Assalamualaikum dokter

Izin menginfokan pasien divisi GH

hari minggu 27/12/20

AKSA 3

Kamar 1/1 : Malahayati

Ass

1. CKD Stage 5 dengan uremic sindrom ec dd

- SN

- GNC

2. SLE

3. Hipertensi stage 2

4. Diare akut (perbaikan)

5. Sepsis ec urosepsis

HD senin-kamis

Lab 25/12/2020

Hb/Ht/L/T : 7/19/6,2/97

MCV/MCH/MCHC : 79/29/36

RDW : 14,7

Diftel : 0/0/0/86/5/9

Ur/Cr : 100/3,4

Na/K/Cl/Ca : 135/3,5/106/6,7

Urinalisa 22/12/2020

Protein +3

Keton +

Urobilinogen +
Leu : 25-50

Erit : 100-120

Sel ragi +

Bakteri +

Kamar 1/3 : Masnidar Mahmud

Ass

1. Penurunan kesadaran (perbaikan) ec dd 1) uremic encefalopati 2) imbalance elektrolit 3) Sepsis

2. Sepsis ec dd 1) pneumonia 2) urosepsis

3. PSMBA ec dd 1. Uremic bleeding 2) Stress ulcer 3) Gastritis erosif (Perbaikan)

3. CKD Stage 5 ec dd uremic sindrom ec PNC

4. Hiponatremia normoosmolar hipovolemik (Perbaikan)

5.Anemia sedang HM ec dd 1) peny.kronik 2) Perdarahan

6. Hipoalbuminemia sedang

7.Hipokalemia ringan

8. Ulcus decubitus gr 1

9. Skizofrenia

10. obs seizure

-hd free heparin selasa - kamis - sabtu

Lab 23/12/2020

Hb/L/T : 8,3/9,5/334

MCV/MCH/MCHC: 78/26/34

LED : 114

Diftel : 6/0/0/67/18/9

D-Dimer : >4000

Procalcitonin : 1,15

Albumin : 2,69
Ca: 10,6

Ur/Cr: 135/4,54

Na/K/Cl : 139/4/104

Urinalisa 23/12/2020

Leukosit : + (20-25)

Protein : +1

Glukosa : +1

Keton : +

Urobilinogen : +

Darah : + (25-50)

USG Urologi 22/12/2020

Chronic Parenkimal kidneys bilateral

Kamar 1/4 : Aisyah M.Dhin

Ass

-CKD Stage 5 dengan uremic sindrom ec dd 1) PGOI 2) PNC

-Hipertensi urgensi

-Nefrolithiasis sinistra

-PSMBA ec dd 1) uremic bleeding 2) stres ulcer 3) drug induced

Lab 25/12/2020

Hb/Ht/L/T : 6,3/17/45,4/154

MCV/MCH/MCHC : 85/31/36

RDW : 13,2

Diftel : 0/0/0/92/4/4

PT/aPTT : 1,19/2,61

Ur/Cr : 372/15,6
Na/K/Cl : 142/5/107

Lab 24/12/2020

Hb/Ht/E/L/T : 3,5/10/1,2/23,3/266

PT/APTT : 1,24/0,83

USG Abdomen 22/12/2020 :

Hidronefrosis bilateral dengan nephrolithiasis multiple bilateral

Urinalisa 22/12/2020

Protein +2

Leu : 150-160

Erit : 30-40

Epi : 5-10

Sel ragi +

Bakteri +

Kamar 4/1 : Nurbaidar binti tgk. Hasan

Ass/

1.Penurunan kesadaran (perbaikan) ec dd 1) Uremic ensefalopati 2) Sepsis ec urosepsis 3) Imbalan

