AQSHA 3 (PENYAKIT DALAM WANITA)

Hari/Tanggal : Senin, 8 Oktober 2019

Dokter Jaga : dr. Perdana/ dr. Sadam
Dokter Muda Jaga : Asti/Weni

K1B1 K1B2 K1B3 K1B4

DPJP : dr. Price Maya, Sp.PD DPJP : dr. Islamuddin,Sp.PD DPJP :dr. Azzaki A, Sp.PD
DPJP :dr. Alfi Syahrin, Sp.PD
COW : dr. T Fahril COW :dr. M. Indra COW : dr. Ade
COW : dr. Nasriah
Dr :dr. Hibban DR:dr. Nelvi Dr : dr. Rianda
Dr : dr. Akmal
Raber : Raber : GEH Raber :
Raber : Bedah digestif
Nama : Inas Gina Nama : Salmiah Budiman Nama : Nilawati Ibrahim Nama : Baidah Kasem
Umur : 31/12/1992 (26 tahun) Umur : 15/05/1957 (62 thn) Umur: 12/12/1967 (51 th) Umur: 01-07-1970 (49th)
CM : 1-22-30-82 CM : 1-22-22-70 CM :1-22-23-91 CM :1-12-80-38
Alamat : Banda Aceh Alamat : Aceh Jaya Alamat : Aceh Pidie Alamat : Banda Aceh
Hari rawatan : 3 Hari rawatan : 12 Hari rawatan: 10 Hari rawatan: 3

A/ A/ A/ A/
1. Observasi Febris ec dd/ 1. HAP 1. Ascites ec dd 1. Status Colostomy
- DHF Grade 1 2. Anemia ringan ec dd/ 1. -sirosis hepatis 2. Anemia
- Demam tifoid Perdarahan akut 2. Penyakit -malignancy 3. Hiponatremia
- Malaria kronik 2. Sirosis Hepatis std DC 4. Hipokalemia
- ISK 3. GEA dengan dehidrasi 3. AKI stage I dd Hepatorenal syndrome 5. CKD
- Faringitis ringan 4. multiple cholelithiasis
4. Hipokalsemia ringan 5 Hiponatremia hipoosmolar hipervolemik Th/
Th/ 5. Post PSMBA+PSMBB 6. NGK susp malignancy -Bedrest
- Bedrest -Kapsul garam 3x500
- Diet MB Th/ -IV Ca Glukonas 1amp/8jam
- Bed rest -IV Insulin 10 unit
- IVFD RL 30gtt/menit
- diet MII 1700 kkal/ hari Th/ -Dex 5% 1 fls
- Paracetamol 3x500mg
-IVFD RL 20 tpm - Bedrest -Asam folat 2x400mg
- Curcuma 3x1 - domperidon 3x10 mg -Lenal ace 2x169mg
- Diet hati I 1700kkal/hari
- syinbio 1 sach/ 8 jam - threeway -Paracetamol 500mg/8jam
Lab 6/10/2019 -KSR 3x600 mg
Hb/Ht/E/L/T: 12,7/37/4,4/6,4/98 - IV Omeprazole 40mg/12jam
-Parasetamol drip 1 gr/12 jam - Spironolacton 100mg/12 jam Lab 06/10/2019
MCV/MCH/MCHC: 85/29/34 -IV levofloxacin 500mg/24jam (H4) Na/K/Cl : 127/3,8/100
Diftel: 0/1/0/20/74/5 - Curcuma 3x1
- Lactulac syr 3xCI
Lab 04/10/2019 Lab 05/10/2019
- IV Cefepime 1 gr/12 jam (h5)
Hb/Ht/E/L/T: 10,5/28/3,5/4,3/203 Hb/Ht/E/L/T : 5,9/17/2,1/5,7/268
Lab 5/10/2019 - Nystatin 2cc/6jam
MCV/MCH/MCHC: 80/30/38 MCV/MCH/MCHC : 81/28/35
Hb/Ht/E/L/T: 12,8/37/4,3/2,7/107 Diftel: 0/1/0/46/45/8 - Urdafalk 250mg/8 jam Diftel : 17/5/0/71/7/0
MCV/MCH/MCHC: 86/30/34 Albumin : 3,20
Diftel: 0/2/0/56/37/5 Lab 02/10/2019 Lab 03/10/2019 SGOT/SGPT : 7/9
IgG/IgM : +/+ Hb/Ht/E/L/T: 9,1/24/3,0/227 Hb/Ht/E/L/T : 10,7/32/4/11,4/655 GDS : 116
SGOT/SGPT : 212/233 MCV/MCH/MCHC: 80/30/38 MCV/MCH/MCHC : 80/27/34 Ur/Cr : 352/11,10
Diftel: 1/3/-1/58/35/4 Diftel : 3/1/0/75/144/7 Na/K/Cl : 122/7,0/94
Na/K/Cl: 139/3,0/108 Albumin : 2,9 Anti HCV : Negatif
GDS: 85 Na/K/Cl : 130/5,1/100 HBsAg : Non reaktif
PT/APTT: 13,40/39,90 PT : 14,00
Ur/cr: 25/0,50 APTT : 36,20
Bilirubin total : 0,42
Bilirubin direct : 0,17
Lab 1-10-2019 Bilirubin indirect : 0,25
Urinalisis SGPT/SGOT : 8/44
Kejernihan : keruh Protein total : 5,77
Lekosit : postif Albumin : 2,98
Keton : positif Globulin : 2,79
Darah : positif
Leukosit : 8-10
Eritrosit 6-8 Lab 02/10/2019
Epitel 3-5 Analisa Cairan Asites
Bakteri : positif Warna : kuning
Kejernihan : keruh
Lab 30/09/2019 Bekuan : negatif
Hb/Ht/E/L/T: 8,4/23/2,8/3,4/133 PMN : 34
MCV/MCH/MCHC: 80/30/37 MN : 66
Diftel: 0/0/1/74/18/7 Leukosit : 1950
Total protein : 4,2
Lab 29/09/2019
Hb/Ht/E/L/T: 8,6/22/2,8/5,4/183
MCV/MCH/MCHC: 80/31/39 Lab 30/9/2019
Diftel: 0/1/0/61/25/13 PT/APTT : 1,02/1,09
Na/K/Cl: 134/2,7/102 Bilirubin total/dir/indir: 0,42/0,17/0,25
SGOT/SGPT : 44/8
Protein total : 5,77
Lab 27/09/2019 Albumin/Globulin : 2,98/2,79
Hb/Ht/E/L/T: 9,5/25/3,1/7,3/161 Urinalisis
MCV/MCH/MCHC: 81/31/38 Kejernihan : keruh
Diftel: 0/0/0/65/20/15 Lekosit : positif
Ur/Cr: 29/0,70 Protein : positif (+1)
Na/K/Cl: 134/2,6/105 Keton : positif
Granular cast : positif
Uric Acid : positif
Triple fosfta : positif

