Denah Ruang Rawat

Penyakit Dalam Pria (Aqsha 2)

Hari/Tanggal : Senin, 2 Oktober 2017

Tim Jaga : dr. Chairunnisa /dr. Mirzal
Dokter Muda : DM Zaida/ DM Ghina / DM Rehan / DM Putri / DM Wiri
K1B1 K1B2 K1B3 K1B4
DPJP : dr. Fauzi, Sp.PD DPJP : dr. Fauzi, Sp.PD DPJP : dr. Fauzi, Sp. PD DPJP : dr. Fauzi Sp.PD
COW : dr. Hendra COW : dr. Hendra COW : dr. Hendra COW : dr. Hendra
Dr : dr. Rizqi Dr : dr. Rizqi Dr : dr. Rizqi DR : dr. Rizqi
Div : GEH Div : Rheumatologi, GH Div : GEH, GH Divisi : GH, EMD

Nama: Bachtiar Nama: Yahya Nama: Andi Dermawan Nama :Lukman

Umur: 43 th Umur: 68 th Umur: 21 th Umur: 48 tahun
CM: 1-14-39-76 CM: 1-03-22-99 CM: 1-14-43-35 CM : 1-14-38-77
Hari rawatan: 6 Hari rawatan: 23 Hari rawatan: 3 Hari Rawatan:6

Ass/: Ass/ Ass/ Ass/

1.Disfagi + hiccup ec dd/ 1. CKD stg V ec kista ginjal 1. DHF grade II 1.penurunan kesadaran
-Parese nervus IX, X multipel sin 2. Sinusitis Maxilla Dextra (perbaikan) e.c dd
-Edema larink 2. hipertensi terkontrol -HAS
2.DD 1.Vertigo sentraldd 3. hiperkalemia ringan (perbaikan) Th/ -KAD
2.vertigo perifer 4. HNP -bed rest -Sepsis
3. Susp miastenia gravis 5. BPH - Diet hati II TKTP 2. Hipoalbuminemia
3. Ulkus Multiple Gaster 6. ISK asimptomatis - IVFD RL 20 gtt/i 3. ISK asimptomatik
4. Ulkus Duodenum 7. Gout athritis - Clindamycin 3x300 mg 4. dd/
5. Susp stroke iskemik - Psidii 2x1 sach (selama 3 hari) 1. PPOK Eksasebarsi
Th/ - Minosep Gargle 2x1 akut
Th/ -Bedrest 2. Pneumonia
-bed rest -diet ginjal 1700kkal + 50gr protein Lab 01/10/2017
-NGT - as folat 2x1 Hb/Ht/E/L/T Th/
-Diet sonde 6x200cc - lenal ace 2x1 13,8/38/4,9/6,9/69 -bed rest
-IVFD NaCl 0.9% 20 gtt/i - allopurinol 1x100mg MCV/MCH/MCHC -Diet ginjal II 1700 kkal +
-IV Ceftriaxon 2gr/24 jam - Gabapentin 1x300 mg 78/28/36 0,6gr/kgBB/hari
-IV Omeprazole 40 mg /12 jam -omeprazole 2x20 mg Diftell: 4/1/046/37/12 -IVFD RL 20 gtt/i
-IV ondansetron 4 mg/8 jam -fit bon tab 1x1 -IV lansoprazole 30 mg/12j
-clorpromazin 2x12,5 mhg -coditam tab 3x1 Lab 30/09/2017 - SC Lantus 0-0-0-8 IU
-Sukralfat syr 3xCI -Recolvar tab 3x1 Hb/Ht/E/L/T - SC Apidra 6-6-6
-Paracetamol 3x500mg -Methylprednisolone tab 2x4 mg 15/42/5,4/8,1/26 - Nebule combivent / 8
