDW/ Hb/Ht/T/L : Lab 13/4/2021
ALP : 340 MPV 14,2/39/427/11,4 Hb/Ht/E/L/T
Lab 06/04/2021 GDS 83 81/28/34/13,1/8,5/9,1 MCV/MCH/MCHC : 7,8/21/2,9/8,9/318
Kalsium : 8,1 Ur/cr/as.urat Difftell : 0/1/0/88/10/1 86/31/37 MCV/MCH/MCHC/RDW/
Na/K/Cl 25/0,85/4,7 Diftel : 0/0/0/77/1/8 MPV
129/3,50/94 Lab 8/4/2021 Bil tot/D/I : 7,76/5,46/2,30 73/27/37
Urinalisis Hb/Ht/E/L/T SGOT/SGPT : 258/330 Difftell : 2/0/0/80/12/6
Lab 4/4/2021 Warna kuning 9,2/28/3,4/11,7/550 Ur/Cr: 16/1 Ur/cr: 79/3,9
Hb/Ht/T/L : 12,7/34/172/11,4 Jernih MCV/MCH/MCHC/RDW/ Na/K/Cl: 129/3,9/99/
MCV/MCH/MCHC : Berat jrnis 1,017 MPV Ca: 8,1
84/32/38 pH 6 82/27/33/13/9,1/8,8
PT/APTT : 0,8/1,03 Urobilinogen (+) Difftell : 4/1/0/59/25/11
Ur/Cr : 88/0,70 Granular cast (+) Ur/Cr: 50/2,4 Urinalisis 14/4/2021
Na/K/Cl : 118/4,00/80 Hyalin cast(+) Na/K/Cl: 139/5,5/108 Warna : kuning
Protein (-) Kejernihan : keruh
Darah (-) Lab 8/4/2021 Berat jenis : 1,008
Lab 2/4/2021 Keton(-) Hb/Ht/E/L/T pH : 5,0
PT/APTT : 0,9/0,8 Leukosit(-) 9,7/29/3,6/9,9/477 Lekosit : +
Glukosa(-) MCV/MCH/MCHC/RDW/ Protein : +1
Lab 1/4/2021 Nitrit(-) MPV Glukosa : -
PT/APTT : 13,9/32,2 Bilirubin(-) 81/27/34/13,1/9,8/9,2 Keton : -
Difftell : 5/1/0/69/16/9 Nitrit : -
Lab 31/3/2021 Urobilinogen : -
Hb/Ht/T/L : 12,9/36/265/8,7 FAAL HEMOSTASIS Bilirubin : -
MCV/MCH/MCHC : Waktu perdarahan : 2 Darah : +
83/30/36 Waktu pembekuan : 7 Leukosit : 100-150
LED : 24 Albumin 2,80 Eritrosit : 700-800
Diftel : 0/0/0/72/18/10 Gds : 434 Epitel : 0-1
Retikulosit : 2,1 Ur/Cr : 87/3,00 Ca oksalat : +
PT/APTT : 0 86/0,97 Na : 132 Sel ragi : +
LDH : 774 K : 6,10 Bakteri : +
Cl : 103
CT Scan Thorax dan Lab 12/4/2021
Abdomen 29/3/2021 Ca : 8,1
- Nodul di tiroid kanan kiri Ur/ Cr : 105/4,67
- Massa paru kanan sentral Na/K/Cl : 123/4,3/94
dengan TB paru, metastasis
paru dan efusi pleura kanan Urinalisis 12/4/2021
kiri Warna : kuning
- Limfadenopati paratrakea Kejernihan : keruh
dan subkarina Berat jenis : 1,008
- Metastasis hepar dengan pH : 6,0
hepatomegali Lekosit : +
- Kista ginjal kiri Protein : +1
- Aortakalsifikasi Glukosa : -
- Asites minimal Keton : -
Nitrit : -
Lab 26/3/2021 Urobilinogen : -
Na/K/Cl/Ca : 122/4,6/92/8,3 Bilirubin : -
Darah : +
Lab 24/3/2021 Leukosit : 25-50
Fosfatase alkali : 392 Eritrosit : 2-5
Epitel : 0-1

Lab 10/4/2021
Hb/Ht/E/T/L
8,7/24/3,2/367/8,6
MCV/MCH/MCHC/RDW/PDW
