LAPORAN DIVISI NEFROLOGI

3 MARET 2020

BED IDENTITAS DX PROBLEM TERAPI RENCANA KET

L4AD Taufika Nur/ Primer : Problem: Amlodipim 10 Urinalisa/hari KOOPERATIF
5.4 perempuan/1-10- Sindrom Nefritik Akut 1. Edema mg/24 jam/oral Tampung
2007/910469 Hipertensi stage II 2. ascites Furosemid 40 urine 24 jam
Tensi 110/80 mmhg Sekunder: 3. Hipertensi stage II mg/12 jam/oral
P50 98/60mmHg Post operasi pemasangan 4. Hipoalbumin Eritropoetin 3000
P90 109/73 mmHg CAPD hari 11 5. Imbalance elektrolit iu/intravena
P95 113/70 mmHg Penyakit jantung rematik 6. Anemia penyakit (selasam kamis,
P95+12 125/88 mmHg Hipoalbumin kronik sabtu)
nadi : 88 kali/menit, nafas Imbalance elektrolit Laboratorium Ferrofumarat 180
22 kali/menit, suhu 36.8C. Anemia penyakit kronik Darah (3/3/20) mg/24 jam/oral
SpO2 99 %. Komplikasi : WBC 5.700, HB 10.2, HCT 4) Eritromicin 250
Lingkar perut 62 cm Chronic kidney disease 30, PLT 130 mg/12 jam/oral
Skala nyeri 0 nrs stage V Urinalisa (2-3-2020) 16)
GFR Warna kuning, pH 7,5, bj Methylprednisolon
Konstanta 0,5 1.010, protein ++ 1-0-0 tablet
TB/PB 131 cm +/300,bilirubin negatif, Calnic syrup 10
Creatinin serum 9.80 lekosit +-, blood ++/250 ml/12 jam/oral
GFR 6.68 sedimen lekosit 3, sedimen Na bicarbonat 1x1
ml/menit/1.73m2 eritrosit 1, sedimen kristal tab
BB MRS 23,3 kg negatif, sedimen epitel sel KSR 1 tablet/24
BB Kering 22 kg negatif bakteri=12 jam/oral
BB Aktual 23,7 kg Allupurinol 60
Buang air kecil : Darah (2-3-2020) mg/12 jam/oral
0.86 cc/kgbb/ jam WBC 7.700 HB 9,4
Retikulosit 6.8 Ambulating
PLT 144.000, Ur 154, Cr dialisys 500
9.80, albumin 2,8, ml/4jam
magnesium 1.39, SGOT 35, Pukul 07.00-11.00-
SGPT 4, Na/K/Cl 15.00-19.00
140/4.9/107 Vectrin syrup
Urinalisa (27-2-2020) 5ml/12 jam/oral
Warna kuning keruh, pH 7,5, Aspilet 160 mg-
bj 1.015, protein ++ 160 mg-120 mg
+/300,bilirubin +/10, lekosit
+-, blood ++/80
sedimen lekosit 6, sedimen
eritrosit 469, sedimen kristal
642, sedimen epitel sel 47
bakteri=1
Darah (26-02-20)
WBC 16200 HB 9,4
PLT 261000, Ur 183, Cr
8,24, albumin 2,7, SGOT 31,
SGPT 3, Na/K/Cl
138/5,1/104, kolesterol total
170, asam urat 9,6
Urinalisa (24-2-2020)
Warna kuning tua, pH 7,5, bj
1.010
protein +++/300,, lekosit +-,
blood +-
sedimen lekosit 1, sedimen
eritrosit 29, sedimen kristal
4, sedimen epitel sel 4,
bakteri=1,BYST=14
Darah (24-02-20)
WBC 16400 HB 10,3
PLT 376000, GDS 156, Ur
20, Cr 5, albumin 2,8, SGOT
20, SGPT 5, albumin 2,8,,
Na/K/Cl 137/4,2/101
Darah (17-02-20)
WBC 11800 HB 9,6
