AQSA 2 (Minggu, 24/Oktober/2021)

K1B1 K1B2 K1B3 K1B4 K1B5

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

TTL : 20/6/1967 TTL : 13/10/1997 NRM : 1-28-86-29 CM: 1220069

CM : 1071858 CM : 1288873 MRS : 19/10/2021 TTL: 13/02/1984(37th)

Tgl masuk : 20/10/2021 Tgl masuk : 22/10/2021 TTL : 01/07/1974 TM: 12-10-2021

(HD)

Ass/ Ass/ Ass/ Ass/

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

3. Pneumonia d infeksi paru 4) metastase proses 3. Hiponatremia

spesifik Th/
3. Kolelithiasis dd cholesistitis
4. DM tipe 2 NW Bed rest
4. Nefrolithiasis sinistra Th/
5. Hipertensi stage II Diet DM 1700kkal/hari
5. Hidronefrosis sinistra Bedrest
6. Hypercoagulated IV Omeprazole 40mg/12jam
6. Nefritis bilateral Diet hati 1700 kkal/hari
7. Hiponatremia hipoosmolar IV Meropenem 1gram/8 jam
hipovolemik 7. Hiperkalsemia IVFD NaCl 0,9% 20 gtt + 1
amp Tramadol Drip Paracetamol 1gr/8jam

Drip Aminofusin hepar 1 SC Lantus 0-0-0-12 IU

Th/ Th/ fls/hari
SC Novorapid 8-8-8 IU
Bedrest Bedrest IV Cefoperazone sulbactam 1
gr/8 jam (23/10) Sukralfat syr 3xCII
Diet DM 1700 kkal rendah O2 2-4 L/menit
garam IV Omeprazole 40mg/12jam Flumucyl 3x200mg/hari
Diet lunak hati 1700kkal via
IV Meropenem 1g/ 8 jam NGT Curcuma 3x1 tab Metoclopramide 200mg/12 jam

IV lansoprazole 30/12 jam IVFD NaCl 0,9% 20 tpm Cetirizine 1x10 mg Silostazol 100mg/hari

IV metoclopramide ½ amp/8 IVFD Aminofucin hepar Gabapentin 300mg/hari

jam 1fls/12jam
P/ MRCP (jadwal 2-11-21) Albumin 1 fls/hr
PCT 1g/ 8 jam IV Omeprazole 40mg/12 jam

Amlodipine 1x10 IV Ondancetron Lab (23/10/2021)

P/
Valsartan 1x160 PO paracetamol 500mg/8 jam Hb/Ht/Eri/L/Tr:
9,6/24/3,2/8,3/365 Cek kgdp/hr
Sc heparin 5000/12 jam PO Sucralfat CI/8jam
MCV/MCH/MCHC/RDW: Rawat luka
SC Apidra 8-8-8 PO Curcuma tab/8jam 75/30/40/25,2

SC Lantus 0-0-0-10 IV Cefoperazone Sulbactam Diftel: 3/1/0/77/10/9

1gr/8jam Lab 23-10-2021
Grafalac 3xCII Protein total: 5,11
Subkaltropen supp (K/P) Hb/L/T: 6,8/26,9/792
Curcuma 3x1 Albumin: 2,76
PO Tramadol 50mg/12 jam MCV/MCH/MCHC: 70/24/34
Drip Novorapid titrasi dosis Globulin: 2,35
(stop) PO UDCA 2x500mg Diftell: 3/0/0/85/8/4
ALP: 314
Domperidone 3x10mg Albumin: 2,40
 AQSA 2 (Minggu, 24/Oktober/2021)
P/ Lab (21/10/2021) RDW: 15,0

