MAPPING AQSHA 1

Senin, 9 Maret 2020

Tim Jaga: dr. Utha/dr.Wahyu
Dokter Muda: Dian Islami

KELAS 1 KELAS 2 KELAS 3 KELAS 4

DPJP: dr. M. Riswan SpPD K-HOM DPJP: dr.Hendra Zufry, Sp. PD-KEMD DPJP: dr. M. Riswan SpPD K-HOM
COW: dr. Reza Tandi DPJP : BEDAH COW: dr. T Emier COW: dr. Reza Tandi
Dr: dr. Nelvi Raber : EMD Dr: dr. Zaid Dr: dr. Nelvi
Raber : GH Raber :

Nama: Fuadi Johan Nama : T. Hasanuddin Nama : Bustami AB

Umur: 23-06-1973(46th ) Umur: 21-12-1951(68 th)
TTL : 7-1-1955 (65 th)
CM:1062909 CM :1082223
Alamat : lhokseumawe Alamat: Banda Aceh Alamat: Kuta Alam
Hari Rawatan : 3 CM: 0799735 Hari Rawatan: 13
Hari Rawatan: 5
A/ A/
1.AKI stg 3 dd acute on CKD ec 1.Penurunan kesadaran ec dd
dd
A/
Sepsis
-contrast induce nefropati 1. ALI
Uremic ensephalopati
-sindroma lisis tumor 2. PSMBA ec dd 2.CKD stage V on HD reguler
-urat nefropati - gastritis erosive 3.Sepsis ec dd
2.anemia sedang NN ec dd - ulkus gaster pneumonia
-peny kronis
- ulkus duodenum uro sepsis
-perdarahan
3. DM Tipe 2 NW 4.PSMBA (perbaikan) ec dd
3.PSMBA ec dd
Uremic Bleeding
-uremic bleeding 4. Stroke iskemik
-stress ulcer Stress ulcer
4. Limfoma hodgxin 5.DM tipe 2 overweight dgn critical ill
5.Hidronefrosis grade IV bilateral
th/ 6.HT on therapy
Bedrest
Th/ Diet MB 1700 kkal/hari Th/
1.bed rest 1. Sc novoraped 10-10-10 Bed rest
2.diet ginjal 1700kkal/hr Diet ginjal 700 Kkal
2. Sc lantus 0-0-0-30
3.IVFD Nacl 0,9% 10gtt 02 2 4liter
4.vit K 1amp/8j 3. Citicolin 2x500 mg -Sulcrafat SYR 3xc11
5.lansoparazole 30mg/24j iv 4. Omeprazole 40mg drip -Lenal Ace 169 2x1
6. bicnat 1tab/8j po 5. Fosen Enema supp -As folat 400mg 2x1
7.ventolin nebul 1resp extra 6. IV Ceftriaxone 2gr/24 jam -AS traxenamat 500mg /8j
8.IV insulin 10u dalam dex 40% -Vit K 1gr /24j
sebanyak 50cc (extra) -Drip Humulin 50cc+NACL 0.9%
9.kalitake 2 sach/8j Lab 8/3/2020
-Nebul NaCl 3% 3cc/12 jam
10.ca glukonas 1amp/8jam Ratio PT/APTT: 0,88/0,86
-Fluconazole 200mg/24jam
11.allopurinol 100mg/24j
-Levofloxacin 500mg/48jam
12. lenal Ace 169 mg/12 jam Lab 6/3/2020 - Valsartan 160 mg/24 j