K2B1 K2B2 K2B3 K2B4 K2B5

DPJP : dr. T. Mamfaluti, Sp.PD DPJP : Dr. dr. Azhari Gani, DPJP : DPJP : dr. T Mamfaluti, DPJP :dr.M Diah, Sp.PD-KKV
COW : dr.Nazarudin Sp.PD KKV COW : Sp.PD COW : dr. Arie
DR: dr.Akmal COW: dr T M Reza Dr : COW : dr. Nazaruddin Dr : dr.Reyza
 DR: dr Teguh Raber: DR: dr. Akmal Raber : Bedah Plastik
Raber: GEH
Raber : Rematologi, GH Raber:
Nama : Yuliana Jakfar Nama : Marmiati Yahya Nama : Nama : Cut Maimunah Nama : Hasbiah Rasyad
Umur : 01/07/62 (57 ) Umur : 20-08-1978 (41tahun) Umur : Umur : 43 tahun Umur : 46 thn
CM :1-12-20-23 CM : 1-09-14-36 CM : CM : 1-22-30-87 CM :1-13-79-55
Alamat : Aceh Pidie Alamat : Aceh Besar Alamat : Alamat : Aceh Besar Alamat : Aceh Besar
Hari rawatan: 6 Hari rawatan: 14 Hari rawatan: Hari rawatan : 3 Hari rawatan: 6

A/ A/ A/ A/
1. Sirosis hepatis stad 1. CKD stg 5 ec PNC 1. Asites ec dd/ 1. Gangrene diabetikum a/r
decompensata related 2. CHF fc NYHA II-III ec HHD - CHF pedis dextra
hepatitis B child pugh 3. Hiponatremia hipervolemik 2. AKI stage 3 dd akut on CKD
- Hipoalbumin
C 4. Gout artritis 3. Gastropati diabetic
2. Bisitopenia ec dd
2. Colesistitis dengan 5. OA genu sinistra 4. Skizofrenia paranoid
- Hepatoma
colelitiasis 6. ISK 5. DM tipe 2
3. Asites permagna ec - Kista Hepar 6. HT stage 1
7. Anemia sedang ec CKD 3. LBP ec Spondylosis
- sirosis hepatis 7. CHF Fc NYHA II-III ec dd
- malignancy Lumbalis - HHD
Th/
4. Hipoalbumin - IHD
- Diet ginjal 1700 kkal/hari Th/
5. Anemia sedang - DCM
+45gr protein - Bedrest
Th/ - Lansoprazole 30/12jam - Diet hati II 1700 kkal/hari Th/
Bed rest - Furosemide 20mg/8jam
- - IVFD Aminofusin hepar - Bed rest
- Diet Hati III 1700 Kkal/hari - Amlodipine 10mg/24jam
1 fls/hari - Diet DM 1300 kkal/hari
- Three way - KSR 600mg/12jam
- Spironolacton 2x100mg - NaCl 0,9% 20 tpm
- spironolakton 3 x200 mg - PCT 1000mg/24jam
- MST 2X15mg - Iv. Ceftriaxone 2gr/24jm
- Lactulac syr 3c CI - Allupurinol 300mg/24jam
- Lactulac syr 3XCI - Domperidon 10mg/8jam
- Paracetamol 500mg/8jam - Ostriol 0,25mg/24jam
- Paracetamol 500mg/8jam
- Acetylsistein 200mg/8jam - Alprazolam 0,5mg/24jam
Lab 5/10/2019 - Valsartan 80mg/24jam
- Vit K amp/8jam - Capsul garam 3x1
Hb/Ht/E/L/T: - Resperidon 2mg/24jam
- Cefotaxime 1gr/8jam - Lenal Ace 169mg/12jam
11,4/34/4,2/11,9/422 - Diazepam 2mg/8jam
- Albumin 100cc/hari - Ondansetron 3x1
MCV/MCH/MCHC: 81/28/34 - Lactulosa Syr 3xCII
- Cetirizine 10mg/12jam - Nystatin syr 2cc/6jam
Diftel: 2/0/0/78/13/7 - Combivent 1 Resp/12jam
PT/APTT : 13,00/35 - Flumucyl 3x1
Lab 03-10-2019
Lab 3-10-2019 Anti HCV/HBsAg :
Hb/Ht/E/L/T :
Urinalisis Negatif/Non reaktif Lab 04/10/2019
8,5/24/3,5/11,3/480
Warna kuning SGOT/SGPT : 37/61 Ur/Cr : 102/5,9
MCV/MCH/MCHC : 68/24/35
Kejernihan keruh GDS : 124
Diftel :1/0/0/86/10/3
Berat jenis 1.025 Ur/Cr : 43/0,50 Lab 02/10/2019
Ph 5,5 Na/K/Cl: 144/4,1/106 Hb/Ht/E/L/T : 6,8/19/2,4/9,1/301
Lab 02-10-2019
Leukosit + MCV/MCH/MCHC : 79/28/35
Ca :8,3
Protein - Diftell : 1/0/1/70/22/6
Ur/cr :113/5,10
Glukosa – albumin : 3
Na/K/Cl :124/3,5/96
Keton + Na/K/Cl: 138/3,7/114
Nitrit -
Urobilinogen +
Bilirubin +
Darah +
Hyalin positif