PT/APTT, D-Dimer Lab 23/10/2021 Bilirubin : (+) Na/K/Cl: 135/4,50/103

Na/K/Cl: 145/5,4/118 Darah (-), Glukosa : (-) Ca: 7,2

Lab 22/10/2021 Ca: 9,9 Granula cast (+), Keton (+),

Bakteri (+)
Hb: 14 Lab 19-10-2021
Leukosit (-), Protein (-)
Ht: 38 Lab 22/10/2021 Hb/L/T: 8,5/24,9/510
Urobilinogen (+)
E/L/T: 4,9/37,6/572 Hb/L/T: 12/22,6/83 MCV/MCH/MCHC: 69/24/34
CA 19-9 : 355,49
MCV/MCH: 78/29 MCV/MCH/MCHC: 80/28/35 Diftell: 1/0/0/86/9/4
CEA : 19,29
Diftel: 0/0/0/93/2/5 Diftell: 0/0/0/85/5/10

HbA1C: 13,5 RDW: 14,9 Lab 16-10-2021

USG :
HDL/LDL: 22/71 PT/APTT: 17,4/58,10 Hb/L/T: 8,2/25,3/487
- susp koledokolitiasis
Kolestrol Tot: 120 D-Dimer: 1740 MCV/MCH/MCHC: 68/24/35
- ascites
Trigliserid: 109 Anti HCV/HbsAg: - / non Diftell: 3/0/0/83/9/5
reaktif
Ur/Cr: 43/1,35
Bilirubin direk/indirek: Lab (19/10/2021)
Lab 20/10/2021 10,2/4,87 Albumin: 2,10
Hb/L/T: 11,4/9,9/392
Hb/L/Tr : 13,6/36/615 Bilirubin total: 15,09 PDW: 11,0
MCV/MCH/MCHC: 76/30/40
Mcv : 78/28/36 SGOT/SGPT: 18/12 RDW: 14,3
RDW: 22,4
Diftel : 0/0/1/91/2/6 Albumin: 2,6 Na/K/Cl: 135/3,60/101
Diftel: 0/0/0/83/9/8
Pt/aPtt : 1,1/1 GDS: 115 Ca: 7,3
Ur/Cr: 68/1,7
Ddimer 2270 Ur/Cr: 112/3,0
Na/K/Cl: 131/4,2/200
Cal 9,1 Na/K/Cl: 138/5,3/112 Lab 12-10-2021
Ca: 9,4
GDS 490 Ca: 11,1 Hb/L/Tr: 8,8/22/478
GDS: 113
Ur/Cr : 29/0,8 MCV/MCH/MCHC: 68/24/36
Anti HCV/HbsAg: -/Non
Na/K/Cl ; 124/4/92 reaktif Diftell: 0/0/0/89/5/6

Bilirubin total: 38,8 PT/APTT: 1,01/ 1,34

Bilirubin direct/indirect: Na/K/Cl/Ca: 126/3,9/93/7,9

26,18/12,63
Albumin: 2,70
SGOT/SGPT: 61/53
Ur/Cr: 67/1,80
Protein total: 6,10
GDS: 467
Albumin: 3,10

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

COW: dr. M. Firdaus COW : dr.Rizqy COW: dr.Suprinardi

Kamil
Ruangan : dr.Marcell Ruangan: dr. Santun
Ruangan: dr. Suhemi

Nama : Suardi Bintang Nama : Muhammad Yusuf Nama : Tgk. Abdurrahman

TTL : 1/7/1950 NRM : 1-28-51-82 NRM : 1-24-48-54

CM : 1158060 Ttl : 09/07/1971 Ttl : 01/07/1967(54th)