13. Asam folat tab /12 jam PT/APTT: 13,90/72,00 - Concor 0,5 mg/ 24 j
14. EAS Pfrimer 1 fls/ hri
- Amlodipin 10 mg/24 j
Lab 6-3-2020 - Fossen enema K/P
Lab 07-03-2020
Hb/Ht/E/L/T: 11,5/34/4,2/5,0/194 Hb/Ht/E/L/T: 13,5/40/5,2/18,1/407 - pct 1000 k/p
MCV/MCH/MCHC: 82/28/33 MCV/MCH/MCHC: 77/26/34 - lansoprazol 30 mg/12 jam
Diftel: 0/0/0/92/7/1 Diftel: 0/0/0/88/5/7 - Ca gluconas 1 amp/12j
Albumin : 3,30 - Ca gluconas 1 ampul extra
Na/K/Cl/Ca: 146/4,2/96/9,3 Lab 5/3/2020 - HCT bolus pelan 25mg 1x1
Ur/Cr: 101/10,10 PT/APTT : 13,3/57,20
Lab 08/3/2020
Lab 3-2-2020 Na/K/Cl/Ca : 140/4,5/108/6,5
UR/CR 199/16.10
Lab 07/3/2020
Lab 2-2-2020 Hb/Ht/E/L/T: 7,3/22/2,6/9,7
Ur/cr : 189/14.30 MCV/MCH/MCHC: 82/28/34
Diftel : 1/0/0/80/12/7
Lab 28-2-2020 NA/K/CL/Ca : 147/3,7/106/6,9
Hb/Ht/E/L/T: 9,0/26/3,2/2,9/95
MCV/MCH/MCHC: 82/28/34 Lab 06/3/2020
Diftel: 1/1//0/76/13/9 Alb:3,25
Ca:7,4
Urinalisis (27-02-2020) Na/K/CL:144/3,7/109
(Makroskopik)
Warna: Kuning Lab 05/3/2020
Kejernihan: Keruh Hb/Ht/E/L/T: 8.4/24/3.0/12,2/385
Berat Jenis: 1,007 MCV/MCH/MCHC: 80/28/35
pH: 5,0 LED 60
Leukosit: positif Diftel : 0/0/1/83/11/5
Protein: +1 NA/K/CL/Ca : 146/3,6/110/7,3
Glukosa: negatif -
Keton: Positif Lab 03/3/2020
Nitrit: Negatif NA/K/CL/Ca : 145/4/109/7,5
Urobilinogen: Negatif
Bilirubin: Negatif Lab 01/3/2020
Darah: Positif Hb/Ht/E/L/T: 8.2/24/3.0/288/14.7
(Mikroskopik) MCV/MCH/MCHC: 82/28/34
Leukosit:10-20 Diftel : 1/1/0/81/10/7
Eritrosit: 40-50
Epitel: 3-5 Lab 01/3/2020
NA/K/CL 147/3.9/110
Lab 24-2-2020 Kalsium 7.3
Hb/Ht/E/L/T: 8,8/3.07/3,68/27,2/111
MCV/MCH/MCHC: 88,5/28.7/32,4
Diftel: 0/0/0/80,71/10,3/7,65
Bil:0,13
Sgot/sgpt:21/7
Ur/cr:220.00/16,83
As urat:13,6
 KELAS 5 `KELAS 6 KELAS 7 KELAS 8
DPJP: dr. Price Maya, SP.PD
DPJP : dr. Fauzi Yusuf , SP.PD DPJP BEDAH VASKULER
COW: dr. Ridhalul Ikhsan
COW : dr. Derina DPJP NEUROLOGI RABER EMD
Dr :dr Zulfikar
Dr : dr. Vincen

Nama: M. Yasin Nama: Masyunita Muhammad

Umur: 67th Umur: 3/04/1968 (51th)
CM: 0963653 CM: 1093693
Alamat: Banda Aceh Alamat: Lingke, B.Aceh
Hari Rawatan: 5 Hari Rawatan: 15