-Balance cairan - Hemodialisis senin-kamis MCV/MCH/MCHC jam
-IV Mecobalamin 1 amp/8 jam 78/28/36 - Nebule flixotide 1 mg/12
-IV citicolin 500 mg /12 jam Lab 29/09/2017 Diftell: 2/1/0/52/35/10 jam
-Asam Folat 2x1 Hb/L/T GDs: 107 - Drip albumin 20% 100
-Amoxicilin 2x1000 mg (H4) 9,1/7,8/359 Ur/Cr: 26/0,94 cc/24 jam
-Azitromicin 1x500 mg (H4) MCV/MCH/MCHC Na/K/Cl -IV parasetamol 1 gr/8 jam
-Betahistin mesilate 3x10 mg 86/29/33 134/3,6/102 -IV Meropenem 1 gr/8 jam
-Mestinon 4x1 Ur/Cr: 87/4,37 PT/APTT : 10,2/43,1 -IV Neropenem 1 gr/8 jam
-Iv Dexametason 4x1 Na/K/Cl Anti Dengue IgG/IgM : positif /
133/4,5/102 positif Lab 30/09/2017
Lab 28/09/2017 LED : 130 Analisa gas darah
Hb/Ht/E/L/T APTT : 40,7 PH : 7,493
16,3/46/5,2/8,5/214 PT : 1,08 pCO2 : 33,90
MCV/MCH/MCHC D dimer = 1006,75 pO2 : 92
87/31/36 HCO3 : 26,2
Diftell: 3/1/0/72/16/8 Lab 26/09/2017 Total CO2 : 27,3
CT/BT: 7/2 Hb/Ht/E/L/T BE : 3,7
HbsAg; negatif 9,9/29/3,4/11,8/384 Saturasi O2 : 97,9
MCV/MCH/MCHC
Urinalisa (28/09/2017) 24/29/35
Lab 29/09/2017
Makroskopik: Diftell: 3/2/0/70/12/13
Ca/Mg : 8,6/1,4
Keton: positif Ur/Cr: 123/9,64
Na/K/Cl; 140/3,8/116
Urobilinogen: positif Na/K/Cl
Gds : 246
Mikroskopik: 130/4,2/95
Na/k/Cl : 147/3,5/112
Leukosit: 1-2
Eritrosit: 0-1 Lab 22/09/2017
Epitel: 4-6 Urinalisa
Lab 28/09/2017
Warna kuning keruh
Ca/Mg : 8,4/1,9
Lab 27/09/2017 Protein: +2
Na/K/Cl; 139/3,0/111
Hb/Ht/E/L/T Glukosa: -
16,4/45/5,2/10,4/167 Urobilinogen: -
MCV/MCH/MCHC Bilirubin: -
Lab 27/09/2017
87/32/37 Hb/Ht/E/L/T
Hb/Ht/E/L/T
Diftell: 1/0/0/83/10/6 11,3/33/3,9/19,7/428
10,3/30/4,0/31,4/129
Ca: 8,8 MCV/MCH/MCHC
MCV/MCH/MCHC
GDS: 155 84/29/34
74/26/35
Ur/Cr: 23/1,01 Diftell: 2/1/0/82/8/7
Diftell: 0/0/0/93/4/3
Na/K/Cl: 135/3,8/102 Ur/Cr: 94/8,18
Ur/Cr: 136/2,33
Na/K/Cl
Na/K/Cl: 134/3,2/109
134
K2B1 K2B2 K2B3 K2B4 K2B5
DPJP: dr.Fauzi DPJP: dr. Fauzi DPJP: dr. Fauzi DPJP: dr. Fauzi DPJP:dr. Fauzi,
Sp.PD Sp.PD Sp.PD Sp.PD Sp.PD
COW: :dr. Hendra COW: dr. Hendra COW:dr.Hendra COW: dr. Hendra COW:dr.Hendra
Dr: dr. Rizqi Dr : dr. Rizqi Dr:dr. Rizqi Dr : dr. Rizqi Dr :dr. Rizqi
Div : GEH Div : EMD Div : Div : Div :