PLT 318000, GDS 104, Ur
279, Cr 13,10, SGOT 30,
SGPT 24, albumin 3, Ca 5.9,
Na/K/Cl 122/5,7/93
Prodia (13-2-20 )
C3 96.1
ANA tes 1:100
BGA 13/2/20
pH 7.372
PO2 55,7, PCO2 28,5
HCO3 16,7, BE -8,6
Darah (9-2-20)
Ur 280, Cr 17,44
Coomb test negatif
Echocardiografi 12/2/20
Fungsi RV dan LV baik
MR mild, TR Mild
Darah (11-2-2020)
Ca 4,9
Mg 2,35
Urinalisa (10-2-2020)
Warna kuning tua, pH 6,5
protein +3, nitrit negatif,
lekosit +2, blood +3, glukos
+2,
sedimen lekosit 46, sedimen
eritrosit 26
Lab prodia 31/1/2020
 Albumin 3,4 , ASTO 400
Darah (10-2-20)
WBC 19600 HB 7,9
PLT 234000
Apusan darah tepi (10-2-
20)
Anemia normositik
normokrom dengan
gambaran gangguan fungsi
ginjal
Analisis Gas Darah (10-2-
20)
Asidosis metabolik
terkompensasi sebagian
USG Abdomen (9-2-20)
PNC Bilateral
Darah (9-2-20)
WBC 25100 HB 8,0
PLT 236000, GDS 110, Ur
220, Cr 13,86, SGOT 22,
SGPT 12, albumin 3,2
Na/K/Cl 122/5,7/93
PICU Tiara/ Perempuan/3-6- Primer : Problem: Balance cairan Urinalisa/hari KOOPERATIF
12 2007/910402 Sncephalopathy dengue 1. Penurunan kesadaran Koreksi Imbalance Tampung
Tensi 140/110 mmhg, Sekunder : 2. Terpasang ventilator elektrolit urine 24 jam.
p50 104/61 mmHg Community Aquired Laboratorium : Tampung urine/24 Periksa
p90 116/75 mmHg Pneumoni Darah (1-3-2020) jam esbach urine
p95 120/78 mmHg proteinuria B=WBC 20.600,HB 11.4,
P95+12 132/90 mmHg Nutritional marasmus PLT 108.000, HCT Furosemid 1
nadi : 112 kali/menit, Komplikasi: 33,Albumin 3.5, Na/K/CL : mg/kgBB/24 jam =
nafas 30 kali/menit, suhu 142/3.0/103 30 mg/ 24 jam/
37.3 C. Prodia (25-2-20) oral
SpO2 99 %. C3 Komplemen 99,4
Skala nyeri 0 NRS Darah (25-2-20) Catopril 0.3
Lingkar perut 65 cm ASTO 376 mg/kgBB/ 8 jam
GFR0 Urinalisa (24-2-20) = 9 mg/ 8 jam/oral
Konstanta 0,5 Warna kuning tua, pH 6,0,
TB/PB 152 cm BJ 1,010 Protein trace, Amlodipin 2
Creatinin serum 5 urobilinogen +/10, blood ++ mg/kgBB/24 jam
GFR 15,2 +/200 lekosit +/70, sedimen =5 mg/24 jam/oral
ml/menit/1.73m2 lekosit 11, sedimen eritrosit
BB MRS 29 kg 39, sedimen epitel sel 5,
BB Kering - kg sedimen lain-lain bakteri
BB Aktual 29 kg =44, BYST=7
Buang air kecil : Darah (24-2-20)
1.5 cc/kg bb/jam ureum 240, kreatinin 4,55,
SGOT 75, SGPT 4, albumin
2,7 Na/K/Cl 135/3,5/96
Darah (18-2-20)
WBC 10400, HB 11,2 PLT
154000
Urinalisa (17-2-20)
Warna kuning tua, pH 7,0,
BJ 1,019 Protein ++/100,
bilirubin +/10, urobilinogen
_/1, blood +++/200 lekosit
+/70, sedimen lekosit 3,
sedimen eritrosit 67, sedimen
kristal 0, sedimen epitel sel