A/ A/
1. Chest pain ec dd 1.Riwayat penurunan kesadaran
- STEMI (perbaikan) ec hipoglikemi
- NSTEMI 2.CKD stage V on HD regular ec PNC
2. Dispepsia tipe dysmotility dd 3. CHF FC NYHA I-II ec dd
- tipe mixed 1/HHD
- gastropati diabetic 4. Britte Diabetes
3. DM Tipe 2 NW 5. ISK
6.Dyspepsia type like ulcer dd type
Th/ dismortility
- Bedrest 7. Anemia sedang ec PGK
- Diet DM 1700 kkal/hari
- IVFD NaCl 0,9% 20tpm Th/
- IV Ondancetron 4mg/12 jam - Bedrest
- SC Lantus 10ui 1x1 - Diet ginjal MB1700 kkal/hr + 60gr
- Clopidogrel 75mg 1x1 protein /hari
- Aspilet 80mg 1x1 - Threeway
- Atorvastatin 20mg 1x1 - HD Rabu Sabtu
- Drip Humulin R dalam 50c c NaCl 0,9% - Pantoprazole 40 mg/12 mg
- IV Lansoprazole 30mg - As.Folat 400 mcg 2x1
- SC Arixtra 2,5cc/ 24 jam - Domperidone 10 mg/8jam PO
-Meropenem 500mg/24jam
Lab 06-03-2020 - SC Apidra 6-6-6 ui
Hb/Ht/E/L/T: 11,6/35/4,2/11,0/249 - SC Lantus 6 ui/ 24 jam
MCV/MCH/MCHC: 84/28/34
Diftel: 0/1/0/76/15/8 Lab 06-03-2020
GDS : 365 Hb/Ht/E/L/T: 87,7/23/2,8/9,6/523
Na/K/Cl: 142/4,6/100 MCV/MCH/MCHC: 83/27/33
Diftel: 1/1/0/77/15/6
Ur/Cr : 51/2,80

Lab 28-2-2020
Hb/Ht/E/L/T: 8,7/26/3,1/10,5/415
MCV/MCH/MCHC: 83/28/34
Diftel: 1/0//1/84/9/5
Ur/Cr : 76/3,1

Urinalisis (26-02-2020)
(Makroskopik)
Warna: Kuning
Kejernihan: Keruh
Berat Jenis: 1,007
pH: 5,0
Leukosit: positif
Protein: negatif
Glukosa: negatif
Keton: Negatif
Nitrit: Negatif
Urobilinogen: Negatif
Bilirubin: Negatif
Darah: Positif
(Mikroskopik)
Leukosit: 6-8
Eritrosit: 4-6
Epitel: 3-5
Hyalin :positif
Bakteri:positif

Lab 19-02-2020
Hb/Ht/E/L/T: 11,8/33/4,2/15,0/170
MCV/MCH/MCHC: 78/28/36
Diftel: 0/0/0/92/44
Ur/Cr: 129/6,00
Anti-HCV : Negatif
HBsAg : Non-Reaktif
Na/K/Cl : 112/5,1/83
GDS : 179
Albumin : 2,70
 KELAS 9 KELAS 10 KELAS 11 KELAS 12
DPJP: dr. M. Diah, Sp.PD- KKV DPJP: dr. Desi Maghfirah SpPD
DPJP: dr.Hendra Zufry, Sp. PD-KEMD DPJP: dr. Islamuddin, Sp.PD
COW: dr. Muhamajdi COW: dr. Radiyana
COW: dr. T Emier COW: Dr: dr. Dedi
Dr: dr. Zaid DR: dr. Dedi DR: dr. Hibban Raber :EMD dan KKV