Tgl masuk 20/10/2021 MRS : 18/10/2021 MRS : 13/10/2021

Ass/    A/ Ass/

1. Syok sepsis ec dd 1.Leukositosis ec dd/ CML 1. Vomittus (perbaikan) ec dd

-Urosepsis 2. Anemia sedang ec  dd : -gastritis erosiva

-Pneumonia - hematology malignancy -uremic syndrom

2Pneumonia (cap) dd infeksi   2. CKD st V dan HD reguler ec

paru spesifik psi score>130 dd
Th/
3. Gross hematuria ec dd - urat netrofati
- Diet mb 1700 kkal/hari
- Ca Buli -Diabetic nefropati
-threeway
4. aki stage I post renal -PGOI
- Tramadol 3x1 tab
5. anemia berat HM ec dd 3 PSMBA (perbaikan )ec
- Curcuma 3x1
-defiensi besi - ulkus gaster
- domperidone 3x10 mg
-penyakit kronis - ulkus duodenum
- Cytodrox 2x500mg
6.hipoalbuminemia sedang ec -limfoma
dd  
4. Dm tipe II NW terkontrol
-related infeksi p/
5. Hipertensi st I
-low intake Transfusi PRC 1 kolf (jika
ada stok) 6Hipokalemia ringan
-renal loss
Cek DR 4 jam post transfusi 7.Massa ar rectum ec dd
6.Geriatri problem
Menunggu hasil pemeriksaan 1) Ca rectum 2) polip recti
7. malnutrisi BCR ABL
8.multiple cholelitosis
8.Lipoma multiple  
9.Hidronefrosis post op
9 high risk trombosis Lab 20/10/21 nefrostomy bilateral

Hb/L/T : 9,6/188.100/362.00 10.cystitis

th/ Diftel : 6/7/0/71/10/6 11. Esofagitis LA grade B

O2 3L/i nasal canul MCV/MCH : 86/30 12 Massa heterogen pada

cavum pelvis
diet sonde 1700 kkal/hari  
13.
IVFD nacl 0,9 30 tpm  

IV meropenem 1 gr/8 jam Lab 17/10/2021

Drip Vascon titrasi dosis
IV Vit K 1 amp/8 jam
Transfusi PRC sampai Hb>1
Hb/L/Tr : 7,4/217,7/382
MDT :
- Ditemukan sel Blast 6 %
Th/
Bedrest
Diet ginjal 1700 kkl/hari +
protein 1-1,2 kg/bb/hari

- Kesan Leukositosis ec susp Threeway

hematology malignancy
Lab 21/10/2021
 AQSA 2 (Minggu, 24/Oktober/2021)
PT/APTT : 1,4/ 1,4 Damperidone 3x10g

Fibrinogen pasien : 257,00 iv levofloxacine 500/24 (H-2)

D-Dimer : 1950,00 Amlodipine 1x10 g

PSA total : 4,46 Sucralfat syr

Besi Fe/iron : 11 KSR 2x600

TiBC :163

LDH : 478 p/

CT scan abdomen susul hasil

susul hasil biopsi

Lab 20/10/2021 pantau hemodinamik

Hb/L/Tr : 4,3/45,3/164 Hd besok

Mcv : 66/20/31

Diftel : 0/0/0/87/7/6 Lab 22/10/21

Hbsag/anti HCV/HIV : PT: 1,21

negative
APTT Kontrol:36,7
Albumin 2,3
APTT pasien : 60,20
Kalsium 7,3
 
GDS 122
Lab 21/10/21
Ur/Cr : 96/1,8
Hb/L/Tr: 9,1/11,5/268
Na/K/cl : 138/5,1/109
Ur/cr: 78/4,3

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

K3B1 K3B2 K3B3 K3B4 K3B5

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

Nama : Akmaluddin Bin A Nama : Husaini bin Saridin Nama : Abd.Wahab

 AQSA 2 (Minggu, 24/Oktober/2021)
Bakar CM : 0995189 CM : 128 89 78

CM : 128 34 22 TL : 02/05/1968 (53th) TL : 20/4/1972 (49 th)