18, sedimen lain-lain bakteri
=1, mucucs = 2
Darah (16-2-20)
WBC 11700, HB 8,8 PLT
219000, ureum 254, kreatinin
5,25, SGOT 221, SGPT 12,
albumin 2,7 Na/K/Cl
127/4,9/94
Urinalisa (15-2-20)
Warna kuning tua pH 7.0 Bj
1010 protein ++
+/300bilirubin +/10,
utobilinogen 3+, sedimen
lekosit 1, sedimen eritrosit 1
Darah (13-2-20)
WBC 10700, hb 10,1
PLT153000, PT12,8, INR
1,25 APTT 30,6 ureum 185,
kreatinin 3,80 albumin 2,6 D-
Dimer 1,93 Na/K/Cl
127/4,5/95
Urinalisa (11-2-20)
Warna coklat pH 6.0 Bj 1020
protein +3, lekosit +, blood
+3, sedimen lekosit 4,
sedimen eritrosit 14,
Kultur urine 11-2-2020
Tidak ada pertumbuhan
Darah (11-2-2020)
WBC 8500 HB 7,4 PLT
47.000, Ureum 60, Kreatinin
0.59, SGOT 3522, SGPT
1549, Albumin 2,9, Na/K/Cl:
137/6.0/101
Darah (8-2-2020)
Dhf IgG positif
Dhf IgM positif
 Urinalisa (8-2-20)
Warna coklat pH 5.5 Bj 1030
protein +3, lekosit negatif,
blood negatif, sedimen
lekosit 2, sedimen eritrosit 2,
L4AB Algulfam Qadaffi/laki- Primer : Problem: 6) Amikasin 115 Tampung KOOPERATIF
9.4 laki/29-6-2019/911379 Infeksi saluran kemih Infeksi saluran kemih mg/24 urine 24 jam.
Tensi - mmhg, Sekunder : Laboratorium jam/intravena Kultur urine
P50 - mmHg Encefalopati et causa Urin Rutin 2/3/2020) Usg abdomen
P90 - mmHg anofi brain regio temporal Warna kuning muda, pH 5.5 Kerjasama divisi
P95 - mmHg Komplikasi : BJ <=1,005 Protein negatif, Hematologi: Pasang
P95+12 - mmHg nitrit positif, lekosit negatif, 12) Ferish sirup 7 kateter urin
nadi : 124 kali/menit, blood negatif, ml/24 jam/oral
nafas 28 kali/menit, suhu Sedimen leukosit 1, sedimen
36,7 C. eritrosit ), sedimen epitel sel
Kerjasama divisi
Skala nyeri 0 FLACC 4, sedimen lain-lain negativenutrisi dan
Lingkar perut 58 cm penyakit metabolic
GFR Hasil kultur (27-2-20) :
Konstanta 0,45 Biakan aerob : klebsiella - Bubur Saring
TB/PB 64 cm pneumoniae ssp pneumoniae 3X150 ml
Creatinin serum 0,2 Gram : bacil gram negatif - Susu Lactogen
GFR 144 ml/menit/1.73m2 5x120 ml
BB MRS 6,4 kg Urinalisa (21-2-20)
BB Kering 6,4 kg Warna kuning, pH 6,0 BJ Konsul Bagian
BB Aktual 6,4 kg <=1,005 Protein 1+, nitrit fisioterapi
Buang air kecil : positif, lekosit 2+, blood (Rehabilitasi
3.4 ml/kgbb/jam negatif, Medik) untuk
Sedimen leukosit 19, bladder training
sedimen eritrosit 2 , BACT
46,
Darah (20/2/20)
WBC 5800 HB 8,5 PLT

L4AD Saskia/perempuan/15-9-
3.1 2008/864671
Tensi 110/70 mmhg,
P50 85/40mmHg
P90 99/52 mmHg
P95 102/54 mmHg
P95+12 164/60 mmHg
nadi : 92 kali/menit, nafas
24 kali/menit, suhu 36,8
C.