Nama: Zainuddin Yusuf Nama: Rustam Affan Nama: Sofyan S Nama: Amirudin Wahidin
TTL: 02/06/1957 (52th) TTL: 05/08/1965 (54th) TTL: 24/3/1965 (54 th) TTL: 10/1/1963 (57 th)
Alamat: Banda Aceh Alamat: Banda Aceh Alamay: Aceh besar Alamay: banda aceh
CM: 1-09-62-77 CM: 0851251 CM: 0944729
CM: 1-07-63-71
Hari rawatan: 5 Hari rawatan: 5
Harirawatan: 5 Harirawatan:20
A/ A/
A/ A/ 1. Efusi pleura recurrent ec dd 1.ulkus diabetikum digiti 1 pedis dextra
1 Post amputasi digiti V pedis dextra 1.penurunan kesadaran ec dd - Related HD 2.gastropati diabetik dd dyspepsia tipe
2.ALI -sepsis - Malignancy mix
3.Pneumonia geriatri -uremic encephalopati - Hipoalbuminea 3.DM tipe 2
4.DM tipe 2 -stroke recurrent - Pleuropneumonia 4.HT stg 2
5. Hipertensi Stage 1 2.CKD stg 5 ec dd - CHF 5.pneumonia CAP dd inf paru spes
-HN 2. CKD stage V on HD Reguler (Rabu-Sabtu) ec 6.OMI inferior
Th/ -PNC dd 1. DN, 2. PNC 7. Neuropati diabetik
1.bedrest 3.BSK 3. DM Tipe 2 NW
2.diet DM 1700kkal/hr 4. Hipertensi stage 1 Th/
4.Pneumonia (HAP) perbaikan
5. ISK -bedrest
3.sc lantus 24ui/24j sc 5.HHD
-kateter
4.iv ceftriaxone 1gr/12j 6.Anemia sedang ec peny ginjal kronik Th/ -diet DM 1700kkal
5.sc novorapid 10ui/8j 7.recurrent stroke iskemik - Bedrest -threeway
6.novalgin drip1amp dlm 500cc nacl 8. hipokalsemia - Diet ginjal 1700 kkal/hari -iv omeprazole 40mg/12j
0,9% - Trheeway -iv donperidon 10mg/8j
7. Alprazolam 0,25 mg k/p Th/ - Herbesser CD 200 mg/24 jam -valsartan /24j
- Bedrest - Valsartan 80 mg/24 jam -furosemid 20mg/18j iv
Lab 05-03-2020 - Diet ginjal 6x200cc/24j+pro 65mg/hr - Lenal ace 169 mg/24 jam -clyndamisin 300mg/8j
APTT:40,70 -NGT/Kateter - Asam folat 400 mg/12 jam -ceftriaxone /24j
-vancomycin 500mg - Curcuma tab /8 jam -gabapentin 300mg/24j
Lab 03-03-2020 - citicolin 500 mg/12 jam - Paracetamol 500mg/8j -CPG 75mg/24j
Hb/Ht/E/L/T: 13,5/4/5,1/10,8/406 - Lasix 40 mg/8 jam - Drip Levofloxacin 500mg/48j -amaryl-M