Lab 02/10/2019
Hb/Ht/E/L/T : 7,7/22/2,1/50
MCV/MCH/MCHC : 106/36/34
Diftel: 10/0/1/44/29/16
ur/cr : 21
alb: 1,70
bil total/ dir/indirect :
3,06/1,14/1,92
SGOT/SGPT: 63/28
Na/K/Cl: 134/4,8/105
 K3B1 K3B2 K3B3 K3B4 K3B5

DPJP : dr. Abdullah,Sp.PD DPJP : dr. Krisna W S, Sp.PD DPJP :dr. Hendra Jufry, DPJP : dr.M. Riswan, Sp.PD
DPJP :dr. Azzaki Abubakar,
COW : dr. Intan KEMD Sp.PD KEMD KHOM
Sp.PD
Dr : dr. Okdimur COW : dr. Afrizal COW : dr. Chairunnisa COW : dr. Alul
COW : dr. Rianda
Raber : Dr : dr. Nelvi Dr : dr. Teguh Dr : dr. Rianda
Dr : dr. Ade Barwin
Raber: Bedah saraf Raber : Raber :
Raber :HOM
Nama : Yessy Asiska Nama : Linda Andani Nama : Erlin Rusli Nama : Habsah Usman Nama : Nurlaili M. Ali
Umur :17-09-1984 (35thn) Umur :07/04/1996 (23th) Umur : 16/07/1985 (34th) Umur : 01/07/1938 (81th) Umur : 17/01/1977 (42)
CM :1-22-07-07 CM : 1-22-26-20 CM :1-22-22-75 CM :0-77-27-72 CM :1-22-06-14
Alamat : Subulussalam Alamat :Aceh Timur Alamat : Aceh Barat Daya Alamat : Banda Aceh Alamat : Aceh Pidie
Hari rawatan : 7 Hari rawatan:7 Hari rawatan: 11 Hari rawatan: 3 Hari rawatan : 6