Nama: Hasballah Nama: Abdullah Nama: Zainal Arifin Nama: Nasrullah Nasir Nama: Jouhari Yusuf
Umur: 49 tahun Rahman Umur: 40 tahun Umur: 37 tahun Umur: 48 tahun
CM: 1-14-01-65 Umur: 55 tahun CM: 1-03-65-66 CM:1-14-43-38 CM: 1-14-42-18
Hari Rawatan: 22 CM: 1-14-43-10 Hari Rawatan: 3 Hari Rawatan : 3 Hari Rawatan: 4
Ass/ Hari Rawatan: 3
1.Hepatoma dengan Ass/ Ass/ Ass/
cancer pain Ass/ 1.Pansitopenia ec dd/ 1.CAP 1.Hematoskezia ec
2.Hipoalbumin ec 1.Abdominal pain ec -Myelofibrosis 2. PSMBA ec dd:
penyakit hati kronis dd -leukimia 1. Gastritis erosif -colitis infeksi
3.Hiponateremi -colitis infeksi -MDS 2. Ulkus Gaster -chron disease
hipoosmolar -colitis ulseratif -Thalasemia 3. Ulkus Duodenum -polip recti
hipervolemia ec -IBD -PNH 3. Hepatomegali ec -hemoroid interna
sirosis hati 2. Trombositosis 2. hipokalemia sedang 1. Abses Hepar 2. Oral Kandidiasis ec
4.Hepatorenal reaktif 2. Kista Hepar dd:
syndrome 3.Hiponatremia Th/ terinfeksi -Autoimmune disease
5.Candidiasis oral hipoosmolar -bedrest 3. Hepatoma 3.sellulitis a/r pedis
(perbaikan) hormovolemik -diet mII 1700 4. Anemia Sedang ec dextra
6.OA shoulder joint kkal/hari 1. Perdarahan 4.abses a/r
dex Th/ -ivfd Nacl 0,9% 20 2. Penyakit kronik antebrachii D
7.Anemia normokrom - Bedrest gtt/i 5. hernia scrotalis
normositer ec - Diet M II 1700 kkal/hari -iv ciprofloxacin Th/ reponible sinistra
penyakit kronis -IVFD NaCl 0,9% 20 200mg/12j -Bed Rest 6.anemia sedang
8,Hemoroid eksterna gtt/i -KSR 3x600mg tab - IVFD NaCL 0,9% 20 normokrom ec dd
gr II - IV Cefoperazone -transfusi PRC s.d Hb gtt/i -perdarahan
9.High Risk Trombosis sulbactam 1 gr/8 jam > 9 gr/dl - Diet MII 1700 -peny. kronis
10.ISK kkal/hari
-IV Lansoprazole 30 mg/12
Lab 01/10/2017 - IV. Cefoperazone
Th/ jam Hb/Ht/E/L/T Sulbactam 1 gr/ 8 jam Th/
- Bedrest - Sucralfat syr 3xCII 6,5/21/2,4/1,6/210 - IV Lansoprazole 30 -Bedrest
- Diet hati II 1700kkal + - Trombo aspilet 1x MCV/MCH/MCHC mg/12 jam -Diet sonde oral
80mg 87/27/32 -Sucralfat 3xC1 6x200cc
Hepatosol susu 3-4x/h
- IVFD aminofusin hepar 1 Diftell : 1/1/0/32/62/4 -Balance Cairan -Ivfd Nacl 0,9 % 20
Lab 29/09/2017 -Sistenol 3x1 tab gtt/i
fls/hr Hb/Ht/E/L/T Lab 29/09/2017 -Donperidon 2x10 mg -iv. ceftriaxone 2
-IV Ceftriaxon 1 gr/12 jam 11,0/32/3,9/14,7/1252 Hb/Ht/E/L/T -Drip tramadol dalam gr/24 j
(H9) MCV/MCH/MCHC 6,6/21/2,5/1,1/86 Nacl 0,9% 20 gtt/i -iv transamin
- Durogesic patch 37 82/28/34 MCV/MCH/MCHC 500mg/8 jam
mg/3hari Diftell: 9/1/0/56/20/14 85/27/32 Lab RSU Langsa -clindamycin 2x300
1. Duragesic patch HbsAg: Negatif Diftell: 1/1/0/42/48/8 26/09/2017 mg
25 mg (H3) GDS: 135 GDS: 148 Hb/Ht/E/L/T -drip Pct 500 mg/8 j
2. Duragesic patch Ur/Cr: 8/0,59 Ur/Cr: 22/0,61 8,5/25/3,17/10,47/353 -nistatin drop 4x2 cc
12 mg (H2) Na/K/Cl: 126/4,2/95 Na/K/Cl: 138/2,5/109 Diftell:1,5/0,1/9,8/94/0 - Minocep gargle
- Lactulac syr 3xCII ,4/0
(30cc) Lab RSU Arun MCV/MCH/MCHC :
- Coditam 3x1 tab 27/09/2017 79,2/ 26,8/ 33,9 Lab 29/09/2017
- Becombion syr 3xCII Hb/Ht/E/L/T Hb/Ht/E/L/T
- Sucralfat syr 3xCII 10/32,5/3,6/21,1/1002 8,8/27/2,8/23,6/331
- anti hemoroid 1 Diftell:2/0/5/72/14/7 MCV/MCH/MCHC
supp/12j 96/32/33
- spironolacton Diftell: 1/0/0/79/12/8
1x300mg PT/APTT : 11,0/50,4
- pradaxa 1x75mg Bilirubin total : 1,11
-IV Ceftriaxon 1g/12J Bilirubin direct : 0,88
-IV Furosemid 1 Bilirubin indirect : 0,23
amp/12 jam SGOT/SGPT : 50/75
Lab 28/09/2017 LED : 120
Hb/Ht/E/L/T
8,8/25/2,8/13,0/345
MCV/MCH/MCHC Lab 29/09/2017
89/31/35 Hb/Ht/E/L/T
Diftell:2/0/0/75/13/10 8,4/25/2,7/22,3/368
Na/K/Cl MCV/MCH/MCHC
126/4,8/98 95/32/33
Ur/Cr: 65/1,27 Diftell: 0/0/0/82/11/7
Urinalisa CT/BT: 8/2
(28/09/2017) GDS: 112
Protein (+2) Ur/Cr: 21/0,72
Bilirubin (+) Na/K/Cl: 126/3,7/101
Leukosit: 6-8
Eritrosit: 1-2
Epitel: 3-5
Lab 25/09/2017
Hb/Ht/E/L/T
9,0/25/2,9/14,6/295
MCV/MCH/MCHC
88/31/36
Diftell:1/1/0/75/15/8
GDs: 61
Na/K/Cl
127/5,4/103
Ur/Cr: 76/1,45
Lab 22/9/2017
(14:39)
Hb/Ht/E/L/T
7,7/21/2,5/12,8/271
MCV/MCH/MCHC
87/31/36
Diftell: 0/0/1/78/13/8
MDT: anemia
normokrom
normositer