Elektrolit

2.CKD stage 5 ec dd 1) DN 2) GNC

3.Anemia NN ec peny.kronis

4.DM tipe 2

5.ISK

Lab 25/12/2020

HIV : non reaktif

Albumin : 2,3
Ur/Cr : 140/5,6

Kamar 4/3 : Maryam Dhin

Ass

-Penurunan kesadaran perbaikan ec dd 1) uremic ensefalopati 2) sepsis 3) stroke

-AKI stage 3 post renal ec dd 1) ca bulli 2) CKD

-Hidronefrosis bilateral grade 2-3

-Susp ca bulli

-Pneumonia geriatri

-Sepsis ec dd 1) pneumonia 2) urosepsis

-Hipertensi on terapi

-Geriatri problem

-PSMBA ec dd 1) uremic bleeding 2) stres ulcer 3) ulkus duodenum

-post nefrostomi ai hidronefrosis bilateral

Lab 22/12/20

Hb/L/tr: 8,5/17,4/197

Diftel: 2/0/0/86/5/7

Pt/aptt: 1/1

Alb: 2,34

Kolestrol total/HDL/LDL/Tg: 115/27/62/137

Na/k/cl/ca: 137/3,9/103/9,1

Ur/cr: 97/10,24

CT scan abdomen 18/12/2020 : hidronefrosis sedang bilateral disertai hidroureter bilateral, tak tampak
gambaran batu sepanjang traktus urinarius, massa solid ukuran 10,04x10,07x9,22 cm di cavum pelvis
(kesan di bladder), kalsifikasi uterus, ascites, efusi pleura bilateral, skoliosis lumbalis, susp kolelitiasis
USG urologi 14/12/2020 : hidronefrosis bilateral grade 2-3 dengan parenchymal kidney disease kanan,
ascites, massa bulli dd uterus

Rontgen thorax 14/12/2020 : cor normal, susp bronchiectasis dengan pleuropneumonia kanan

Kamar 5/1 : Imelda binti Makmur

Ass

-CKD stage 5 ec dd 1.PGOI, 2.PNC dengan uremic sindrom

-Febris ec dd 1.ISK, 2.Viral infection, 3.BSK

-Post pemasangan DJ stend

-HD senin-kamis

25/12/20

Na/k/cl/ca: 149/3,5/110/8

Hb/L/tr: 8,2/5/175

Diftel: 3/1/0/49/31/16

Ur/cr: 43/4,10

Kamar 5/3 : cut safriana

Ass

1.Penurunan Kesadaran (perbaikan) ec dd - Sepsis

- Uremic Encephalopathy

2. Sepsis ec dd 1.Urosepsis 2.Pneumonia

3. AKI stage III dd acute on CKD

4.DM Tipe 2 NW

5.Susp.Mioma uteri

6. Hipoalbuminemia sedang (2,4)

Lab 25/12/2020

Hb/Ht/L/T : 8,3/25/21,3/442

MCV/MCH/MCHC : 77/26/34

RDW : 17,2

Diftel : 2/1/0/84/9/4

Ur/Cr : 102/1,9

Na/K/Cl/Ca : 138/4,7/110/7

USG Abdomen 21/12/2020

Ginjal Kiri : ukuran Ap 12,7cm, system pelviokalises sedikit melebar, tidak tampak lesi fokal

