Sudiono 54 tahun Wiraswasta Dusun V desa mangkai lama kec lima puluh Islam Tamat SD Tgl 18/4/1 2 S Nyeri

ulu hati O Sens: CM TD: 120/80 HR: 84 x/i RR: 20x/i Temp: 36,9 A Susp. Ca rectal + Anemia ec peny. kronis T Tirah baring Diet hati III IVFD D 5% 20gtt/i Inj.Ranitidin 1 amp/12 jam Inj.Ketorolac 1 amp/8jam Tirah baring Diet hati III IVFD D 5% 20gtt/i Inj.Ranitidin 1 amp/12 jam Inj.Ketorolac 1 amp/8jam Tirah baring Diet MB IVFD NaCl 0,9% 20gtt/i Omeprazole 1x20 mg Tirah baring Diet MB IVFD NaCl 0,9% 20gtt/i Omeprazole 1x20 mg Laxadyn syr 1xc2 Urdapalc 3x1 Tirah baring Diet MB IVFD NaCl 0,9% 30gtt/i Cefotaxim 2 gr/8jam Omeprazole 1x20 mg PCT 3x500mg Laxadyn syr 3xc1 Urdapalc 3x1 Tirah baring Diet MB IVFD NaCl 0,9% 30gtt/i Inj.Cefotaxim 1gr/12jam Omeprazole 1x20 mg PCT 3x500mg Laxadyn syr 3xc1 Urdapalc 3x1

19/4/1 2

Nyeri ulu hati

Sens: CM TD: 120/80 HR: 98 x/i RR: 28x/i Temp: 38,5 Sens: CM TD: 110/60 HR: 65 x/i RR: 18x/i Temp: 36 Sens: CM TD: 110/60 HR: 102 x/i RR: 24x/i Temp: 36,6 Sens: CM TD: 110/80 HR: 82 x/i RR: 22x/i Temp: 37,6

Susp. Ca rectal + Anemia ec peny. kronis

20/4/1 2

Nyeri ulu hati

Susp. Ca rectal + Anemia ec peny. kronis

21/4/1 2

Nyeri perut kanan atas

Susp. Ca rectal + Anemia ec peny. kronis

22/4/1 2

Susp. Ca rectal + Anemia ec peny. kronis

23/4/1 2

Sens: CM TD: 120/70 HR: 80 x/i RR: 22x/i Temp: 36,8

Susp. Ca rectal + Anemia ec peny. kronis

24/4/1 2

Nyeri perut kanan atas

Sens: CM TD: 120/70 HR: 80 x/i RR: 22x/i Temp: 36,8

Susp. Ca rectal + Anemia ec peny. kronis

Tirah baring Diet MB IVFD NaCl 0,9% 30gtt/i Inj.Cefotaxim 1gr/12jam Omeprazole 1x20 mg PCT 3x500mg Laxadyn syr 3xc1 Tirah baring Diet MB IVFD NaCl 0,9% 30gtt/i Inj.Cefotaxim 1gr/12jam Omeprazole 1x20 mg Laxadyn syr 3xc1 PCT 3x500mg Tirah baring Diet MB IVFD NaCl 0,9% 30gtt/i Inj.Cefotaxim 1gr/12jam Omeprazole 1x20 mg PCT 3x500mg Laxadyn syr 3xc1 Tirah baring Diet MB IVFD NaCl 0,9% 30gtt/i Inj.Cefotaxim 1gr/12jam Omeprazole 1x20 mg PCT 3x500mg Laxadyn syr 3xc1 Urdapalc 3x1 Tirah baring Diet MB IVFD NaCl 0,9% 30gtt/i Inj.Cefotaxim 1gr/12jam Omeprazole 1x20 mg PCT 3x500mg Laxadyn syr 3xc1 Urdapalc 3x1 Th/ ERCP