A/ A/
1. CKD stage V on HD ec HN 1. Penurunan Kesadaran ec
2. Hypoalbuminemia -Sol
3. Iskemik anteroseptal -Anemia aplastic
-MDS
Th/ -Leukemia
- Bedrest 2. Bisitopenia ec dd/
- Mobilisasi bertahap 3. Pneumonia (CAP)
- Threeway 4. Hipoalbuminemia (2,0)
- Diet ginjal 1700 kkal/hari + 60g 5. Hipokalemia (6,0)
protein/hari 6. AKI stage III
- IV Meropenem 500g/24jam
- Lenal Ace 2x169mg Th/
- Asam Folat 400mg 2x1 - Bedrest
- Drip Paracetamol 1gr/8jam - Diet sonde 6x200cc
- IVFD NaCl 0,9% 20 gtt/1
Lab 02/10/2019 - IV Meropenem 1gr/8jam
Hb/Ht/E/T/L: 7,8/23/3/153/8 - IV Omeprezole
MCV/MCH/MCHC: 76/26/34 40mg/12jam
Diftel: 1/1/0/94/3/1 - Drip paracetamol 1gr/8jam
Albumin : 2,8 - Amlodipin 1x10mg
Ca : 6,3 - Kalitake 3x1
Na/K/Cl : 136/4/103 - Flumucyl 3x1
- Drip Albumin 25%
Lab 01/10/2019 100cc/hari
Hb/Ht/E/T/L: 7,8/23/3/153/8
MCV/MCH/MCHC: 76/26/34 Lab 04-10-2019
Hb/Ht/E/L/T : 10,3/30/3,4/13,1/63
Diftel: 1/1/0/94/3/1
MCV/MCH/MCHC :87/30/34
Diftel : 0/0/0/70/22/8
Lab 1-10-2019
Procalcitonin: 100 PT: pasien/control/INR:
12,60/14,1/0,88
Urinalisis
APTT;pasien/control : 27,70/35,8
Kejernihan : keruh
D-dimer : 5553,31
Lekosit : positif Ca/Mg:8,0/2,4
Protein : positif (+1) Na/K/Cl: 144/6,0/166
Darah postif
Leukosit : 6-8
Lab 02-10-2019
Eritrosit : 8-10
Hb/Ht/E/L/T : 8,5/26/2,7/53/7,5
Epitel : 3-5
MCV/MCH/MCHC :93/31/33
Bakteri : positif Diftel : 0/0/0/74/18/8
MDT
Lab 30-9-2019
Eritrosit : normokromik
Hb/Ht/E/T/L: 6,8/21/2,7/90/6,6
anisositosis
MCV/MCH/MCHC: 77/25/33
Leukosit : normal sel -, blast –
Diftel: 2/0/1/78/17/2 Trombosit : menurun, giant -
Albumin : 2,9
Kesimpulan : anemia
SGOT : 62
normokromik normositik
SGPT : 37
Malaria : negative
Ca: 4,3
Widal/ salmonella titer
Ur/Cr : 244/13 S.Typhi O : 1/80
Na/K/Cl: 130/3,8/95
S. Paratyphi AO :1/160
S.Paratyphi BO : negative
S.Paratyphi CO : negative
S.typhi H: 1/80
S.paratyphi AH: -
s..paratyphi BH :-
S..paratyphi CH : 1/80
Urinalisa
Warna : kuning
Kejernihan : keruh
BJ :1,025
pH :5
Lekosit : positif
Protein : positif (+3)
Keton : positif
Darah : positif
Leukosit : 10-15
Eritrosit: 40-50
Epitel : 3-5
Sel Ragi : positif
Bakteri : positif
A/ A/ A/ Bisitopenia ec dd/
1. Bisitopenia ec dd 1. Penurunan kesadaran ec - MDS
- anemia aplastic dd/ - Anemia aplastic
- mds - Sepsis - Leukemia akut
- itp - SDA
2. Limfadenopati ec dd - Imbalance Elektrolit
- Limfoma maligna 2. Sepsis ec dd/ Th/
- Limfadenitis TB - Pneumonia 1. Bed rest
3. AUB ec dd 2. Diet Mii 1700 Kkal/hari
- Urosepsis
- ITP 3. Sandimoon 2x100 mg
3. Hipoalbuminemia
- Mioma Uteri 4. Iv. Methyl prednisolone
4. AKI stage I pre renal 125mg /24jam
Th/ 5. Hiperkalemia ringan
- Bedrest 6. LBBB Complete
- Diet MII 1700kkal/hari Lab 06/10/2019
- Futrolit 1 fls 20 gtt/1 Th/ Hb/Ht/E/L/T: 10,3/31/3,8/7,3/4
- Bedrest MCV/MCH/MCHC/: 82/27/33
- Ciprofloxacin 200mg/12jam
- Diet sonde 6x200cc Diftel : 0/1/0/54/31/14
- Betadine gurgle 3x1
- IV Omeprazole 40mg/12 jam
- O2 2-4lpm
- Clindamycin 300 mg/8 jam - IVFD NaCl 0,9% 30tpm Lab 03/10/2019
- IV Meropenem Ur/cr : 35/0,4
- Sandimun 100 mg/24 jam
500mg/12jam Na/K/Cl : 141/4/104
- Asam Traneksamat 500mg/8
- Bicnat 3x500mg
jam
- Flumucyl 3x1 Lab 02/10/2019
- Ca Glukonase 1gr/hari Hb/Ht/E/L/T: 6/18/2,2/5,3/4
- Kalsitriol 0,25mg/hari - Nebule ventolin 1
resp/8jam MCV/MCH/MCHC/: 81/27/33
- Metilprednisolon RDW: 15,8
125mg/12jam - Kalitake 3x1 sachet
Difftel: 0/0/1/46/33/20
Lab 05/10/2019 Lab 05/10/2019
Hb/Ht/E/T/L: Lab 30-9-2019
Hb/Ht/E/T/L: 6,5/21/2,5/10,6/3 Hb/Ht/E/T/L: 7,3/22/2,6/4,8/4
MCV/MCH/MCHC : 85/26/31 11,4/35/4,1/11,5/221
MCV/MCH/MCHC : 85/28/33 MCV/MCH/MCHC: 83/28/33
Diftel: 14/5/0/67/11/3
Diftel: 0/0/0/33/57/10
Na/K/Cl : 140/4,3/108 Diftel: 0/0/0/81/13/6
Albumin : 2,80
Lab 03/10/2019 Ca : 8,3
GDS : 133
Hb/Ht/E/T/L: 4,6/15/1,8/6/13,5
Ur/Cr : 98/1,90
MCV/MCH/MCHC: 80/25/32
Na/K/Cl : 140/5,9/108
Diftel: 0/0/0/82/14/4
Lab 01/10/2019
Hb/Ht/E/T/L: 6/12/2,4/17,7/6
MCV/MCH/MCHC: 80/25/31
Diftel: 0/0/0/85/2/3
Lab 30/9/2019
Hb/Ht/E/T/L: 6/18/2,3/16/3
MCV/MCH/MCHC: 79/26/33
Diftel: 0/1/0/87/9/3
Lab 28/9/2019
Hb/Ht/E/T/L: 4/13/1,6/19,5/6
MCV/MCH/MCHC: 80/26/32
Diftel: 0/0/0/86/11/3
Lab 27-9-2019
Hb/Ht/E/T/L: 5,1/16/2,0/15,6/3
MCV/MCH/MCHC: 79/25/32
Diftel: 1/0/0/88/9/2
PT/Kontrol: 13,40/14,0
APTT/Kontrol: 31,00/33,3
HBsAg: non reaktif