Lingkar perut 62 cm
GFR
Konstanta 0,5
TB/PB 126 cm
Creatinin serum 0,50
GFR 126 ml/menit/1.73m2
BB MRS 26,7 kg
BB Kering 26,7kg
BB Aktual 27 kg
Buang air kecil : 2.3
cc/kgbb/jam
351000 SGOT 38, SGPT 12,
ferritine 22,13
Darah (18/2/20)
WBC 4720 HB 8,9 PLT
322.000 Ureum 15, Kreatinin
0,20, SGOT 42, SGPT 13,
Albumin 3.5, Na/K/Cl:
137/4,1/109
Primer : Problem : Infus dekstrose 5% Tampung KOOPERATIF
Cutaneous lupus 1. Makula eritem seluruh 20 tetes/menit urine 24 jam.
Sekunder : tubuh Na diklofenak 24 Urinalisa
Komplikasi : Laboratorium mg/12 jam/oral Konsul kulit
Urinalisa (2-3-2020) Salep mupirocin
Warna kuning muda, pH 7,0, pagi-sore
bj 1.005, protein Salep dexametason
negatif,bilirubin negatif, pagi-sore
lekosit negatif, blood negatif 10)Claritromicin 5
sedimen lekosit negatif, ml/12 jam/oral
sedimen eritrosit negatig, 4) Metilprednison
sedimen kristal negatif, 48 mg/24 jam /
sedimen epitel sel negatif oral
Darah (2-3-2020)
WBC 10.800 HB 11.5
Retikulosit 1.3
PLT 759.000, Ureum 24,
Creatinin 0.50, albumin 3.9,
SGOT 52, SGPT 68,
Na/K/Cl 142/3.6/112
Urinalisa (27-2-20)
Warna kuning, pH 6,5 BJ
<=1 .005 Protein negatif,
lekosit negatif, blood negatif,
Sedimen leukosit 1, sedimen
eritrosit 0, sedimen kristal 4,
bakteri=1
Darah (24/2/20)
WBC 12900 HB 13,2 PLT
357.000 Ureum 12,
Kreatinin 0,41, SGOT 68,
albumin 3,6, Na/K/Cl:
132/3,7/105
Urinalisa (24-2-20)
Warna kuning, pH 6,5 BJ
<=1 .005 Protein negatif,
lekosit negatif, blood negatif,
Sedimen leukosit 1, sedimen
eritrosit 1
Prodia (4/11/19)