Ginjal Kanan : Normal

USG Ginekologi : Lesi hipoekoik di uterus 3,4x2,9 cm

Susp.Mioma uteri

Kamar 5/4 : Linawati binti Abdul Mutalib

Ass

-CKD stage 5 ec dd 1) nefritis lupus

2) GNC

-Susp SLE derajat berat

-Hipertensi stage 2

-Anemia berat normokrom normositer ec dd 1) penyakit kronik 2) perdarahan

26/12/20

Na/k/cl/ca: 144/5,2/117/6,8

Hbsag/anti hcv: negative

Ur/cr: 143/8,9

Swab RT PCR SARS CoV2 25/12/2020 : negatif

Lab 24/12/2020

Hb/Ht/L/T : 6,4/19/9,4/280

MCV/MCH/MCHC : 84/28/34

RDW : 13,3

Diftel : 6/0/0/71/18/5

Anti HCV / HbsAg : negatif / non reaktif

Albumin : 3,5

Ur/Cr : 130/8,2

Na/K/Cl : 143/5,2/116

Antibodi anti SARS CoV2 IgM / IgG : non reaktif / non reaktif

Kamar 6/2 : Nurahwan

Ass

-CKD stage 5 on HD regular

-Anemia berat normokrom normositer ec penyakit kronik

26/12/20

Na/k/cl/ca: 140/6,2/100/9

Hbsag/anti hcv: negative

Ur/cr: 176/13,8

Lab 25/12/2020

Hb/Ht/L/T : 5,6/17/6,8/205

MCV/MCH/MCHC : 84/28/34

RDW : 14,4

Diftel : 1/1/0/75/13/10

GDS : 85

Ur/Cr : 132/11,8
Na/K/Cl : 139/5,6/104

AKSA 2

Kamar 1/4 : Arifin M.Ali

Ass/

1. CKD stg 5 dgn uremic syndrome ec dd:

-HN

-PNC

2. hiperkalemi ringan

3. hiponatremi hipoosmolar hipervolemik

4. anemia berate c PGK

22/12/20

hb/L/tr: 4/8,7/97

diftel: 3/0/0/87/5/5

mcv/mch/mchc: 84/30/35

hiv: negative

hbsag/antihcv: negative

gds: 96

ur/cr: 385/22,8

na/k/cl: 125/5,7/97

Kamar 2/3 : Yusri MY

Ass

1. CKD Stage V ec dd

- HN dengan uremic

- PNC

2.Hepatomegali ec dd

-Liver kongestif

- kista hepar
- limfoma maligna

- Metstase proses

3.Hipoalbumin

4.ISK

5. HHD

6.CHF FC NYHA I II ec dd 2.HHD 2. IHD

7. PSMBA

8.ASites

Lab 26/12/2020

Hb/Ht/E/L/T : 12,8/35/4,7/9,3/142

Diftel : 5/0/0/80/14/1

Albumin/Ca : 2,6/8,0

Ur/cr : 295/13

Na/K/Cl : 137/5,0/105

Urinalisa 23/12/2020

Lekosit +

Protein +3

Darah +

Leukosit 10-25

Eritrosit 400-500

Epitel 0-1

Granular cast +

Bakteri +

Lab 23/12/2020

HIV non reaktif

AFP 4,14
Albumin 2,36

Thorax 23/12/2020

Cardiomegaly dengan kongestif paru

USG urologi 23/12/2020

PNC bilateral

Asites

Kamar 3/1 : M.Daud Ali

Ass/

1.CKD stg V ec DN dgn uremic syndrome

2.Orchitis

3.Hipertensi stg II

4.DM tipe 2

5.Ulkus diabetic a/r Cruris Sinistra

Lab 23/12/2020

Hb/HT/L/T : 7,8/21/25,1/371

MCV/MCH/MCHC 72/26/37

Diftel : 1/0/0/92/3/4

Protein Total : 5,30

Albumin/Globulin : 1,84/3,46

Ur/Cr : 110/6,81

Asam Urat : 8,1

Na/K/Cl : 132/4,0/102

USG Urologi dan Dopler (22/12/20):

-struktur dinding vaskular normal, tidak tampak trombus intra lumen

-efusi pleura bilateral

-asites

-ginjal bilateral dalam batas normal

Lab 20/12/2020

PT/APTT : 1,02/1,44

Kamar 3/2 : Abdul Halim

Ass/

1.CKD stg V ec dd/

a.HN

b.PNC

dgn edema paru akut

2.Pneumonia dd/ covid-19

3.Anemia berat NN ec PGK

4.Hipertensi B kronis

Lab 24/12/20

Na/k/cl: 142/4,4/110

Hb/L/tr: 6,2/4,6/53

Diftel: 2/1/1/69/16/11

Hbsag: reaktif

Anti hcv: negatif

Gds: 104

Cr: 19,5

Kamar ¾ : M. Dahlan

Ass
-AKI stage 3 pre renal dd acute on CKD

-Anemia berat hipokrom mikrositer ec dd 1) penyakit kronik 2) perdarahan

-PSMBA ec dd 1) gastropati NSAID 2) ulkus gaster 3) ulkus duodenum

-Pneumonia CAP

-PPOK eksaserbasi akut

-Hiponatremia hipoosmolar euvolemik (perbaikan)

24/12/20

Hb/L/tr: 9,3/19,8/100

Diftel: 4/0/0/91/4/1

Echocardiography 23/12/2020 : EF 65 %, MR dan TR mild, disfungsi diastolik ringan, global normokinetik

wall motion

Kultur darah 22/12/2020 : tidak ada pertumbuhan

Kamar 3/5 : Wahyudi Bin Ismail

Ass

-CKD stage 5 dengan uremic sindrom ec dd 1) PNC 2) GNC 3) PGOI

-Ulkus diabetik at regio pedis sinistra (perbaikan)