25/4/1 2

Nyeri perut kanan atas

Sens: CM TD: 120/70 HR: 82 x/i RR: 20x/i Temp: 37,1

Obs.Jaundice ec CBD stone

8/4/12

Sens: CM TD: 110/70 HR: 80 x/i RR: 20x/i Temp: 37,1

Obs.Jaundice ec CBD stone

9/4/12

Nyeri perut kanan atas

Sens: CM TD: 120/80 HR: 96 x/i RR: 24x/i Temp: 36,2

Obs.Jaundice ec CBD stone

10/4/1 2

BAB + nyeri perut

Sens: CM TD: 110/80 HR: 60 x/i RR: 24x/i Temp: 36,1

Obs.Jaundice ec CBD stone

11/4/1 2

Sens: CM TD: 120/80 HR: 70 x/i RR: 24x/i Temp: 36

Obs.Jaundice ec CBD stone

Tirah baring Diet MB IVFD NaCl 0,9% 30gtt/i Inj.Cefotaxim 1gr/12jam

Omeprazole 1x20 mg PCT 3x500mg Laxadyn syr 3xc1 Urdapalc 3x1 12/4/1 2 Sens: CM TD: 130/80 HR: 70 x/i RR: 24x/i Temp: 36 Obs.Jaundice ec CBD stone Tirah baring Diet ginjal 1800 kkal + 36 gr protein IVFD NaCl 0,9% 30gtt/i Inj.Cefotaxim 1gr/12jam Omeprazole 1x20 mg PCT 3x500mg Laxadyn syr 3xc1 Urdapalc 3x1 N-acetyl sistein Tirah baring Diet ginjal 1800 kkal + 36 gr protein IVFD NaCl 0,9% 30gtt/i Inj.Cefotaxim 1gr/12jam Omeprazole 1x20 mg PCT 3x500mg N-acetyl sistein Tirah baring Diet ginjal 1800 kkal + 36 gr protein IVFD NaCl 0,9% 30gtt/i Inj.Cefotaxim 1gr/12jam Omeprazole 1x20 mg PCT 3x500mg N-acetyl sistein Tirah baring Diet ginjal 1800 kkal + 36 gr protein IVFD NaCl 0,9% 30gtt/i Inj.Cefotaxim 1gr/12jam Omeprazole 1x20 mg PCT 3x500mg N-acetyl sistein

13/4/1 2

Sens: CM TD: 130/80 HR: 64 x/i RR: 20x/i Temp: 36,6

Obs.Jaundice ec CBD stone

14/4/1 2

Sens: CM TD: 130/70 HR: 68 x/i RR: 20x/i Temp: 36,4

Obs.Jaundice ec CBD stone + CKD stg.V ec PNC dd AKI std failure

15/4/1 2

Sens: CM TD: 110/70 HR: 60 x/i RR: 16x/i Temp: 36,5

Obs.Jaundice ec CBD stone + CKD stg.V ec PNC dd PGOI + AKI std failure

K 19-04-12

Faal Hemostasis

09-04-12

Darah lengkap

Kimia Klinik

imunoserologi

PT APTT TT Fibrinogen D-dimer Besi TIBC Hb Eritrosit Leukosit Hematokrit Trombosit MCV MCH MCHC RDW MPV PCT PDW LED E/B/N/L/M Bilirubin total Bilirubin direk ALP SGOT SGPT Protein Total Albumin Globulin LDH CEA CA 125 CA19-9

(12,5/19,7) (28,6/37,0) (12,0/17,3) 145 mg/dL 180 ng/dL (N<500) 41 mg/dL (N:61-157) 86 ug/dL 7,5 g% 2,86. 106 /mm3 6,97. 103 /mm3 23,7% 290. 103 /mm3 82,9 fL 26,2 pg 31,6 g% 15,8% 9,2 fL 0,27% 9,8 fL 40 mm/jam 41,2/40,3/11,9/6,5/0,1 1,04 mg/dl 0,74 mg/dl 78 U/L 38 U/L 18 U/L 5,1 g/dL 2,6 g/dL 2,5 g/dL 280 g/dL

1,7ng/ml 19,52 U/ml 7,4 U/ml