K3B1 K3B2 K3B3 K3B4 K3B5

DPJP : dr. Krisna DPJP : dr.Krisna DPJP : dr. Krisna DPJP : DPJP : dr. Krisna
Sp.PD Sp.PD Sp.PD COW : Sp.PD
COW : dr. COW COW : dr. DR : COW :dr.
hendra/dr.Alfi :dr.Hendra/dr.Alfi Alfi/dr.Hendra Divisi : Alfi/dr.Hendra
DR : dr. Irwandi DR : dr. Irwandi DR : dr. Irwandi DR : dr. Irwandi
Divisi : GEH Divisi : GH Divisi : Divisi : GEH
HOM,Respirologi
Nama: Sukardi Nama: Nazaruddin Nama: Marzuki Nama : Mawardi
Umur: 34 th Umur: 52 th Umur: 62 th Umur : 55 thn
CM: 1-14-37-48 CM: 1-14-37-47 CM: 1-14-33-80 CM : 1-09-84-94
Hari rawatan: 6 Hari rawatan: 7 Hari Rawatan : 10 Hari Rawatan: 5

Ass/ Ass/ Ass/ Ass/

1.Hepatomegali ec dd/ 1.CKD stageV on HD 1. sepsis (Perbaikan )ec 1.Ulkus gaster a.r.
-Abses hepar piogenik reguler ec dd antrum dengan
-kista hepar -PNC -HAP gastritis antral sedang
2.Hiponatremia -HN -ulkus pedis dextra 2.Anemia sedang ec
hipoosmolar euvolemik 2. HAP dd/ - Urosepsis dd:
bronkiektasis 2.DVT ar Pedis dekstra -Penyakit kronik
Th/ 3. Anemia berat ec dd -perdarahan
-Bedrest penyakit kronik 1. Sellulitis
-Diet hati II dengan 4.Hipertensi stage II 3.AKI stg.II Pre Renal Th/
kebutuhan kalori 1700 5.Hiperkalemia 4.HAP dd -Bed rest
kkal/hari 6.Susp stroke iskemik Bronchiektasis -Diet MII 1700 kkal
-IVFD Aminofusin hepar 5.Anemia hipokrom -IVFD RL 30 gtt/i
1 fls/hari 20 gtt/i Th/ mikrositer ec dd/ -IV omeprazole 40
-IV Cefoperazone -Bedrest -perdarahan mg/ 12 jam
1gr/12jam (H6) -Diet ginjal 1700 -defisiensi Fe -IV Tramsamin 500mg
-IV Metronidazole 500 kkal/hari + 60 gram 6. dd/ 1. Ileus paralitik /8jam
mg/8 jam protein 2. mechabical -Sucralfat syrp 3xCI
-Sistenol 3x1(k/p) -O2 2-4 L/i bowel - Paracetamol 3x500
-Kaltropen supp -three way syndrome mg
-Curcuma 3x1 -IV ceftriaxon 2 gr/ 24 Th/
-Coditam 2x1 (k/p) jam -Bedrest Lab 29/09/2017
-drip tramadol 1 amp/8 -drip paracetamol 1 - O2 2-4L/i nasal kanul Besi (Fe/Iron) : 59
jam gr (k/p) -Diet hati II dengan Ur/Cr : 36/ 0,95
- valsartan 1x160 mg kebutuhan kalori 1700 Na/K/Cl : 136/3,9/109
Lab 26/09/2017 -amlodipin 1x10 mg kkal/hari
Hb/Ht/E/L/T - HCT 1x25 mg - kateter
13,0/36/4,2/24,2/289 -HD selasa-jumat -IVFD NaCl 0,9% 20 Lab 28/09/2017
MCV/MCH/MCHC -Transfusi PRC s.d gtt/i Hb/Ht/E/L/T
87/31/36 Hb>10gr/dl -IVFD Clinimix 1 fls/hari 8,2/28/4,2/6,4/438
Difftel: 2/0/0/79/5/14 -Bisoprolol 20 gtt/i MCV/MCH/MCHV
HbsAg: Negatif - IV Prosogan 30 mg/12 66/20/30
Bil total/direk/indirek Lab 29/09/2017 J Diftell : 3/1/1/68/18/9
2,10/1,76/0,33 Hb/Ht/E/L/T -IV Meropenem 1g/12 J CT/BT : 9/3
SGOT/SGPT: 72/80 8,0/24/2,9/10,1/212 -IV Parasetamol 1 gr/8
GDS: 103 Difftel: 1/0/0/84/11/4 jam
Ur/Cr : 77/1,00 -Clindamicin tab
Na/K/Cl : 126/3,9/96 Lab 26/09/2017 3x300mg
Hb/Ht/E/L/T -IV plosogan 30 gr/12
4,9/15/1,8/11,0/238 jam
Difftel: 1/1/0/80/12/6 -Sukralfat syr 3xCI
HbsAg : negatif -IV Paracetamol 1gr/8J
Anti HCV : negatif -Kalitake 3xsachet I
GDS : 113 -SC Lovenox
Ur/Cr : 169/14,61 0,6cc/24jam
Na/K/Cl : 195/6,0/102 -Atorvastatin 1x40mg
-IVFD clinimix 1 fls/hari
-tranfusi PRC 2 kolf /
hari (pagi-malam) sd
Hb ≥ 10 gr/dl
 Lab 29/09/2017
Hb/Ht/E/T/L
5,4/18/2,9/214/12,2
MCV/MCH/MCHC :
64/19/30
Diftel: 3/0/0/82/10/5
CT/BT : 8/3
Ur/Cr : 63/0,95
Na/K/Cl : 136/5,1/117
Lab 23/09/2017
Na/K/CL: 134/6,0/111
Lab 20/09/2017
Hb/Ht/E/T/L
6,9/22/3,5/244/23,2
MCV/MCH/MCHC :
63/20/31
Diftel: 0/0/0/97/1/2
Ur/Cr : 149/2,31
Na/K/Cl : 130/7,1/107