MCV/MCH/MCHC: 80/27/33 -Aspilet 80mg/24 jam
-lansoparazole 30mg/12j iv
Diftel: 4/1/0/71/16/8 Urinalisis (06-03-2020) -Nitrokaf R 20mg/24 jam
-as folat 400mg/12j -Lactulac CI/8j
GDS: 175 (Makroskopik)
-lenal ace 169mg/12j Warna: Kuning
Ur/cr : 35/1,50 -amlodipin 10mg/24j Kejernihan: Jernih Lab 08-03-2020
-kalsitriol 1,25mg/24j po Berat Jenis: 1,024 Na/K/Cl/Ca : 123/5,1/81/7,4
-clopidogrel 75mg/24j po pH: 6,5
-pct 500mg/8j po Leukosit: negatif Lab 05-03-2020
-concor 1x25 mg Protein: positif (+3) Hb/Ht/E/L/T: 9,4/26/3,2/399/27,2
Glukosa: positif (+2) MCV/MCH/MCHC:80/29/37
Lab 06-03-2020 Keton: Negatif Diftel: 0/0/0/89/4/7
Hb/Ht/E/L/T: 9,7/29/3,4/4,2/308 Nitrit: Negatif Albumin :3,20
MCV/MCH/MCHC: 85/28/33 Urobilinogen: Negatif
GDS 76
Diftel: 6/3/0/59/15/17 Bilirubin: Negatif
Ur/cr:31/1,10
Ca: 7,2 Darah: positif
Na/k/cl/ca:117/4,1/84
Na/K/C; : 140/4,5/99
(Mikroskopik)
Leukosit: 6-8
Lab 03-03-2020 Eritrosit: 10-15
Hb/Ht/E/L/T: 7,5/22/2,6/6,1/252 Epitel: 2-3
MCV/MCH/MCHC: 84/29/34 Hyalin Cast : positif
Diftel: 3/1/0/80/7/9 Bakteri : positif
Ca: 6,4
Ur/cr:102/7,00 Analisa Cairan Pleura (06-03-2020)
Na/k/cl:137/4,6/101 Warna : Kuning
Kejernihan : Keruh
Lab 28-02-2020 Bekuan : ngatif
Hb/Ht/E/L/T: 8,6/25/3,0/6,4/235 PMN Sel : 30
MCV/MCH/MCHC: 83/29/34 MN Sel : 70
Diftel: 2/1/0/76/13/8 Leukosit : 93
Total protein : 3,7
Pt/aptt:17,30/42,70
Glukosa : 242
Ca/mg:5,5/2,0
GDS:118 Lab 05-03-2020
Ur/cr:172/11,60 Hb/Ht/E/L/T: 8,5/26/3,1/7,6/308
Na/k/cl:126/5,5/95 MCV/MCH/MCHC: 84/27/32
Diftel: 1/1/0/70/16/12
Lab 25/02/2020 Albumin 2,9
GDS 187
Hb/Ht/E/L/T: 8,4/24/3,1/67,3/378 Ur/cr:75/7,40
MCV/MCH/MCHC: 80/27/34 Na/k/cl/ca:141/5,2/103/8,1
Diftel: 4/0/0/67/19/10
 ISO 1 ISO 2 ISO 3 ISO 4
DPJP: Dr. dr. Kurnia F Jamil, Sp. PD-KPTI DPJP: dr.Price Maya, Sp. PD
COW: dr. Nadi COW: dr. Ridhalul
Dr: dr. Rianda Dr: dr. Zulfikar KAMAR RUSAK DPJP ANAK
Raber: GEH, Bedah Plastik Raber: GH, GEH