Lab 27-09-2019
Hb/Ht/E/L/T : 10,3/30/3,4/13,1/63
MCV/MCH/MCHC :87/30/34
Diftel : 0/0/0/70/22/8
PT/APTT :12,60/27,70
Ca/Mg : 8,0/2,4
Na/K/Cl : 144/6,0/116
 K4B1
DPJP : dr. Hendra Jufry,
Sp.PD KEMD
COW : dr. Charunissa
Dr : dr. Teguh
Raber :
Nama : Sapinah Taher
Umur : 07/01/1940 (79th)
CM : 1-04-91-69
Alamat : Pidie Jaya
Hari Rawatan : 4
A/
1. Diare akut dengan
dehidrasi berate c dd/
- Infeksi bakteri
- Infeksi virus
- Imbalance elektrolit
2. Geriatric problem (Infeksi,
inanisi, Instabilitas dan
jatuh)
3. Pneumonia (CAP)
Th/
- Bedrest
- O2 2-4 L/menit
- Diet Sonde 6x200 kkal
- IV ceftriaxone
2gr/24jam
- KSR 600mg/24jam
- Synbio tab/8jam
- Attapulgite
2tab/mencret (k/p)
- Atorvastatim
20mg/24jam
Lab 4-10-2019
Hb/Ht/E/T/L:
12,6/36/4,3/253/17
MCV/MCH/MCHC: 84/29/35
Diftel: 0/1/0/73/17/9
Albumin : 3,60
Ur/cr: 57/2,20
Na/k/cl : 142/3,0/108
K4B2 K4B3 K4B4 K4B5
DPJP : dr. M. Riswan,SP.PD- DPJP : dr. Hendra Zufry, DPJP: dr. T. Mamfaluti, Sp.PD
DPJP: dr. Azhari Gani, Sp.PD
KHOM Sp.PD-KEMD COW : dr. Nazarudin
KKV
COW : dr. Ridhalul COW : dr. Chairunissa DR: dr. Akmal
COW :dr. Reza
Dr : dr. Rianda Dr : dr. Teguh Raber : Kardio
DR:dr. Teguh
Raber : Raber : GH
Raber :
Nama : Siti Rohana Nama : Rita Wahyuni Nama : Fatimah M Ali Nama : Anita Mahyuddin
Umur : 07/01/1976 (43 th) Umur : 36 tahun Umur : 01/07/1946 (73th) Umur : 31 tahun
CM : 1-20-99-89 CM : 1-20-24-13 CM : 0-80-40-11 CM : 1222975
Alamat : Pidie Jaya Alamat : Sabang Alamat : Aceh Besar Alamat : Aceh timur
Hari Rawatan : 8 Hari rawatan: 4 Hari Rawatan : 3 Hari rawatan : 4
A/
A/ A/ 1. PSMBA ec dd A/
1. CKD stage V dengan - Gastritis Erosif 1. CHF Fc NYHA II-III ec dd/
1. Anemia berat ec anemia uremic syndrome ec dd/ - - Ulkus gaster - IHD
aplastik (perbaikan) - PNC - Ulkus Duodenum - HHD
2. Pneumonia CAP (perbaikan) -PGOI 2. Pneumonia (CAP) - DCM
2. Anemia berat NN ec dd/ 3. Anemia Berat 2. Dyspepsia type like ulcer dd/
Th/ 1. PGK 2. Perdarahan 4. OA genu bilateral - Type dysmotility
- Tirah baring 3. Hipertensi stage 2 5. Reaktif hiperglikemia DM - Tipe mixed
- Diet MII 1700 kkal/hari 4. Hiperurisemia tipe 2 3. ISK dd BSK
- IVFD NaCl 0,9% 20 tpm 6. Hipertensi grade 1 dd HHD 4. Susp. SLE
- IV Omeprazole 40 mg/12 Th/ 7. Geriatri Problem (Inanisi,
jam - Bedrest infeksi, immobilisasi, Th /
- Sandimun 2x 1cc - O2 2-4 l NK impaksi) - Bedrest