RNP/Sm (RNP/Sm) ++, Sm
(Sm) +, SS-A native (60
kDa) (SSA) +++, R0-52
recombinant (52) +++, SS_B
(SSB) +++, ribosomal
protein (RIB) +++, control
(Ko) +++
L4AD Afikah Apriliya Primer : Problem : Kebutuhan cairan Tampung KOOPERATIF
3.5 Ahmad/perempuan/3-4- Sindrom nefrotik relaps 1. Edema 725 ml/24 jam urine 24 jam.
2012/912256 sering Laboratorium 6)Metilprednisolon Urinalisa
Tensi 100/70 mmhg, Sekunder : Urinalisa (2-3-2020) 40 mg/24 jam/oral
P50 94/52mmHg 1. Imbalance Warna kuning muda, pH 8.0 (pagi)
P90 107/68 mmHg elektrolit BJ 1.010 Protein +/30, 2)Ceftazidim 900
P95 110/71 mmHg 2. Community lekosit negatif, blood gr/12 jam/intravena
P95+12 122/83 mmHg acuired pneumonia negatif , Sedimen leukosit 1, 2)Amikasin hari
nadi : 100 kali/menit, 3. Trombositosis sedimen eritrosit 1 pertama 325 mg/24
nafas 22 kali/menit, suhu reaktif Darah (2/3/20) jam/Intravena
37,2 C WBC 19.100 HB 11.4 PLT Ambroxol 10 mg/
Skala nyeri 0 NRSl Komplikasi : 561.000 Ureum 9, Kreatinin 8 jam/ oral
ingkar perut 51 cm 0,6 SGOT 26, SGPT 11, Zink 20 mg/24
GFR magnesium 0.66, albumin 1,4 jam/oral
Konstanta 0,5 kolesterol total 373, Na/K/Cl: Paracetamol
TB/PB 120 cm 138/2,9/97 190 mg/8
Creatinin serum 0,60 jam/intravena
GFR 100 ( bila suhu ≥
ml/menit/1.73m2 Urinalisa (27-2-20) 38,5 C )
BB MRS 24kg Warna kuning muda, pH 7,5 Albuforce 5 ml/8
BB Kering 18 kg BJ 1.010 Protein ++/100, jam/oral
BB Aktual 18.4 kg lekosit negatif, blood Elkana 5 ml/24
Buang air kecil : negatif , Sedimen leukosit 1, jam/oral
3 cc/kgbb/jam sedimen eritrosit 1 Diet nefrotik
Darah (26/2/20) Kalori 1900 kkal
WBC 10300 HB 13,8 PLT Protein 15,2 gram
285.000 Ureum 59, Kalsium 1000 mg
Kreatinin 0,59, SGOT 34, Garam 5 gram
SGPT 11, albumin 1,4 Natrium 2 gram
kolesterol total 373, Na/K/Cl: Vitamin D 800-
124/2,8/102 1000 IU
Urinalisa (26-2-20) Calnic plus syrup
 Warna kuning, pH 6,5 BJ 10 ml/12 jam/oral
1.025 Protein +++/300,
keton +-, lekosit +-/15, blood
+-
Sedimen leukosit 3, sedimen
eritrosit 1, sedimen torak 2,
sedimen epitel sel 23 43,
bakteri = 13

Palem Zherha Natasya Primer : Problem : Conecta Tampung KOOPERATIF

Bawah Wardhana/perempuan/1 1. Peritonitis related 1. Nyeri perut berkurang Paracetamol urine 24 jam.
4-12-2004/844416 continous ambulatory 390 mg/ 8 jam/ Urinalisa
Tensi 120/80 mmhg, peritoneal dialisis Laboratorium intravena
NBP <120/80 mmHg 2. Chronic kidney Darah (3-3-2020) ( bila nyeri ≥
EBP 120/80 - 129/80 disease stage V WBC 10.900, Hb 8.9, PLT 3 NRS atau
mmHg Sekunder : 330.000 HCT 25%, GDS suhu ≥ 38,5)
Stage I 130/80 - 139/89 1. Anemia penyakit 141, Ureum 76, Kreatinin Peritoneal dialisis
mmHg kronik 6.47, SGOT 17, SGPT 8, Pukul 07.00
Stage II >140/90 mmHg 2. Hipertensi stage II Albumin 2.2, Na/K/Cl : Pukul 11.00
nadi : 120 kali/menit, Komplikasi : 133/3.1/101 Pukul 15.00
nafas 24 kali/menit, suhu Pukul 19.00
36,8 C Mikrobiologi cairan CAPD 3) Vancomycin 25
Skala nyeri 2 NRS (28-2-20) mg/liter
GFR Sel lain : leukosit 1+ dan intraperitoneal
Konstanta 0,7 epitel sel 1+ dalam cairan
TB/PB 156 cm Darah (26/2/20) dialisat 1.4 liter
Creatinin serum 6.47 WBC 13900 HB 10,7 PLT tiap ganti cairan
GFR 16.88 266.000 Ureum 99, (pukul 7-11-15-19)
ml/menit/1.73m2 Kreatinin 6,57, SGOT 25, Furosemide 60