75/27/36/13,6/9,8
Difftell : 1/4/0/74/16/5
Anti HCV : negatif
Albumin 3,40
Ca 8,9
Ur/ Cr : 142/5,10
Na/K/Cl : 126/5,50/99

Lab 8/4/2021
HIV non reaktif
Ca : 8,8
Na/K/Cl : 130/ 5,70/ 101

Lab 7/4/2021
Hb/Ht/E/T/L
9,2/26/3,4/449/11,6
MCV/MCH/MCHC/RDW/MPV
76/27/35/14,2/9,4/10,2
Difftell : 1/0/0/79/14/6
Anti HCV : negatif
HBsAg : Non reaktif
Albumin 3,40
Ca 8,9
GDS 101
Ur/ Cr : 147/5,60
Na/K/Cl : 127, 6,20/102
 Arafah 3 K 7E Pinere K 2/2 Shafa K1B2
DPJP : dr.Vera Dpjp: dr. Siti Dpjp: dr. Vera,
Abdullah, Sp.PD Adewiyah, Sp.PD Sp.Pd-Kpsi
KPSi Cow: dr. Rizqi Cow: dr. Saddam
COW : dr. Saddam Ruangan: dr. Iqbal Emir
Emir Ruangan: dr. Santun
Ruangan : dr. Santun
Nama : Suwaibah Nama: Rosmiana Nama: Samsidar binti
Ismail CM: 0953572 Nyak Adam
TTL : 13/02/1983 TTL: 3/4/1957 TTL: 28/03/1980
CM : 1259618 Tgl masuk: Cm: 0980537
Tgl masuk : 02/04/2021 6/4/2021 Tgl masuk: 28/3/2021
Ass/ Ass/ Ass/
1.pre leukemia tipe 1. Covid 19 confirmed 1.CKD stage V dengan
mielositik fase uremic sindromec
2.pneumonia HAP 2. Selulitis cruris dextra -PNC
3.hipokalemia sedang 3. AF NVR -HN
4. CAD post PCI -DN
Th/ 5. HHD 2.Pneumonia HAP
6. DM tipe 2 3.Anemia beratec
-Bedrest
7. Mikrotrombosis -PGK
-IVFD NaCl 0,9% 20 sistemik -Perdarahan
gtt/m 4.Post PSMBA ec
- Paracetamol 500 mg/ Th: -Uremic bledding
8 jam Ivfd NaCl 0,9% 20 -stress ulcer
- Transfusi PRC s/d ≥ GTT -Ulkusgaster
Iv ceftriaxon 2 gr/24 -Ulkus duodenum
10 gr/dl jam
- KRS 1x600 mg Paracetamol 1 gr/8 jam
-Levofloksasin 500 Iv furosemid 20 mg/12 Th
mg/24 jam iv jam Bed rest
-Transamin 1000 Iv ondansentron 4 mg/8 O2 2-4 lpm
jam Diet sondeginjal NGT
gr/8jam iv
Iv Ranitidin 1 amp/12 6X200 cc/ hari +
-Lactulosa CI/8 jam PO jam protein 1gr/kgbb/hari
-furosemid 40mg/6 jam SC heparin 5000 u/12 Threeway
-citodrox 500mg/12 jam Vascon 1 amp dalam
jam Cpg 1x75 mg 50 cc nacl 0,9 % dosis
Vit E 1x1 titrasi
P/ Zink 2x20 mg IV meropenem
Atorvastatin 1x20 mg 1gr/8iam
-Pantauhemodinamik
Digoxin 1x0,25 mg IV omeprazole 40
-tranfusi TC Azitromicin 1x500 mg mg/12 jam
Pavipiravir 2x600 mg IV ondansetron
Lab 14/04/2021 Vit c 2x500 mg 4/12jam
Hb/L/Tro: 6,9/343/30 Ostriol 2x0,25 mg IV Furosemid 1 amp/8
Lab 8/4/2021 jam
Lab 13/04/2021 Hb/L/T: 13,9/5,0/258 Bicnat 3x500 mg
Hb/L/T :7,9/311,5/8 MCV/MCH/MCHC: Asamfolat 2x0,4 mg
81/27/34 Lenal ace 16 mg/12
Lab 11/04/2021 Diftel: 0/0/0/47/46/7 jam