- Sucralfat syr 3xCI - Diet ginjal 1700 kkal/hari 8. Hipolbumin sedang - Diet MB 1700 kkal/hari
- IV Ceftriaxone 2gr/24jam - Three way 9. AKI stage I prerenal - IV furosemide 20 mg/8 jam
(H5) - Iv furosemid 20 mg/8jam - IV omeprazole 40 mg/12 jam
- Asam folat 2x1 Th/ - IV ondansetron 4 mg/12 jam
Lab 6-10-2019 - Allopurinol 1x300 - Tirah baring
Hb/Ht/E/L/T : 8,0/24/2,6/8,4/153 - Bicnat 3x1 - Diet MII 1700 kkal/hari Lab 4-10-2019
MCV/MCH/MCHC: 90/31/34 - Herbesser 1x200 mg - IVFD NaCl 0,9% 20 tpm Hb/Ht/E/T/L: 14,7/42/5,4/41/6,1
Diftel: 0/0/0/85/10/5 - Bisoprolol 1x 5 mg - IV Omeprazole 40 mg/12 MCV/MCH/MCHC: 78/27/35
- Nicardipine 10mg dalam jam Diftel: 0/0/0/41/45/14
Lab 2-10-2019 50cc NaCl 0,9% - IV Ceftriaxone 2gr/24jam GDS : 125
Hb/Ht/E/L/T : 7/21/2,3/8,1/90 - Sucralfat syr 3Xcii Ur/cr: 22/0,6
MCV/MCH/MCHC: 93/31/33 Lab 4-10-2019 Na/k/cl : 141/3,8/106
Diftel: 0/0/0/89/83 Hb/Ht/E/T/L: 6,9/20/2,6/196/10 Lab 5-10-2019
MCV/MCH/MCHC: 78/27/35 Hb/Ht/E/T/L: 4,9/15/2,0/18,8/231
Lab 2-10-2019 Diftel: 0/0/0/86/11/3 MCV/MCH/MCHC: 78/25/32
Hb/Ht/E/T/L: 4,2/13/1,2/139/9,8 GDS : 91 Diftel: 0/0/0/83/13/4
MCV/MCH/MCHC: 103/34/33 Ur/cr: 133/12 Anti HCV/HBsAg :
Diftel: 0/1/0/88/8/3 Na/k/cl : 140/5,4/111 Negatif/Nonreaktif
AGDA Albumin : 2,70
Lab 30-9-2019 pH : 7,34 GDS: 254
Hb/Ht/E/T/L: 2,5/8/0.7/204/9,3 pCO2 : 31,7 Ur/cr : 144/1,90
MCV/MCH/MCHC: 108/34/31 pO2 : 37 Na/K/Cl : 137/5,1/113
Diftel: 0/0/0/89/7/4 HCO3 : 16,4
Bil. Total : 6,18 Total CO2 : 17,3
Bil. Direct : 0,87 BE : -7,9
Bil. Indirect : 5,31 Saturasi Oksigen : 69,7
SGOT/SGPT : 133/240 Anti HCV : -
Ur/Cr : 31/ 0,60 HbsAg : non reaktif
Na/k/Cl : 139/4/107
 K5B1 K5B2 K5B3 K5B4 K5B5
DPJP:dr. Azzaki Abubakar,Sp. DPJP : dr. M Darma, Sp.PD
DPJP : dr. Price Maya, Sp.PD DPJP:dr. Diana Erlita,Sp. PD
PD COW : dr. Nadi
COW : dr. T Fahril COW :dr. Nasriah
COW : dr Ade Dr : dr. Okdimur
Dr : dr. Hibban DR:dr. Akmal
DR:dr. hibban Raber : GH, Pulmo
Raber : Raber : EMD
Raber :
Nama :Jawani Dosmi Nama : Nurbaiti Harun Ali Nama : Khatijah Puteh Ali Nama :Nursyidah ABD
Umur : 27/09/1955 (64 th) Umur : 29-03-1961 (58 th) Umur : 01-07-1955 (64 th) Umur :06-06-1961 (58th)
CM : 1-22-30-73 CM :1-20-00-83 CM :1-22-30-71 CM :1-22-16-28
Alamat : Aceh Selatan Alamat : Aceh utara Alamat : Aceh besar Alamat :Bireuen
Hari rawatan: 3 Hari rawatan: 2 Hari rawatan: 3 Hari rawatan: 16