BB MRS 39kg SGPT 9, albumin 3,6 mg/12 jam/oral
BB Kering kg Na/K/Cl: 130/3,6/97 Sprinolakton 25
BB Aktual 39 kg mg/12 jam/oral
 Buang air kecil : Amlodipin 10
1.3 ml/kgbb/jam mg/24 jam/oral
Losartan 50 mg/24
jam/oral
Metil dopa 250
mg/8 jam/oral
Amlodipin
sublingual
bila tensi ≥
160/100 mmhg
Diet rendah lemak
Diet rendah garam
Kalori 1950 kkal
Calvic plus 1
tablet/12 jam/oral
Elkana 1 tablet/24
jam/oral
L4AD Hildayanti/perempuan/1- Primer : Problem : Conecta Urinalisa/hari KOOPERATIF
10-2002/912610 Sindrom nefrotik 1. Edema Kebutuhan cairan Tampung
Tensi 120/70 mmhg, Sekunder : 1080 ml/24 jam urine 24 jam
NBP <120/80 mmHg 1. Hipertensi stage II Laboratorium Prednison 60 mg Cek Urin
EBP 120/80 - 129/80 2. Anemia penyakit Kimia Darah (3/3/20) (12 tablet)/24 Rutin bsok
mmHg kronik Kolestrol Total 265, Asam jam/oral pagi
Stage I 130/80 - 139/89 3. Hipoalbuminemia Urat 11.3, ASTO 105 Furosemide 100
mmHg 4. Hipercholesterolem Darah (2/3/2020) mg/24 Cek C3 (jika
Stage II >140/90 mmHg ia WBC 4.400 HB 9,9 PLT jam/intravena keluarga
nadi : 82 kali/menit, nafas Komplikasi : 185.000, Retikulosit 0.76 Captopril 12,5 bersedia)
22 kali/menit, suhu 36,9 C Ureum 52, Kreatinin 1, mg/8 jam/oral
GFR SGOT 32, SGPT 19, albumin Diet nefrotik
Konstanta 0,7 2,7 kolesterol total 255, Kalori 2140 kkal
TB/PB 151 cm Na/K/Cl: 134`/3,8/106 Protein 74,2 gram
Creatinin serum 1.00 Prokalsitonin 0.1 Kalsium 1000 mg
GFR 105.7 Apusan darah tepi : Anemia
ml/menit/1.73m2 Normositik Normokrom,
BB MRS 51,8kg Suspek kajsa penyakit
BB Kering 50 kg kronik, disertai leukosit
BB Aktual 51 kg dengan tanda infeksi
Buang air kecil :
1.63 ml/kgbb/jam Urinalisa (2-3-2020)
Warna kuning, pH 6.0 BJ
1.010 Protein +++/300,
lekosit +/70, blood +++/200, mg/12 jam/oral
Sedimen leukosit 13,
sedimen eritrosit 36, sedimen
epitel sel 2
Garam 6 gram
Natrium 2,4 gram
Vitamin D 800-
1000 IU
Calnic tablet 1
tab/12 jam/oral
Elkana tablet 1
tab/24 jam/oral
Ranitidin 150

Darah (28/2/20)
WBC 3200 HB 9,6PLT
131.000 Ureum 26,
Kreatinin 0,57, SGOT 37,
SGPT 19, albumin 2,4
kolesterol total 219, Na/K/Cl:
13`/3,5/108
Urinalisa (28-2-20)
Warna kuning, pH 7,0 BJ
1.010 Protein +++/300,
lekosit negatif, blood ++
+/200, Sedimen leukosit 25,
sedimen eritrosit 11, sedimen
epitel sel 64, Bakteri 33
Darah (28-2-20)
Coomb’s test : negative
L4AD Arif Harun/ Laki-laki/ Primer : Problem : Conecta Cek C3 (jika KOOPERATIF
11-11-2002/912658 Hipertensi Stage II 1. Nyeri Kepala Kebutuhan cairan keluarga `
Tensi 130/100 mmhg, Sekunder : 2. Penglihatan kabur 1940 ml/24 jam bersedia)
NBP <120/80 mmHg 1. Acute Kidney Laboratorium
EBP 120/80 - 129/80 Injury (teratasi) ASTO (3/3/20) 53 Amlodipin 5 Urinalisa
mmHg 2. Peningkatan enzim Kimia Darah (2-3-2020) mg/24 jam/oral (senin, kamis)
Stage I 130/80 - 139/89 transminase Ureum 33, Kreatinin 1.00,
mmHg 3. Imbalance SGOT 42, SGPT 144,, Furosemide 40 Cek darah
Stage II >140/90 mmHg elektrolit Na/K/Cl: 128`/3,1/93 mg/24 jam/oral lengkap
nadi : 92 kali/menit, nafas (Hiponatremia +
(senin,kamis)
22 kali/menit, suhu 38,9 C Hipokalemia) Urinalisa (2-3-2020) Paracetamol 500
GFR Komplikasi : Warna kuning tua, pH 6,0 BJ mg/8jam/intravena Tampung
Konstanta 0,7 1.020 Protein +++/300,
urine 24 jam.