K4B1 K4B2 K4B3 K4B4 K4B5

DPJP : DPJP : dr. Krisna DPJP : DPJP : dr. Krisna, DPJP : dr. Krisna
dr,Krisna,Sp.PD Sp.PD COW : Sp. PD Sp.PD
COW : COW :dr. DR : COW : dr. COW
dr.Hendra/dr.Alfi Hendra/dr.Alfi Alfi/dr.Hendra :dr.Alfi/dr.Hendra
DR : dr.Irwandi DR : dr. Irwandi DR : dr. Irwandi DR : dr. Irwandi
Divisi : Divisi : HOM Divisi : HOM, PTI Divisi :
Reumaologi,GEH

Nama : M. Hartama Nama : Wismanto Nama : Nama: Imran Nama: Hardianto

Umur : 18 tahun Umur: 57 tahun Umur: Umur: 34 th Umur: 34 tahun
CM : 0-89-33-43 CM : 0-97-14-42 CM : CM: 0-98-70-38 CM: 1-14-43-03
Hari rawatan : 1 Hari Rawatan: 3 Hari Rawatan: Hari rawatan: 9
Hari Rawatan: 3
Ass/ Ass/ Ass/
1. Thalasemia 1. PPOK eksaserbasi 1.dd/ Ass/
akut -Hepatitis viral infection 1.PSMBA ec dd/
Th/ 2.Abdominal distensi -Hepatitis thyposa -ulcus gaster
-Kaltropen supp 4x1 ac -Leptospirosis -ulcus duodenum
-Lansoprazole - Ileus 2.Trombositopenia ec -varises bleeding
1x30gr -Meteorismus dd/
-gastritis erosiva
- Buscopan tab -Infection induces
1x10mg Th/ trombositopenia 2.Anemia ec def. besi
-Transfusi PRC sd Hb -bed rest -Clumping
≥ 10 gr/dl -O2 2-4 l/i , target trombositopenia Th/
-Exzade tab 2x500gr SaO2 : 94% -ITP -bedrest
-As.Folat 2x1 -Diet bebas lemak -Leukemia -diet MII 1700
-Vit E 2x1 karbo 3. Cholesystitis kkal/hari
-NGT dekompresi
-IVFD futrolit 20 gtt/i
Lab 01/10/2017 sementara diet 40 % Th/
Hb/Ht/E/L/T dari kebutuhan kalori -Bedrest -IV lansoprazole 30
8,2/23/3,2/2,9/46 -Diet cair sonde -Diet MB dengan mg/12 jam
MCV/MCH/MCHV -Seretide 2 dd 1 pulf kebutuhan kalori -IV. Vit K 1 amp/8j
74/26/35 -Domperidne 3x 10 1700kkal/hari -IV transamin
Diftell : 0/0/1/58/32/9 mg -IVFD RL 20 gtt/i 500mg/8j
Bilirubin tot : 4,26 - IV Ceftazidine 2 g/ 8 -IV ceftriaxone 3 gr dlm -Sucralfat syr 3xCI
Bilirubin direct/ind jam 100 cc dex 5% habis
-Transfusi PRC 2 kolf
2,10/2,16 - Ventolin nebule/ 8 dalam 2 jam
SGOT/SGPT : 24/17 jam -IV paracetamol 1gr/8 j s.d Hb > 10 gr/dl
GDS : 82 - Omeprazole 2x1 tab -IV Novalgin 1 amp/8 j, (pagi malam)
Ur/Cr: 29/0,32 jika temp > 38,6 C
Na/K/Cl: 135/4,3/110 Lab 29/09/2017 -Transfusi TC 10 kolf Lab 29/09/2017
Hb/Ht/E/L/T bila trombosit <10.000 Hb/Ht/EL/T
14,8/44/5,0/12,0/278 dan trombosit <20.000 5,6/20/3,1/8,5/168
s + perdarahan
MCV/MCH/MCHC
MCV/MCH/MCHV
87/30/34 Lab 01/01/2017 63/18/28
Diftell : 2/0/0/63/28/7 Hb/Ht/E/L/T Diftell: 0/1/0/76/17/6
HbsAg: negatif 13,0/37/4,6/5,6/4 SGOT/SGPT:16/18
SGOT/SGPT: 25/42 MCV/MCH/MCHC PT/APTT : 10,8/32,6
Albumin: 3,32 82/29/35 GDS: 181
Ur/Cr: 39/0,82 Diftell: 1/0/0/34/57/8 Ur/Cr: 46/0,48
Na/K/Cl: 140/3,9/106 Na/K/Cl: 139/3,6/104
Ca/Mg : 8,0/2,0 Lab 29/09/2017
 CT/BT : 9/3 Hb/Ht/E/L/T
12,8/37/4,5/7,/7
MCV/MCH/MCHV
82/29/35
Diftell : 0/1/0/56/37/6
Bilirubin total : 0,82
Bilirubin direct : 0,67
Bilirubin indirect : 0,15
SGOT/SGPT : 390/360
ALP : 220 s
Lab 28/09/2017
Hb/Ht/E/L/T
12,5/35/4,4/7,6/2
MCV/MCH/MCHV
81/29/36
Diftell : 0/1/1/60/34/4
Lab (27/09/2017)
Anti HCV negatif
Hbsag negatif
Urinalisa:
Protein (+2)
Leukosit 10-20
Eritrosit 6-8
Epitel 8-10
Lab 25/09/2017
Hb/Ht/E/L/T
14,8/44/5,5/8,0/30
MCV/MCH/MCHC :
80/27/34
Diftel: 1/0/0/39/35/25
Bilirubin : 1,36
Bilirubin direct/indirect
0,90/0,46
Anti dengue IgG (-)
Lab 24/09/2017
Hb/Ht/E/L/T
15.8/43/5.4/7.9/10
MCV/MCH/MCHC :
80/29/37
Diftel: 0/0/0061/34/5
Anti dengue IgM (-)
Anti dengue IgG (-)