A/ A/ A/ A/
1. Selulitis dd DVT 1. Hematoskezia ec dd/ 1. CKD stage V dengan edema 1. Efusi pleura sinistra ec dd/
2. PPOK stabil -Ca colorectal paru akut ec dd - Malignancy
3. Geriatri problem (Inanisi, -metastase proses -HN - Pleuritis TB
Infeksi, Instabilitas dan jatuh, 2. Hipertensi stg 1 -PNC - Pleuropneumonia
Immobilisasi 3. Ca ovarium post kemoterapi 6 2. Hipertensi stg 2 - Heart failure
siklus 3. DM tipe 2 NW 2. HHD
Th/ 4. DM tipe 2 NW 4. Anemia sedang NN ec CKD 3. CHF FC NYHA Iii-IV ec dd/
- Bedrest - HHD
- Diet MB 1700 kkal/hari Th/ - IHD
Th/
- IVFD NaCl 0,9% 20 gtt/i - Bedrest 4. AKI stg 3 renal dd acute on
- Bedrest
- IV cefuroxim 150mg/8jam - Diet ginjal 1700 kkal CKD (diabetic nefropaty
- Diet bubur kecap
- SC Lovenox 0,6cc/12jam - Threeway stage 5)
- IVFD NaCl 0,9 20 TPM
- Nebule Combivent 1 - Furosemide 20 mg/8jam 5. Anemia sedang HM ec dd
- Amplodipin 1x10mg
resp/12jam - Amlodipine 10mg/24jam peny. Kronis occult bleeding
- Transamine tab 3x5mg
- Domperidon 3x10mg - Valsartan 80mg/24jam 6. Hipoalbuminemia ec dd/renal
- Metformin 2x500mg
- Lenal ace 169/12jam loss
Lab 5/10/2019 - Asam folat 2x1 7. DM tipe 2 Normoweight
Lab 1/10/2019
Hb/Ht/E/L/T: 8,8/26/3,4/19,4/138 - ISDN 5mg/8jam
Hb/Ht/E/L/T: 11,1/32/3,9/9,0/237
MCV/MCH/MCHC : 76/26/34 Th/
MCV/MCH/MCHC : 84/29/34
Diftell : 14/4/1/63/11/7 Lab 6/10/2019 - Bedrest
Diftell : 2/0/2/65/23/8
PT/APTT : 13,9/52,5 Hb/Ht/E/L/T:
CT/BT : 2/7 - Mobilisasi bertahap
D Dimer : 8160,52 8,8/25/3,3/11,0/259
SGOT/SGPT : 12/13 - Diet DM 1500 kkal
Ur/Cr: 83/1,9 MCV/MCH/MCHC : 78/27/35
GDS : 165 - Iv furosemide 2x20mg
Abumin : 2,7 Diftell : 2/1/0/73/15/9
Ur/cr : 12/0,80 - IV cefepime 2x500mg
Na/K/Cl/ Ca: 135/3,4/105/8,2 Kalsium (Ca): 9,1
GDS : 72 Ur/Cr: 80/3,5 - SC lantus 0-0-0-10 IU
Na/K/Cl: 144/4,0/107 - Novalgin 1 amp/8 jam
- Amlodipin 10mg/24jam
Lab 5/10/2019 - IV Ondansetron 4 mg/ 8 jam
Hb/Ht/E/L/T: -IV Omeprazole 40mg/12 jam
9,3/29/3,5/4,5/388 - Flumucyl 200mg/8jam
MCV/MCH/MCHC : 82/27/32 - BicNat 3x1
Diftell : 12/5/0/58/18/7 -Valsartan 1x80 mg
Anti HCV : negated -albumin 25 %
HbsAg : non reaktif
Analisa gas darah Lab 3/10/2019
- pH : 7,290 Hb/Ht/E/L/T:
- pCO2 : 38,10 8,8/25/3,4/8/340
MCV/MCH/MCHC :
- pO2 : 70
75/26/35
- HCO3 : 18,5
Diftell : 6/0/0/74/7/13
- CO2 : 19,7 Kalsium (Ca): 7,8
- BE : -6,8 Fe : 48
- Saturasi O2 : 91,7 Ca : 7,8
Albumin : 3,70 Ur/Cr: 108/3,47
Ca : 8,4 Na/K/Cl: 133/4,8/104
GDS : 346
Ur/Cr: 115/4,80 Lab 1/10/2019
Na/K/Cl: 142/5,7/110 Hb/Ht/E/L/T:
9,2/27/3,5/6,5/345
MCV/MCH/MCHC :
73/26/34
Diftell : 5/1/0/66/8/20
Kalsium (Ca): 8
Ur/Cr: 120/3,81
Na/K/Cl: 135/4,3/106
 K6B1 K6B2 K6B3 K6B4 K6B5
DPJP : dr. Fauzi Yusuf, Sp.PD DPJP : dr. Hendra Jufry, DPJP : dr. M. Diah, Sp.PD DPJP : Dr. dr. Azhari Gani,
DPJP :dr. Abdullah, Sp.PD
COW: dr. Adjie Sp.PD KEMD KKV SpPD KKV
COW : dr.Intan
DR: dr. Hibban COW : dr. Chairunnisa COW : dr. Arie COW :
Dr : dr.Okdimur
Raber: Dr : dr. Nelvi Dr : dr. Reyza Dr :
Raber: Neurologi, EMD
Raber: Raber:GH, EMD, BTKV Raber:
Nama : Nuraini Sufi Nama : Sumarni Sulaiman Nama :Anisah M Amin Nama : Khairani Abdullah Nama : Sri Hastuti
Umur : 58th Umur :01/07/1948 (71th) Umur :53 tahun Umur : 05/04/1971 ( 48 th) Umur : 02-02-1995 ( 24 th)
CM : 0-91-18-34 CM : 1-22-31-16 CM : 1-22-17-52 CM : 0-79-86-50 CM : 1-04-70-33
Alamat : Aceh Besar Alamat :Aceh Besar Alamat :Nagan Raya Alamat :Aceh Besar Alamat :Aceh Barat Daya
Hari rawatan : 4 Hari rawatan: 3 Hari rawatan: 15 Hari rawatan : 12 Hari rawatan : 3