Nama : Muhammad Nur Nama : Lasmi Darmi

TTL : 02/10/1950 TTL : 1-07-1990 (49th)
Alamat: Aceh Pidie Alamat: Aceh Barat
CM: 1188771 CM: 1201353
Hari Rawatan: 4 Hari Rawatan: 26

A/ A/
1. Sepsis (perbaikan) ec ulkus pedis 1. Penurunan kesadaran (perbaikan) ec dd -
sinistra (MRSA) - uremic encephalopaty
2. PSMBA (perbaikan) ec dd - sepsis
- gastritis erosive 2. PSMBA ec dd/ 1. induced heparin, 2.
- ulkus gaster ulkus gaster, 3. uremic bleeding
- Ulkus duodenum 3. Sepsis ec dd 1. pneumonia, 2. ISK, 3.
3. Pneumonia (HAP) perbaikan wound dehiscend a.c brachialis, 4. Abses
4. MRSA a.r coli
5. Ulkus diabetic a/r pedis sinistra 4. CKD stg V on HD reguler
6. DM tipe II Overweight (terkontrol 5. DM tipe II NW
dengan insulin) 6. ISK
7. Anemia sedang NN ec PSMBA 7. Anemia ec
(perbaikan) -Perdarahan
8. OA Genue bilateral K-L 2-3 -Penyakit Kronik
9. CHF FC NYHA 1-II ec dd 8.Hipertensi Stage 2
- HHD 9. Ulus decubitus grade1
- CAD
10. Hipoalbuminemia berate c dd Th/
- sepsis - Bedrest
- low intake - Diet MB ginjal 1700 kkal/hari
11. Diabetik neuropati - Drip Vancomisin 500mg/48 jam post HD
12. Susp. neuropati diabetic - Nystatin drop 2cc / 6 jam
- Lansoprazole 40 mg/ 12 jam
Th/ - Fosen Edema ekstra
-Bedrest - sulcralfat 3x1
-Diet DM MII 1700 kkal/hari - Herbeser cp 10mg1x1
- IV. Meropenem 1gr/8jam
- IV. Lansoprazole 30mg/12 jam Lab 3/3/2020
- drip albumin 25% 100cc/ 24 jam Hb/Ht/E/L/T: 9.9/30/3.7/15.0/276
MCV/MCH/MCHC: 80/27/33
- Clindamicin 3x300mg tab
Diftel : 2/0/0/82/11/5
- paracetamol 2x1000mg tab
- asetyl sistein 3x200mg tab Lab 29/2/2020
- gabapentin 1x100mg tab Hb/Ht/E/L/T: 7,3/23/2,8/15,6/291
- Mecobalamin 3x500mg tab MCV/MCH/MCHC: 82/26/32
- Sucralfat 3 x CII syr Diftel : 3/1/0/80/12/4
- IV Transamin 500mg/8j Anti HCV/HBsAg : Negatif/Non reaktif
Bil Dire/Indir : 0,45/0,49
- SC Lantus 0-0-0-10 IU
SGOT/SGPT : 11/0
Na/K/Cl/Ca : 139/3,9/102/7,7
Lab 6/3/2020
Hb/Ht/E/L/T: 9,2/27/3,1/17,9/339
Lab 26/2/2020
MCV/MCH/MCHC: 87/30/34
Hb/Ht/E/L/T: 8,1/25/3,1/20,4/259
Diftel : 5/0/0/77/12/6
MCV/MCH/MCHC: 80/26/33
Diftel : 2/1/1/86/8/2
Lab 5/3/2020
Procalsitonin : 0,30 Lab 24/2/2020
Hb/Ht/E/L/T: 9,9/30/3,8/23,7/256
Lab 2/3/2020 MCV/MCH/MCHC: 81/26/33
Hb/Ht/E/L/T: 5,6/16/1,8/24,9/300 Diftel : 3/1/0/87/7/2
MCV/MCH/MCHC: 89/31/35
Diftel : 0/0/0/92/6/2 Lab 22/2/2020
PT/APTT : 15,70/37,80 Hb/Ht/E/L/T: 9.5/29/3.5/20.8/233
Albumin : 2,30 MCV/MCH/MCHC: 81/27/33
GDS : 220 Diftel : 2/1/0/82/10/5
Ur/cr : 75/0,90
Na/K/Cl : 139/4,8/105 Lab 20/2/2020
Hb/Ht/E/L/T: 9,8/29/3,7/10,6/214
MCV/MCH/MCHC: 79/27/33
Diftel : 1/1/0/79/12/7
PT/APTT: 15,80/28,20
 ISO 5 ISO 6 ISO 7* ISO 8
DPJP: dr. M. Diah, Sp.PD- KKV
DPJP BEDAH COW: dr. Muhamaji
BEDAH ORTHO RABER GEH DR: dr. Dedi KOSONG

Nama :Zubaidah N Ali Kaoy

Umur: 12/01/1945 (75 th)
CM : 0971856
Alamat: aceh Pidie
Hari Rawatan: 6

A/
1. DVT a/r Pedis Sin dd Selulitis
2. HT stage I
3. CAD
4. Pneumonia (CAP)
5.reaktif hiperglikemia ec infectid