-Efusi pleura ec dd 1) pleuropneumonia 2) pleuritis TB

-HHD

-DM tipe 2 obese grade 1 dengan charcot foot

-Iskemik lateral

Lab 26/12/2020

Hb/Ht/E/L/T : 10,4/32/3,9/3,1/129

Diftel : 20/0/0/68/7/5

Albumin/Ca : 3,1/8,0
Ur/Cr : 167/6,9

Na/K/Cl : 140/3,6/103

Thorax PA 22/12/2020 : Efusi pleura kanan

USG Urologi 22/12/2020 : chronic parenchymal bilateral kidney disease

USG Doppler 22/12/2020 : Kaliber a.brachialis kiri 0,45 cm a radialis kiri 0,21 a. ulnaris kiri 0.21 cm,
struktur dinding vascular narmal, tidak tampak thrombus intra lumen

Kamar 4/2 : Sukono Patah Subari

Ass/

1. ckd stg 5 dengan uremic syndrome dd:

-urat nefropati

-pnc

2. anemia berate c pgk

3. hipokalsemia

Lab 26/12/2020

Hb/Ht/E/T/L : 5,8/16/2,0/167/17,8

Diftel : 0/0/0/91/4/5

PT/APTT : 1,18/1,09

Kamar 4/4 : Ibrahim M

Ass/

1.CKD stage 5 dengan uremic syndrome e.c dd/

1. PGOI

2. PNC

3. HN
2. HT on therapy

3. Hidronefrosis Bilateral

4. BPH

5. Hiperkalemia ringan

6.ISK

-Hemodialisa senin rabu dan jumat

p/ CT scan abdomen dan pelvis daftar senin

USG urologi 22/12/2020

PNC dengan hidronefrosisi bilateral ec hipertrofi prostat

USG Doppler 22/12/2020

Struktur dinding vascular normal

Lab 22/12/2020

Hb/Ht/L/T 10.8/31/7,9/214

MCV/MCH/MCHC 81/28/35

LED 44

Diftell 8/1/0/67/12/12

Ca 9,2

UR/CR 181/7,55

As. Urat 6,9

Na/K/Cl 138/4,80/106

Urinalisa 21/12/2020

Lekosit +

Glukosa +1
Darah+

Leukosit 5-10

Eritrosit 0-2

Epitl 0-1

AKSA 1

Kamar B8 : Azhariah

Ass

-Penurunan kesadaran ec dd 1) imbalance elektrolit 2) uremic ensefalopati 3) sepsis

-CKD stage 5 dengan uremic sindrom ec dd 1) DN 2) HN

-DM tipe 2 obese grade 1

-HHD

-Hiponatremia hipervolemik

-Anemia sedang normokrom normositer ec dd 1) penyakit kronik 2) perdarahan

-Hipoalbuminemia

-Hipokalsemia

-Efusi perikard tanpa tanda tamponade

Lab 24/12/2020

Na/K/Cl/Ca : 125/3,8/96/7

Lab 23/12/2020

Ur/Cr : 111/6,6

Na/K/Cl/Ca : 120/3,8/91/7,1

Urinalisa 22/12/2020

Makroskopis

-Leukosit : (+)
-Protein : (+1)

-Darah : (+)

Mikroskopis

-Leukosit : 150-160

-Eritrosit : 10-25

-Epitel : 0-1

-Bakteri : (+)

Lab 22/12/2020

KGDP/KGD2PP : 51/102

Na/K/Cl/Ca : 107/4/81/6,6

Kamar B10 : Ridwan Abubakar

Ass/

1. AKI stage III dd Acute On CKD

2. DM tipe 2 overweight

3. Ulkus Diabetik ar Pedis

4. Pneumonia

5. Efusi Pleura (S) ec dd

1) pleuropneumonia

2) pleuritis TB

6. Neuropati DM

7. Anemia Berat ec dd Peny. Kronik

Th/

- Bedrest

- Diet Lunak 1500kkal/hari

- IV Meropenem 1 gr/8 jam

- Drip Furosemid 50 mg/jam

- Ca Gluconas 1 amp/8 jam

- Lenal Ace 169 mg/12 jam

- Clindamicin 3 x 300mg

- Atorvastatin 1 x 20 mg

- Gabapentin 1 x 300mg

Zamzam 1

Kamar 1 : Mufti bin Kamaruddin

Ass

-CKD stage 5 on HD regular ec urat nefropati

-Geriatri problem

-Anemia sedang normokrom normositer ec dd 1) penyakit kronis 2) perdarahan

-LBP ec spondilosis lumbalis

-Hiperkalemia (perbaikan)