TB/PB 136 cm lekosit negatif, blood +/25, Urdafalk 140
Creatinin serum 1.00 Sedimen leukosit 2, sedimen mg/8jam/oral Tunggu hasil
GFR 95.2 eritrosit 3, mucus 7
foto Thoraks
ml/menit/1.73m2 Diet rendah garam
BB Kering 43 kg USG Dopplet abdomen Diet rendah lemak
BB Aktual 44 kg 29/2/2020 Energi 2100 kkal
Buang air kecil : - Resistive index ginjal Protein 78 gram
3.2 ml/kgbb/jam dekstra 0.51
- Resistive index ginjal
sinistra 0.45

Darah (29/2/20)
WBC 6600 HB 15.4 PLT
286.000 Ureum 34,
Kreatinin 0,92, SGOT 45,
SGPT 174, albumin 3.8,
Na/K/Cl: 130`/3,4/93
Urinalisa (29-2-20)
Warna kuning muda, pH 7,0
BJ 1.010 Protein negatif,
lekosit negatif, blood negatif,
Sedimen leukosit 1, sedimen
eritrosit 1, sedimen epitel sel
2, sedimen epitel kristal 2
Laboratorium RS Faisal
Kimia Darah (27/2/20)
Ureum 43, Kreatinin
1.9,GFR 59 (trun 47%)
SGOT 77, SGPT 289,
Albumin 2.8
Darah (22/2/20)
WBC 8.300 HB 12.2 PLT
260.000 Ureum 37,
Kreatinin 1.3, SGOT 533,
SGPT 493, albumin 3.4,
Na/K/Cl: 132`/4.0/100
Urinalisa (27-2-20)
Warna kuning muda, pH 5.5
BJ 1.030 Protein +3, lekosit
negatif, blood trace, Sedimen
leukosit 2-3, sedimen eritrosit
2-3, sedimen epitel sel 4-6
Urinalisa (23-2-20)
Warna kuning muda, pH 5.5
BJ 1.030 Protein +1, lekosit
negatif, blood negatif,
Sedimen leukosit 2-3,
sedimen eritrosit 2-3,
sedimen epitel sel 6-7,
L4AD Aryani Fil Ardha/
Perempuan/5-4-2004/
912656
Tensi 110/60 mmhg,
NBP <120/80 mmHg
EBP 120/80 - 129/80
mmHg
Stage I 130/80 - 139/89
mmHg
Stage II >140/90 mmHg
nadi : 82 kali/menit, nafas
22 kali/menit, suhu 36,9 C
GFR
Konstanta 0,7
TB/PB 136 cm
Creatinin serum 1.57
GFR 60.63
ml/menit/1.73m2
BB Kering 28 kg
BB Aktual 28.5 kg
Buang air kecil :
1.93 ml/kgbb/jam
Primer : Problem : Conecta Urinalisa KOOPERATIF
Glomerulonefritis akut 1. Nyeri Kepala IWL + urin output (senin,
Sekunder : Laboratorium 1100 ml/24 jam kamis)