K5B1
K5B2 K5B3 K5B4 K5B5
DPJP : dr. M. DPJP : dr. Riswan, DPJP : dr. Riswan, DPJP : dr. M.Riswan, DPJP : dr. M. Riswan,
Riswan, Sp.PD Sp.PD Sp.PD Sp.PD Sp.PD
COW:dr.Hendra/dr COW : dr. COW : COW : dr. COW : dr.Hendra/dr.Alfi
.Alfi Hendra/dr.Alfi dr.Hendra/dr.Alfi Hendra/dr.Alfi Dr : dr. Utha
Dr : dr. Utha Dr : dr. Utha Dr : dr. Utha Dr : dr. Utha Div :
Div : GEH Div : Div : GH
Nama : Wahab Abu Nama: Asnawi Ilyas Nama: Darmansyah Nama: D Ginting Nama: Thamrin Yusuf BA
Umur: 61 tahun Umur: 65 th Umur: 45 th Umur: 60 Tahun Umur: 69Tahun
CM : 1-14-38-79 CM :1-14-40-66 CM: 1-03-45-65 CM: 1-14-25-91 CM: 1-08-77-69
Hari rawatan : 5 Hari rawatan: 4 Hari rawatan: 6 Harirawatan: 16 Hari rawatan : 4

Ass/ Ass/ Ass/ Ass/ Ass/

1.Sirosis hepatis 1.PSMBA ec dd/: 1.CKD stage V ec 1. CKD stage V ec. HN 1.Ca recti
stadium DC dengan -Ulkus gaster PGOI on HD reguler on HD reguler 2.Hepatomegali ec dd/
hepatoma -Ulkus duodenum 2.CHF FC NYHA III-IV 2. Anemia berat NN ec. 1.Metastase proses
2. HAP -Gastritis erosif ec -Penyakit kronik 2. HCC
3. Anemia sedang ec 2.Anemia berat -HHP - Perdarahan 3. Hiponatremia
dd: hipokrom mikrositer -DCM 3. Hipertensi grade II normoosmolar
-penyakit kronik ec dd: 3.Dyspepsia type 4.DVT
-perdarahan -perdarahan mixed dd/ type like
-penyakit kronik ulcer Th/ Th/
Th/ -Bedrest Bedrest
-Bedrest Th/ Th/ - Diet ginjal Diet MB
-three way -Bedrest -Bedrest 1700kkal/hr Ivfd Nacl 0,9% 20gtt/i
-O2 2-4 L/i -NGT terpasang -Diet ginjal 1700 - lenal ace 2x1 Iv kalnex 500mg/8j
-IVFD aminofusin -Diet MIII 1700 kkal/ hari + 70 gr - As folat 2x1 Iv omeprazole 40mg/12 j
heapr 1 fls /hari kkal/hari protein - Amlodipin 1x10mg Graphalac syr 3x CII
-Diet hati II 1700 -IVFD NaCl 0,9% 20 -three way - Valsartan 1x160mg
kkal/hari gtt/i -Lenal ace 3x169 mg - Bisoprolol 1x5mg Lab 29/09/2017
-IV Cefoperazone -IV Lansoprazole 30 -Asam folat -HCT 1x5mg Hb/Ht/E/L/T
sulbactam 1 gr/12 mg/12 jam 2x400mg - HD 2xseminggu 10,6/30/3,4/10,5/276
jam -Sucralfat syrup 3xCI -Bisoprolol 1x5 mg (selasa-jumat) MCV/MCH/MCHV