Hb/L/T :7,9/274,6/14 PT/ APTT: 0,97/0,92 Paracetamol 3 x 500
MCV/MCH/MCHC : Fibrinogen: 559 KSR 3X600 mg
83/28/34 D-dimer: 1240 Nistatin drop per 8jam
Ur/Cr : 29/11,0 Ferritin: 522,40
Ca : 8,5 P/
Na/K/Cl : 144/3,40/107 Lab 10/04/2021 Tranfusi on HD
INR : 0,95 Cek Ur/cr per 3 hari
Lab 05/04/2021 APTT (kontrol) : 33,6
Urinalisis APTT : 3,10 Lab 11/04/2021
Ratio : 0,95 Hb/L/T :8,6/13,9/273
MAK
MCV/MCH/MCHC :
Warna : kuning 84/28/34
Kejernihan : jernih Difel : 1/1/0/86/5/7
Berat jenis: 1,014 Ur/Cr : 169/9,30
pH :6,5 Ca : 9,1
Leukosit: negatif Na/K/Cl : 138/4,60/97
Protein : negatif
Lab 07/04/2021
Glukosa : negatif Hb/Ht/E/T/L :
Keton : negatif 8,5/25/3,1/298/19
Nitrit : negatif MCV/MCH/MCHC :
Urobilinogen : negatif 83/28//34
Bilirubin : negatif RDW : 16,6
Darah : negatif MPV: 12,7
Diftel : 0/1/0/88/2/9
MIK
Albumin : 3
Sendimen urin : Ca : 8,6
Leukosit : 2-5 Ur/Cr : 199/9,8
Eritrosit : 0-5 Na/K/Cl : 140/4,2/101
Epitel :0-1
 Lab 06-04-2021
Albumin : 3,20
Lab 05/04/2021 Ca: 8,7
Ur/Cr : 280/12,90
Hb/Ht/E/L/T:
Na/K/CL : 136/4,30/94
8/24/3/211,8/15
MCV/MCH/MCHC: Lab 31/3/2021
80/27/33 Ur/Cr : 252/16,20
RDW: 15,3 Na/K/Cl/Ca :
LED : 28 144/3,6/108/8,7
Difel :
Lab 30/3/2021
0/0/1/24/9/66/0,5
Urinalisa
Retikulosit : 0,5 MAK
D-dimer : 710 Warna : kuningmuda
Bilirubin total : 0,36 Kejernihan : keruh
Bilirubun direct : 0,20 Berat jenis : 1,013
Bilirubin indirect : 0,16 Bilirubin : negatif
SGOT/SGPT : 10/6 Darah : positif
Glukosa : negatif
Kolestrol HDL : 19
Keton : negatif
Asam urat : 6,0 Lekosit : Positif
Nitrit : Negatif
Lab 04/04/2021 PH : 5,0
Hb/Ht/E/L/T : Protein : positif (+2)
7,8/23/2,9/ 216,2/24 Urobilinogen : Negatif
MCV/MCH/MCHC : MIK
Leukosit : 5-10
80/27/34
Epitel : 0-1
RDW:15 Eritrosit : 10-25
Difel : 0/1/0/28/10/61

Lab 28/03/2021
Foto thorax (3 april Hb/Ht/E/L/T :
2021) 6,9/20/2,3/13,7/293
MCV/MCH/MCHC :
Cardiomegaly dengan
85/30/35
arterosklerosis Difel : 0/0/1/85/8/6
Pulmo tak tampak Anti Hcv : -
kelainan Hbsag : non reaktif
UR/CR : 272/22,00
Na/K/Cl/Ca :
Lab 30/3/2021 142/5,10/114/8,0
Albumin : 3,60
Hb/Ht/E/L/T ; GDS : 104
6,0/18/2,2/200,4/14
MCV/MCH/MCHC : AGDA :
81/27/34 Ph : 7,240
Difel : 0/0/0/18/11/71 HCO3 : 6,4
SGOT/SGPT : 10/7 BE : -18,4
Albumin: 3,00 PCO2 : 14,70
Ca: 8,2 Saturasi O2 : 95,8
GDS : 106 Total CO2 : 6,8
Ur/Cr : 42/0,80
Na/K/Cl : 144/3,10/109