TL : 13/10/1992 (29 th) TM : 10/10/2021 TM : 23/10/2021

TM : 18/10/2021

Ass/ Ass/ Ass/

1.Syok hipovolemik 1. CKD stage V dengan 1.HE Grade II dgn pencetus

(perbaikan) ec GI tract loss uremic syndrome (perbaikan) konstipasi
ec dd:1) HN 2) PGOI, 3)
2. AKI stage III ec dd DNC, 4)DN 2.Hepatomegali ec dd 1.HCC
Hipovolemik
2. Anemia sedang NN ec. 2. Metastase proses
3.Anemia berat NN (perbaikan) PGK
ec dd 3.Sirosis hepatis std DC
3. DM type II NW childpugh C
1) PGK
4.Hiperuresemia 4.Hepatitis B kronik
2) Defisiensi besi
5. Status hipokoagulasi
4. Susp massa paru dextra
Th/ 6.Anemia berat NN ec dd
5. SN on therapy
Bedrest, threeway 1. Related sirosis hepatis
6. Efusi pleura ec dd
Diet sonde 1700kkal/hari + 2.Occult bleeding
1) pleuropneumonia protein 1 g/kgbb/hari
7. Konstipasi
2) pleuritis TB IV omeprazole 40mg/12jam
8. Hipoalbuminemia sedang
3) Tumor paru IV ondansetron 4mg/8jam

7. Hipoalbuminemia ringan IV furosemide 20 mg/8 jam

Th/
8. ISK Asimptomatik Flumucyl 200 mg/8 jam
Bedrest
Bicnat 500 mg/8 jam
Diet hepatosolola 6x200 cc
Th/ PO Paracetamol 2x1000 mg
IVFD Comafusin hepar 1 fls/24
-Bedrest PO Allopurinol 100mg/24 jam

- Diet M II 1700 kkal/hari PO Amlodipin 1x10mg IV Cefoperazone Sulbactam

1g/8 jam (23/10)
-IV Ceftriaxone 2 g/24 jam PO Lenal ace 169 mg/12 jam
IV Omeprazole 40 mg/24 jam
-IV Omeprazole 40 mg/24 jam Insulin novorapid 10-10-10
iu (ada pada pasien) IV Furosemide 20 mg/12 jam
-IV Metoclorpramid ½ amp/8
jam IV Vit K 1 amp/8 jam

-IV Methyl Prednisolon 125 Lab 22/10/2021 Spironolakton 2x100 mg

mg/8 jam
Hb/L/T : 10/5,4/177 Curcuma 3x1
- IV Ceftazidime 1 gr/8 jam
Diftell : 4/0/68/0/20/0 Propanolol 2x10mg
- IV Metronidazol 500 mg/8
jam Ur/Cr : 62/6,9 Lactulac Syr 3x30 cc

-N asetil sistein 3x200 mg Na/K/Cl : 134/3/101 Fosen enema per hari

-Bicnat 3x500 mg

-Curcuma 3x1 tab Lab 18/10/2021 Lab23/10/2021

Hb/L/T : 10,3/6/156 Hb/L/T: 7,1/13,6/160

P/ - Susul kultur darah dan urin Led : 114 MCV/MCH/MCHC : 83/29/36

-Balance cairan Diftell : 2/0/0/65/17/16 Diftel : 0/0/0/78/13/9

-CT scan thorax kontras dan CRP : + PT/APTT : 1,69/1,69

non kontras (Senin, 1/11/2021)
Koltot/HDL/LDL/TG : Anti HCV : negatif
134/28/81/100
Hbsag : positif
Lab 20/10/21 Ur/Cr : 126/10,11
Bil total/dir/indir :

Hb/L/T : 10,7/11,7/658
Diftel : 0/0/0/95/4/1
MCV/MCH : 80/28
Albumin : 3,3
Ur/Cr : 67/3,40
Lab 19/10/2021
Kolesterol total/HDL/LDL/TG:
182/36/119/140
Ur/Cr: 84/5,9
Urinalisis:
Kuning muda keruh, leukosit
(+), protein (+1), darah (+)
Leukosit: 80-100
Eritrosit: 25-50
Hyalin cast (+), bakteri (+)
Lab 18/10/2021
Hb/L/T : 5,9/15,9/432
MCV/MCH/MCHC : 81/28/35
Diftell : 1/0/0/74/13/12
Anti HCV/HbSAg : Neg/Neg
Albumin : 2,5
GDS : 98
Ur/Cr : 74/5,3
Na/K/Cl/Ca : 133/3/104/7,4
K4B1
DPJP: dr. Desi Maghfirah,
SpPD
COW: dr. Firdaus
Ruangan: dr. Suheimi
Nama : M. Abd Gani
NRM : 1288270
TTL : 28/12/1954
MRS: 14/10/2021
Ass/
 