-IV furosemid 40 -IV asam -Tanapress 1x5 mg -transfusi on HD 88/31/36
mg/12 jam traneksamat -HD senin – kamis Diftell : 3/1/0/71/16/9
-Spironolakton 500mg/8jam -Domperidon 3x 10 Lab 28/09/2017 Ur/.Cr : 25/0,97
2x100 mg -Transfusi PRC sd mg Hb/Ht/E/L/T Na/K/Cl: 128/3,8/104
-Sistenol 3x1 Hb10 gr/dl -IV omeprazole 40 10,1/30/3,5/9,2/252 GDS: 227
-Curcuma 3x1 mg/12 jam MCV/MCH/MCHV CT/BT: 7/2
-Graphalac syr 3x30 Lab 01/10/2017 -Antasid syr 3x1 85/29/34
cc Hb/Ht/E/L/T PT/APTT: 11,5/41,3 AFP: 1,95
-Propanolol 2x10 mg 8,8/27/3,4/5,9/247 Lab 29/9/2017 D-dimer: 1678,66 SGOT/SGPT : 71/30
-Balance cairan MCV/MCH/MCHV Urinalisa: Ur/Cr: 112/7,18 ALP : 243
-Transfusi PRC s.d. 78/26/33 Protein (+2) Na/K/Cl: 136/3,6/109 Albumin :2,96
HB>9 gr/dl Diftell : Leukosit 20-25
-Lamivudin 1x1 3/0/0/75/14/8` Eritrosit 8-10 Lab 25/09/2017
Epitel 6-8 Hb/HtE/L/T : Urinalisa:
Lab 01/10/2017 Lab 28/09/2017 8,1/24/2,7/7,6/236 Protein (+1)
Hb/Ht/E/L/T Hb/Ht/E/L/T Lab 26/09/2017 MCV/MCH/MCHC : Leukosit 6-8
10,8/32/3,7/7,9/125 5,8/18/2,3/8,9/207 Hb/Ht/E/L/T 88/30/34 Eritrosit 1-2
MCV/MCH/MCHV MCV/MCH/MCHV 8,9/27/3,1/6,2/178 Difftell : 8/1/0/67/16/8 Epitel 3-5
86/29/34 78/26/33 MCV/MCH/MCHV SGOT/SGPT: 22/28
Diftell : Diftell : 87/29/33 Ur/Cr/Na/Cl
3/1/1/73/9/13 1/0/0/80/12/7 Diftell : 128/7,03/137/3,5/108
Ur/.Cr : 35/0,70 7/1/0/63/20/9
Na/K/Cl: Albumin: 3,33 Lab 21/09/2017
Lab 28/09/2017
138/3,4/109 HbsAg : negatif Hb/HtE/L/T :
Hb/Ht/E/L/T
HbsAg; negatif GDS:92 7,9/23/2,7/7,8/252
6,7/21/2,2/8,2/89
GDS: 99 SGOT/SGPT: 47/94 MCV/MCH/MCHC :
MCV/MCH/MCHV
CT/BT: 8/3 TroponinI/CKMB: 86/29/34
95/31/32
<0,10/25 Difftell : 6/1/0/61/18/14
Diftell :
Ca: 8,2 SGOT/SGPT: 31/34
2/0/0/78/12/8
Ur/Cr: 90/9,31 Ur/Cr/Na/Cl
CT/BT: 7/2
Na/K/Cl: 134/5,4/108 120/7,64/136/3,5/107
PT/APTT: 14,5/39,5
D-dimer: 603,14

Lab 26/09/2017
Hb/Ht/E/L/T
6,6/20/2,1/11,1/98
MCV/MCH/MCHV
96/32/33
Diftell : 1/1/0/80/9/9
HbsAg: positif
Bil
total/direk/indirek:
2,53/1,88/0,66
SGOT/SGPT: 178/105
Albumin: 2.62
GDS:105
Ur/Cr: 52/0,80
Na/K/Cl: 125/5,2/101