A/ A/ A/ A/ A/
1. Dyspepsia tipe like ulcer 1. Abses ar plantar pedis 1. CKD stage V on HD reguler 1. Sepsis ec dd: 1. Trombositopenia ec dd/
2. Esofagitis grade A dextra 2. pneumonia (HAP) - urosepsis -Infeksi virus
3. Gastritis ringan 2. DM tipe 2 Normoweight 3. DM tipe II underweight - ulkus diabetic pedis -Gestational
4. Hipertensi terkontrol 3. Dyspepsia 4. Iskemik anteroseptal dextra trombositopenik
5. Anemia sedang NN 2. Akut on CKD dd CKD 2. G1P0A0 hamil 27-28 minggu
Th/ Th/ stage IV ec DN
- Bedrest - Bedrest Th/ 3. ISK Th/
- Diet MB 1700 kkal/hari - IVFD NaCl 0,9% 20 gtt/i - bedrest 4. DM Tipe 2 overweight 1. Bedrest
- Rendah garam - IV Ceftriaxone 2gr/24jam - Diet ginjal 1700 kkal/hari 5. Hemiparese sinistra ec 2. Diet M II 1700kkal/hari
- IVFD Futrolit 20tpm - IV Lansoprazole 1x30mg - transfusi PRC s/d Hb >9 mg/dL stroke iskemik
3. PCT 3x500mg
- IV lansoprazole 30mg/12jam - Drip Paracetamol 1gr/8jam - IV Meropenem 1 gr/ 8 jam 6. Ulkus diabetikum ar pedis
- Sucralfat 3xCI - Insulin levemir 0-0-0-12 iu - IV Lansoprazole 60 mg/12 jam dextra
Lab 06/10/2019 (prodia)
- Lactulac syr 3Xci di drip dalam 50 cc NaCL 0,9 7. Keratitis dengan sikatrik
Hb/Ht/E/L/T :
- IV Ondansetron 4mg/8 jam okuli sinistra
10,2/31/4,3/50/106
Lab 0510/2019 (prodia) (HD selasa, jumat) 8. Hipoalbuminemia
Lab 04/10/2019 MCV/MCH/MCHC : 71/24/33
Hb/Ht/E/L/T : 9. Hipertensi stage 2
Hb/Ht/E/L/T : 12/36/4,9/6,6/374 Diftell : 1/0/0/64/27/8
11,8/33,9/4,31/27/365 Lab 04/10//2019 10. Struma Nodusa Non
MCV/MCH/MCHC : 73/24/34 Anti dengue IgM : negative
MCV/MCH/MCHC : Hb/Ht/E/L/T : toksik
Diftell : 2/0/0/50/39/9 Anti dengue IgG : positif
78,7/27,4/334,8 8,3/26/3,8/6,7/96
HbsAg : Non REAKTIF SGOT?SGPT :65/21
Diftell : 0,3/0,3/84,3/8,1/7 MCV/MCH/MCHC :
Gds : 104 GDS :63
GDP : 344 67/22/32 Th/
Na/K/Cl: 147/3,7/109 Ur/cr :7/0,40
HbA1c : 12,4 Diftel : 7/1/0/78/9/5 - Bedrest
Ur/cr: 18/0,70
- Diet sonde 6x200cc/hari
Lab 27/09/2019 - IV Meropenem 1 gr/12 jam
Hb/Ht/E/L/T : - Flumucyl 3 x 200 mg
6,8/20/3,3/11,0 - Lansoprazole 30mg/12 jam
MCV/MCH/MCHC : - Mecobalamin 500mg/12 jam
61/21/34 - CIticolin 120mg/12 jam
Diftel : 2/0/0/84/9/5
- Herbesser CD 100mg/24jam
- albumin 25% /24jam
Lab 23/09/2019
Hb/Ht/E/L/T : - valsartan 160mg/24jam
4,4/ 13/ 2,4/ 29,1/341 - Lantus 0-0-0-10
MCV/MCH/MCHC : - Apidra 6-6-6
55/18/34 - IV Meropenem 1 gram/
Diftel : 0/0/0/91/5/4 12jam
Anti HCV : negatif
HbsAg: non-reaktif Lab 4-10-2019
GDS: 132 Hb/Ht/E/L/T:
Ur/Cr: 215/11,0 9,7/29/3,9/15,7/277
Na/K/Cl: 134/4,2/106 MCV/MCH/MCHC: 73/25/34
Diftel: 1/0/0/83/11/5
Albumin: 2,27
Kalsium: 7,2
GDS : 70
Ur/cr: 125/2,69
Na/K/Cl:140/4,6/112
FT4 : 9,67

Lab 1-10-2019
Hb/Ht/E/L/T:
8,6/25/3,5/14,5/192
MCV/MCH/MCHC:72/25/35
Diftel:1/0/0/80/11/8
Albumin: 1,57
Kalsium: 5,8
Ur/cr:143/3,27
Na/K/Cl:142/2,9/116

Lab 27-09-2019
Hb/Ht/E/L/T : 10/29/4/10,5/76
MCV/MCH/MCHC :73/25/35
Diftel : 1/0/0/85/8/6
GDS : 181
ur/cr : 129/4,1
Na/K/Cl : 133/2,9/106