Th/
-Bed rest
-Diet MB 1700 Kkal
- IVFD Nacl ,9 % 20 gtt/i
- IV Ceftriaxone 2 gr/4 j
- IV lansoprazole 3 mg/24j
- Cilostazole 200 mg/24j
- Arixtra 2,5 mg/ 24 jam
- Atorvastatin 20 mg/24 j
- herbesser 1mg/24 j
- Simarc2 mg/24 j
- Lactulac syr CI/ 24 j
- Coditam tab/8 j
- Furosemid 20mg/12 j
-citirizin 10mg/24j po

Urinalisis (06-03-2020)
(Makroskopik)
Warna: Kuning
Kejernihan: Jernih
Berat Jenis: 1,008
pH: 6,0
Leukosit: negatif
Protein: Negatif
Glukosa: negatif
Keton: Negatif
Nitrit: Negatif
Urobilinogen: Negatif
Bilirubin: Negatif
Darah: Negatif

(Mikroskopik)
Leukosit: 1-2
Eritrosit: 0-1
Epitel: 2-3

Lab 05/3/2020
Hb/Ht/E/T/L: 11,4/36/4.5/261/11,6
MCV/MCH/MCHC: 80/25/32
Diftel : 1/0/0/75/19/5
HbA1c 6,30
HBsAg Non Reaktif
Albumin 3,01
Kolestrol Total : 195
HDL/LDL : 49/109
Trigliserit 164
GDP : 89
GD2PP 164
Asam urat 6,8