1.CKD Stage V uremic ec dd
1.DN  2).GNC 3).HN 4). PNC
2. Anemia sedang NN ec dd
AQSA 2 (Minggu, 24/Oktober/2021)
Na/K/Cl : 135/3,1/99 8,96/5,59/3,37
SGOT/SGPT : 260/30
Lab 13/10/2021 Albumin : 2,9
Hb/Ht/e/l/t: Ur/Cr : 34/0,8
8,9/24/3,0/7.0/144
GDS : 76
Mcv/mch/mchc: 80/30/37
Na/K/CL : 145/4,1/114
Diftel: 2/0/0/79/8/11
Ur/Cr : 136/11,10
Na/K/Cl : 133/3,40/106
Lab 11/10/2021
Hb/Ht/e/l/t:
6,8/19/2,4/4,0/128
Mcv/mch/mchc: 80/29/36
Diftel: 4/0/0/68/20/8
Kol
total/HDL/LDL/trigli:163/31/
107/126
Pt/ ul: 0,92/0,89
HIV :- hbsag ;-HCV :-
Albumin 3,5
Ca: 7,9
K4B2 K4B3 K4B4 K4B5
DPJP : Prof Dr. dr. Kurnia DPJP: Dr. Islamuddin, DPJP : Prof. Dr. Dr. Kurnia
F.J Sp.PD KPTI Sp.PD F.J Sp.PD KPTI
COW : dr. M.Firdaus COW: dr. Suprinardi COW : dr. M. Firdaus
Ruangan : dr. Imam Ruangan dr. Merizka Ruangan : dr. Imam
Nama : Tarmizi Nama : Muhammad Nasir Nama : T. Hermansyah
CM : 1288878 RM : 1-26-47-49 CM : 1286864
TL : 11/3/81 (40th) TTL: 1/7/1980 TL : 4/9/89 (32th)
TM : 22/10/21 MRS : 4-10-202 TM : 28/9/21
Ass/ Ass/ Ass/
1. 1.Diare kronik ec dd 1. Ca
rectosigmoid  2. IBD
1. AKI stage 3 post renal ec 1. CKD stg V on HD reguler
dd 1. Nefrolithiasis 2. Infeksi dengan edema paru akut 2. Hipoalbuminemia berat ec
(perbaikan) dd 1) GI loss 2) low intake
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)

7. RBBB + iskemik out ekstensif IV. Ceftriaxon 2g/24j 5. DM Tipe 2 Normoweight  

 8. Isk asimptomatik IV. Omeprazole 40mg/12j 6. Anemia sedang NN ec dd/ Th/

Asam folat 2x0,4mg    - PGK Threeway

p/ Lenal ace 2x169mg 7. Neuropati diabetik Bedrest

bedrest Fluimucyl 3x200mg 8. HHD Diet MB 1700 kkal/hari

Pacat 3x500mg   IVFD NaCl 0,9% 20 tpm

Th/ Valsartan 1x160mg Th/ IVFD aminofluid 1 fls/24jam

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

DPJP : dr. Desi Salwani, SpPD- DPJP:

AQSA 2 (Minggu, 24/Oktober/2021)
dr. Sarah Firdausa, Dpjp : dr. Diana Erlita, Sp.PD
KGH
Bakteri :+ Sp.PD PDW:  
Cow: dr. Firdaus
  COW : dr. Suprinardi COW: dr.Suprinardi 16/10/2021
Ruangan : dr. putri
Ruangan : dr. Ira
Lab 14/10/2021 Ruangan: dr. Santun Na/K/Cl/Ca