-Hipoalbuminemia ringan

-Hiperurisemia

-Vesicolitiasis

-BPH

-Trombositopenia ec dd 1) ITP 2) viral infection 3) drug induced

Lab 25/12/2020

Hb/Ht/L/T : 9,6/27/7,6/61

MCV/MCH/MCHC : 83/29/35

Diftel : 1/1/0/59/29/10

Biltot/Bildiect/bilindirect :0,63/0,23/0,4

SGOT/SGPT :73/34

Alb : 3,0

Kalsium : 9,1

Ur.Cr : 75/6,2
Na/K/Cl : 140/3,8/105

Lab 21/12/2020

Hb/Ht/L/T : 6,2/18/6,5/59

MCV/MCH/MCHC : 85/29/134

D Dimer 1540

PT/APTT : 1,0/1,2

Ur/Cr : 130/11,1

Na/K/Cl/Ca : 140/4,5/105

Lab 19/12/2020

Hb/Ht/L/T : 6,6/19/4,9/57

MCV/MCH/MCHC : 84/29/34

RDW : 18,1

Diftel : 3/1/0/58/29/9

PT/aPTT : 0,85/0,57

MDT :

Eritrosit :Hipokrom, anisopoikilositosi : target sel, mososit.

Trombosit : jumlah kurang, giant trombosit,

Kesimpulan : hipokrom mikrositer, trombositopenIA

Lab 18/12/2020

Hb/Ht/L/T : 6,8/19/4,7/47

MCV/MCH/MCHC : 83/29/35

RDW : 17,9

Diftel : 2/1/0/58/27/12

Ur/Cr : 96/7,1

Na/K/Cl/Ca : 142/3,9/107/10,2

Lab 16/12/2020
Ur/Cr : 164/9,8

Na/K/Cl/Ca : 140/5/110/8,8

USG urologi 15/12/2020 : parenchymal kidney disease kanan dengan kista ginjal, vesicolithiasis, BPH

Kamar 12 : wahidin

Ass/

1. CKD stage 5 ec DN on HD regular

2. anemiaberatecdd 1. Penyakitkronik 2. Occult bleeding

3. Hipertensistge 2

4. DM tipe 2

Lab 20/12/2020

Hb/L/Tr : 6,9/19/4,7/152

MCV/MCH/MCHC : 85/30/36

Diftel : 5/0/0/61/21/13

Ur/cr : 144/13,7

Na/k/cl : 142/4,9/107

HBsAg: non reaktif

Anti HCV: negatif

Lab 20/12/2020

Hb/L/Tr : 4,9/4,8/181

GDS 120

Ur/cr : 155/15

Na/k/cl : 143/5,2/107

MINA 2

Kamar 2/1
Kamar 2/2

Kamar 6/6 : Umi kasom

1.Penurunan kesadaran perbaikan ec dd

1. Stroke iskemik
2. Imbalance elektrolit
3. Sepsis

2. sepsis ec dd

1. pneumoni

2. urosepsis

3. AKI stage 2 pre renal

Lab 24/12/20

Hb/ht/t/l : 12,9/37/243/16,9

Na/k/cl: 142/4,2/106

Ur/cr : 111/2.3

Arafah 3

Kamar 2A : Nurmalawati usman (pasbar)

Ass/

AKI Stage 2 post renal

Ca ovarium residif post kemo

Hipoalbuminemia

Anemia berat HM ec peny kronis

Asites

KB

Cucu Siti, 39 thn

Dx. PEB + Hipokalemia+ G5P2A2 ( hamil 24-25 minggu)

Yeni

G8P1A6 hamil 20-21 minggu superimposed PEB

Trombositopenia ec dd

1. APS
2. Autoimun disease
3. ITP
4. TTP