1. Acute Kidney AGD Vena (3/3/20) Paracetamol 280 Cek darah
Injury type Injury Dalam batas normal mg/8jam/intravena lengkap
2. Hipertensi stage II Darah (3/3/20) KSR 1 (senin,kamis)
3. Hipokalemia Retikulosit 1.06, WBC 5.900, Tablet/8jam/oral Tampung
4. Short stature HB 9.6, PLT 238, HCT 28 Konservatif urine 24 jam.
Komplikasi : Elektrolit (3/3/20) management
Na/K/Cl : 141/2.3/98 Calnic plus syrup Tunggu hasil
Calsium 5.2 10 ml/12 jam/oral jawaban
Magnesium 1.16, Elkana tablet 1 konsul Bedah
Imunoserologi lain tablet/24 jam/oral urologi
Ferritin 160.37 Diet rendah garam
ASTO 14 Diet rendah lemak
Darah (2/3/20) Energi 1100 kkal
WBC 8.400 HB 9.3 PLT Protein 42 gram
260.000 Ureum 52,
Kreatinin 1.57, SGOT 84, Koreksi kalium
SGPT 54, albumin 3.2 Kebutuhan Kalium
Na/K/Cl: 142`/1.9/101 62.04 meq
Kebutuhan cairan
Urinalisa (3/2/2020) dengan KAEN 3B
Warna kuning, pH 6.5 BJ 1560 cc/hari,
1.005 Protein +/30, lekosit deficit kalium 30.1
negatif, blood +++/200, meq
Sedimen leukosit 1, sedimen
eritrosit 1, sedimen epitel sel Koreksi lambat
248, Muc 4 Botol 1 KAen #B +
10 meq KCL 7.4%,
Darah (29/2/20) Botol 2 KAen #B +
WBC 14.900 HB 11.4 PLT 10 meq KCL 7.4%,
 319.000 Ureum 85, Botol 3 KAen #B +
Kreatinin 2.19, SGOT 211, 10 meq KCL 7.4%,
SGPT 69, albumin 3.9, Kec 65 ml/jam via
Na/K/Cl: 136`/1.5/93 infus pump
Urinalisa (29-2-20)
Warna kuning muda, pH 6.5
BJ 1.005 Protein negatif,
lekosit negatif, blood ++
+/200, Sedimen leukosit 0,
sedimen eritrosit 1, sedimen
epitel sel 110, sedimen epitel
kristal 30, Muc 4, Bac 3
Laboratorium RS Pangkep
Darah (21/2/20)
WBC 21.700 HB 10 PLT
417.000
Urinalisa (28-2-20)
Warna kuning muda, BJ
1.010, ph 6.5 Protein +2,
lekosit negatif, blood +2,
bilirubin +1, , keton negatif,
nitrit negative
NICU By.Ny Primer : Problem: Rawat inkubator Pantau KOOPERATIF
ST.Nurwahidah/Laki- Acute kidney Injury tipe Laboratorium Terpasang Balance
laki/912661/14-02-2020 failure Darah (2-3-2020) ventilator mekanik cairan
Tensi mmhg, Respiratory distress of the Leukosit 14.300, HB 13.0, Enteral : stop Periksa
P50 mmHg newborn et causa PLT 504, Hematokrit 38%, intake oral Analisa Gas
P90 mmHg pneumonia dextra PT 11.9, INR 1.16, APTT Parenteral : Darah (AGD)
P95 mmHg Sekunder : 33.7, Prokalsitonin 0.25 nutrisi parenteral Urinalisa
P95+12 mmHg Komplikasi : Prodia (28-2-20) 2)Meropenem (senin,
nadi : 166 kali/menit, nafas C3 komplemen 109 48mg/8jam/intrave kamis)
56 kali/menit, suhu 36,7 Darah (01-03-20) na Cek darah
C. WBC 17.800 Hb 14,3 PLT lengkap
Spo2 97% 557000, GDS 84, ureum (senin,kamis)
Skala nyeri 0 NIPS 146, kreatinin 4,83 SGOT 43, Tampung
GFR SGPT 3, Na/K/Cl urine 24 jam.
Konstanta 0,45 134/3,9/100 Kultur Urine
TB/PB 45 cm Ususl USG
Creatinin serum 4,83 Ginjal
GFR 90 ml/menit/1.6 m2
BB MRS 2020 gr
BB Kering -
BB Aktual 2020gr
Buang air kecil :
1,6 cc/kgbb/jam