Hb/L/T : 7,6/8,4/312 142/2,70/110/6,6

Nama : Abdul Murad Nama : Ilyas Bin Makasah Nama : Edinur
MCV/MCH/MCHC : 80/28/35  
TTL : 1/7/1976 TTL : 1/5/1968 (53 th) CM : 1288146
Diftel : 2/0/0/81/12/5 Colonoscopy 15/10/21
CM : 1288727 CM : 125 67 35 TL : 12/07/1973 (48)
Albumin : 2,7 - Massa Rektosigmoid dd
Tgl masuk 20/10/2021 TTM : 24/10/2021 TM : 12/10/2021
GDS : 123 - CA rectosigmoid
Ass/ Ass/ Ass /
Ur/Cr : 120/9,7 - Polip
1. CKD stg V dgn uremic syndrome 1.Anemia berat NN ec dd 1. PSMBA ec dd/
Na/K/Cl/Ca: 127/5/102/7,7 EGD
ec dd/ malignancy
1) variceal bleeding
ultiple ulkus gaster ar antrum
1) PNC 2. Neutropenia ec induced
kemoterapi 2) ulkus gaster
2) HN
3. NHL post kemoterapi siklus ke3 3) ulkus doudenum
3) urat nefropati dgn regimen ICE MESNA
4) induced heparin
2. Anemia sedang NN ec dd 4. Sindrom dyspepsia ec dd 1.
Gastritis akut 2. Drug induced 2. CKD stg V dgn uremic ensefalopati
1) penyakit kronik kemoterapi 3. Dyspepsia fungsional syndrome ec dd 1) GN 2) DN 3) HN
4)PNC
2) defisiensi besi 5. Hipokalemia sedang
3. Hipertensi stg 2
3. hipertensi stage I
4. DM tipe 2 nw
4. Hipokalemia sedang Th/
5. hemiparese sin ec stroke iskemik
5. hiponatremia Bedrest
6. pneumonia (CAP) dd infeksi paru
6. Hipoalbumin ringan O2 2-4 lpm spesifik

7. AV block derajat 1 IVFD RL 20 tpm 7. Hiperkalemia ringan

IV Omeprazole 40 mg/12 jam

Th/ MST 2x10 mg Th/

Bedrest Domperidone 3x10 mg -Bedrest

Diet ginjal 1700 kkal/hari + protein Curcuma 3x1 -Threeway

0,8 gr/KgBB
KSR 2x600 mg -Diet ginjal 1700 kkal/hari + protein 1
IV furosemide 20 mg/8 jam gr/kgbb/hr
Transfusi PRC 1 kolf per hari
IV ceftriaxone 2g/24 jam -IV Meropenem 500 mg/24 jam

IV omeprazole 40 mg/24 jam - Drip Omeprazole 5cc/jam

PO Asam folat 2x0,4 g - IV Ceftriaxone 1g/12 jam (stop)

Lab 23/10/2021
PO Lenal ace 2x169 mg - Drip Nicardipin 9 cc/jam, 0,5 meq/jam
Hb/L/T : 5,8/1,3/11 (stop bila TDS <140)
PO Bicnat 3x500 mg
MCV/MCH/MCHC : 86/33/38 - iv furosemide 20 mg/12 jam
PO Valsartan 80 mg/24 jam
Diftel : 2/0/0/60/26/12 - herbeser 1x200 mg

Albumin : 3,0 - asam folat 2x0,4 mg

Lab 21/10/21
Ur/Cr : 11/0,6 - flumucyl 3x200 mg
Hb/Ht/Eri/T/L: 9/23/3,2/163/8,2
Na/K/Cl/Ca: 136/2,7/105/7,7 - citicoline 2x500 mg
MCV/MCH/MCHC/RDW:
69/28/40/12,9 - mecobalamin 2x 500 mg

Diftel: 0/0/0/92/4/4 -Bisoprolol 1x5 mg

Albumin: 3,30 -valsartan 1x160 mg

Ca: 9,3 -Hitros 1x1 tab

Ur/Cr: 135/10,50

Na/K/Cl: 124/2,50/92 Lab 23/10/2021

Ur/Cr; 69/6,9

Lab 20/10/2021 Na/K/Cl: 140/5,20/104

Hb/L/tr: 8,9/7,1/161 Ca: 8,9