K6B1 K6B2 K6B3 K6B4 K6B5

DPJP : dr. M. DPJP : dr. M. DPJP : dr. M. DPJP : dr. M. Diah, DPJP :dr.
Riswan, Sp.PD Riswan, Sp. PD Riswan, Sp.PD Sp.PD M.Riswan,Sp.PD
COW : COW COW : dr. COW : dr. COW : dr.
dr.Alfi/dr.Hendra :dr.Hendra/dr.Alfi Hendra/dr.Alfi Alfi/dr.Hendra Alfi/dr.Hendra
Dr : dr. Utha Dr : dr. Utha Dr : dr. Utha Dr : dr. Utha Dr : dr. Utha
Div : EMD Div : EMD Div : Div : GEH, Div : HOM
Respirologi
Nama : Jahidin Nama: Syamsuddin Nama: Fakhruddin Nsma: Nama :Bakhtiar
Ibrahim HS Umur: 58 tahun Umur: Umur : 49 tahun
Umur : 43 th Umur: 54 th CM: 1-14-30-59 CM: CM : 1-08-22-56
CM : 1-14-43-16 CM: 1-10-48-07 Hari Rawatan: 8 Hari rawatan: Harirawatan :7
Hari rawatan : 3 Hari rawatan: 5
Ass/ As/
Ass/ Ass/ 1. AKI Stage III dd 1. Diare kronik
1.Dd/ 1.CKD stage V ec dd; akut on CKD ec dd/
1. DVT -DN 2. ISK -colitis ulseratif
2. PAD -GNC 3. Hipoalbuminemia -colitis TB
3. Sellulitis 2.Hiponatremi -chronic disease
hipoosmolar Th/ 2. dispepsia like ulcer
Th/ hipovolemik -Bedrest dd/
-bed rest 3.Hiperkalemia -Diet ginjal 1700 kkal - tipe dismodility
-diet MII 1700kkal ringan + protein 0,6 gr/kgbb - tipe mixed
rendah lemak 4.DM type 2 NW -IVFD NaCl 0,9%
-IVFD NaCl 0,9% 20 5. HT terkontrol 20gtt/i Th/
gtt/i -IV Cefepim 1gr/12 -bed rest
- IV Ceftriaxon 2 Th/ jam -diet lunak
gr/24 jam -Bedrest -Paracetamol 1 -IVFD RL 20 gtt/i
-Pradaxa 1x 75 mg -three way gr/8jam - IV Cifrofloxacin 400
- Omeprazole 2x20 -IVFD NaCl 0,9%20 -IV Omeprazole gr/24 jam
mg gtt/i 40mg/24 jam - drip ondansentron 4
- Sucralfat syr 3xCII -Diet ginjal 2100kkal -drip albumin 25% mg/8 jam
+42 gram 100 ml/hari -Atrapulggitte 1
Lab 29/09/2017 protein/hari -Balance cairan tab/diare
Hb/Ht/E/L/T -Lenal ace 2x1 -domperidone 3x10 mg
9,5/30/5,1/5,5/169 -Kalitake 3x1sach Lab 26/9/2017 -Buscopan 3x1
MCV/MCH/MCHC -IV ondancetron 4 Hb/Ht/E/L/T -lacto B 3x1
59/19/32 mg/8jam 10,2/32/3,7/17,3/298 KSR 2x600 mg
Diftell: 3/1/1/65/22/8 -Amlodipin 1x5 mg MCV/MCH/MCHC
Ur/Cr: 27/1,16 85/27/32 Lab 27/09/2017
GDS: 92 Urinalisa Diftell: 3/0/0/83/7/7 HBsAg : negative
Na/K/Cl: 134/3,7/102 (28/09/2017) Ur/Cr: 85/2,54 Analisa tinja
CT/BT : 9/3 Protein (+1) Albumin : 2,52 Eritosit : 8-10
HbSAg : negatif Elukosit 6-8 Na/K/Cl: 141/4,3/110 Leukosit : negative
Eritrosit 1-2 Telur cacing : negative
Epitel 3-5 Parasit: negative
Lab 23/09/2017
Konsistensi : encer
Hb/Ht/E/L/T
Lab 26/09/2017 10,6/32/3,8/16,3/198\
Hb/Ht/E/L/T MCV/MCH/MCHC
11,5/32/3,8/13,6/396 Lab 26/09/2017
84/28/34
MCV/MCH/MCHC Hb/Ht/E/L/T
Diftell: 3/1/0/80/8/8
85/30/36 12,8/39/5,1/21,5/457
Ur/Cr: 86/2,72
Diftell: MCV/MCH/MCHC
Na/K/Cl
11/1/0/68/13/7 77/25/33
141/4,1/112
CT/BT: 8/2 Diftell: 0/1/0/87/9/3
GDS: 150 KGDs : 166
Ur/Cr; 263/14,92 Ur/Cr : 16/0,72
Na/K/Cl:127/5,6/99 Na/K/Cl : 137/3,2/102
CT/BT : 8/3
HBsAg : negatif