Lab 03/3/2020
Hb/Ht/E/T/L: 11,2/35/4.3/230/18,5
MCV/MCH/MCHC: 81/26/32
Diftel : 0/1/0/87/8/4
PT/ APTT rasio : 1,09/1,2
GDS :212
Ur/Cr : 30/0,7
Na/K/CL : 139/4,4/103
 ISO 9 ISO 10 ISO 11 ISO 12
DPJP: dr. Islamuddin, Sp. PD
DPJP: dr. M. Diah, Sp.PD- KKV DPJP: dr.Hendra Zufry, Sp. PD-KEMD
KOSONG COW : dr. Rahmi Juniar
COW: dr. Muhamadji COW: dr. T Emier
dr : dr. Hibban
DR: dr. Dedi Dr: dr. Zaid
Raber: PTI
Nama : Ramzi Muslim Nama : Yusnidar Ramli
Umur:04/04/19780(39th) Umur:01/07/19769(43th) Nama : Eli Murni
CM :1-095237 CM :1-23-96-21 Umur : 06/07/1984 ( 52 th)
Alamat: padang tiji Alamat: Pidie Jaya CM : 1235989
Hari Rawatan: 4 Hari Rawatan: 7 Alamat : sabang
Hari rawatan : 7
A/ A/ A/
1.SIDA stadium III dengan inf oportunistik 1. SIDA stadium II dengan candidiasis oral 1. Tonsilitis membranosa dd difteri
pneumonia + candidiasis oral 2. Pnemunia(CAP)dd infeksi Paru spesifik 2.grave desease
2.pneumonia dd inf paru spesifik 3.Candidiasis Oral 3. Anemia sedang hipokrom mikrositer ec
3.candidiasis oral 4.Hipokalemia Ringan dd
4.diare kronis ec dd 1. SIDA 2. IBD 5.ANEMIA Ringan Hipokrom mikrositter ec - Def FE
5. Hipokalemia ec dd 1. GI loss 2. Low intake dd - Penyakit kronis
- Def Besi
Th/ - Penyakit kronis Th/
-bedrest - Bedrest
-diet MB 1700kkal/hr Th/ - Diet MB 1700 kkal/hari
-ivfd nacl 0,9% 20gtt/i - Bed rest -IVFD RL 0,9% 20 gtt/i
-IV ceftriaxone 2gr//24j iv - Diet MII TKTP 1700 KKAL - propanolol 10mg/12j po
-IV omeprazole 40mg/12j iv - Threeway -curcuma tab /12j po
-nystatin drop gtt2cc/6j - Iv Lansoprazole 30mg/12jam - paracetamol 500mg/8j
-synbio 1tab/8j po - Cotrimoxazole 960mg 1x1 -eritromisin 500mg/6j
-loperamide 1tab setiap BAB K/P po - Vectin 300mg/8jam -minosep 2cc/8j
- KSR 600mg/24 jam - Paracetmol 500mg/8jam -nistatin 2cc/6j
- Nistatin Drop 3x2cc - Alprazolam 0,25mg K/P
Lab 06-03-2020 - Sulcrafat SYR 3x1cc - IV Flukonazole 200mg/ 24 jam
Hb/Ht/E/L/T: 12,3/37/4,4/223/7,1 - KSR 1x600mg - IV Meropenem 1gr/8j
MCV/MCH/MCHC: 83/28/33 - Curcuma 3x1 tab - SC Leukogen 1 vial (ekstra)
Diftel : 5/0/0/40/42/13 - Cetirizin 2x1 po
SGOT/SGPT 29/31 Lab 8-03-2020
Bill:0,38 Lab 8-03-2020 Hb/Ht/E/L/T : 7,9/24/3,1/1,1/475
Anti HCV:negatif Hb/Ht/E/L/T : 11,4/35/4,5/3,7/413 MCV/MCH/MCHC: 76/25/33
HbsAG:non reaktif MCV/MCH/MCHC: 79/26/32 Diftel : 4/1/0/0/91/4
Diftel : 0/1/0/61/30/8
Urinalisis (06-03-2020) SGOT/SGPT : 248/112 Lab 7-03-2020
(Makroskopik) Hb/Ht/E/L/T : 8,0/24/3,2/1,0/492
Warna: Kuning muda Lab 7-03-2020 MCV/MCH/MCHC: 76/25/33
Kejernihan: Jernih Hb/Ht/E/L/T : 10,5/33/4,2/3,5/421 Diftel : 11/2/0/0/81/6
Berat Jenis: 1,008 MCV/MCH/MCHC: 77/25/33
pH: 6,0 Diftel : 0/1/0/63/32/4 Lab 6-03-2020
Leukosit: negarif Na/K/Cl : 145/4,6/109 Hb/Ht/E/L/T : 9,4/28/3,8/1,3/434
Protein: Negatif MCV/MCH/MCHC: 73/25/34
Glukosa: negatif Lab 02-03-2020 Diftel : 10/2/0/1/83/4
Keton: Negatif Hb/Ht/E/L/T: 9,6/30/3,9/5.4/360
Nitrit: Negatif MCV/MCH/MCHC: 76/24/32
Urobilinogen: Negatif Diftel : 2/0/0/78/15/5
Bilirubin: Negatif SGOT/SGPT 115/59
Darah: Negatif GDS 120
UR/KR 16/0.60
(Mikroskopik) NA/K/CL 139/3.4/103
Leukosit: 1-2
Eritrosit:0-1 Urinalisis (05-03-2020)
Epitel: 1-2 (Makroskopik)
Warna: Kuning
Analisis Tinja (6-3-2020) Kejernihan: Jernih
Warna : Kuning Berat Jenis: 1,013
Bau: Khas pH: 6,0
Eritrosit: Negatif Leukosit: positif
Leukosit: Negatif Protein: Negatif
Telur cacing: Negatif Glukosa: negatif
Parasit: Negatif Keton: Negatif
Konsistensi: cair Nitrit: Negatif
Urobilinogen: Negatif
Bilirubin: Negatif
Darah: Negatif
Warna
(Mikroskopik)
Leukosit: 8-10
Eritrosit: 1-2
Epitel: 6-8

Analisis Tinja (5-3-2020)

Warna : Kuning
Bau: Khas
Eritrosit: Negatif
Leukosit: Negatif
Telur cacing: Negatif
Parasit: Negatif
Konsistensi: lunak