MAPPING AQSA 3

Sabtu, 17 Juli 2021

No Nama DPJP Kamar Jumlah

dr. Vera Abdullah Sp.PD-Kpsi K3B3 1

1.

dr. M. Riswan Sp.PD-KHOM K2B1, K2B4, K3B5, Zamzam 3 K15 4

2.

dr. T. Mamfaluti Sp.PD K2B2, K4B3, Nabawi K5B5 3

3.

Dr. dr. Fauzi Yusuf, SP.PD KGEH K3B2, K3B4, K4B2 3

4.

dr. Hendra Zufry SpPD KEMD K2B3, K3B1 2

5.

dr. Desi Salwani, SpPD-KGH Zamzam 3 K02, , Zamzam 3K12 2

6.

Dr. dr. Azhari gani, Sp. PD, KKV K1B4, K5B2, K5B3 3
7.

dr. M. Fuad, Sp.PD KHOM K4B1,K5B4 2

8.

dr. Alfi Syahrin, Sp.PD K2B5, Arafah 2 K6A 2

9.

dr. Islamudin, Sp.PD Zamzam 3K11 1

10.

dr. Azzaki Abubakar, Sp.PD KGEH

11.
 K1B1 K1B2 K1B3 K1B4
DPJP : dr. Azhari Gani, Kosong Kosong DPJP Dr. dr. Azhari Gani, Sp.PD KKV
Sp.PD-KKV COW : dr. Irhash/ dr. Eko
COW : dr. Irhash/ dr. Ruangan : dr. Jupri/dr. Julia/ dr.
Eko Rossyta/ dr. Rina
Ruangan : dr. Jupri/dr.
Julia/ dr. Rossyta/ dr.
Rina
Nama: Irma Suryani Nama: Fatimah Syam
CM: 1-20-04-15 TTL: 10/07/1959
TL: 20-04-1991 CM: 1277095
TM : 13/07/2021
TM: 12/07/2021
Ass Ass/
1. GAD 1. Anemia sedang NN ec dd 1) perdarahan 2)
2. Psmbb ec hemorroid penyakit kronis
interna 2. malfungsi AV shunt
3. CKD stage V on HD regular ec dd: 1) DN
Th/ 2) HN 3)PNC
- Tirah baring 4. DM tipe II NW
- Diet MB 5. Hipoalbuminemia sedang
1700kkal 6. Hipokalemia sedang
- Ivfd nacl 0,9% 7. Syok hipovolemik (perbaikan)
20 gtt
- iv lansoprazole Th/
30 mg/12 jam Tirah baring
- Asam O2 nasal kanul 4lpm
tranexamat Diet ginjal 1700kkal/hari + 1,2 gr
3x500mg protein/kgBB/hari
- IV Lansoprazole IV Meropenem 500 mg/24 jam
30mg/12jam IV Ca glukonas 2 ampul/12 jam
- Anti Hemoroid Transfusi FFP 500 cc
supp/12jam Vitamin K 1 ampul/12 jam
- PO Bisoprolol Iv omeprazole 40mg/12jam
2,5mg/24 jam Asam folat 2x400mg
- PO Alprazolam Lenal ace 1x 169 mg
0,5mg/12jam Amlodipine 1x5mg
- Paracetamol Valsartan 1x160mg
1000gr/12jam IV asam traneksamat 500 mg extra
- Laxadyn KSR Tab 600 mg/12 jam
IIIc/8jam
P/
  Pantau hemodinamik
P/ KGDP/hari
- HD hari ini
Cek elektrolit, ur/Cr, albumin
Lab 14/07/2021
Free T4 : 20,06 Lab 17/7/2021
  Hb/Ht/Eri/Leu/Tr
Lab 13/07/2021 7,1/20/2,4/22/72
Hb/l/t: 12,4/10,4/324 MCV/MCH/MCHC
Mcv/mch/mchc: 73/24/32 82/30/36
Diftel: 3/0/0/70/20/7 RDW/PDW
CK-MB: 20 19,3//14
UR/Cr: 18/0,50 Diftel 7/1/0/84/5/3
PT :1,08
APTT :35,50

Lab 15/07/2021
Hb/Ht/Eri/Leu/Tr
6,2/18/2,2/33,1/99
MCV/MCH/MCHC
82/28/34
RDW/MPV/PDW
18,2/10,3/10,6
LED: 1
Diftel 0/0/0/97/2/1
PT :1,28
APTT :1,3

Lab 14/07/2021
Hb/Ht/Eri/Leu/Tr
8,2/23/3,0/19,4/91
MCV/MCH/MCHC/RDW
78/28/35/17,7
 Diftel 2/1/0/92/3/2
PT/APTT : 1,74/4,69
Albumin 2,80
Ca : 7,5
Ur/Cr : 65/3,60
Na/K/Cl : 135/2,90/105

Lab 12/07/2021
Hb/l/t: 2,7/12,9/116
Mcv/mch/mchc: 78/26/33
Pt/aptt: 1,43/1,12
Hiv: non reaktif
Hbsag/anti hcv:-/-
Albmin 3,2
GDS: 73
Ur/cr: 60/3,8
Na/k/cl/ca: 135/3,7/103/8,1

K2B1 K2B2 K2B3 K2B4 K2B5

DPJP dr. . M. Riswan DPJP dr. T. Mamfaluti, DPJP dr. M. Riswan DPJP dr. Alfi Syahrin,
SpPD KHOM SpPD SpPD KHOM Sp.PD
COW : dr. COW : dr. Irhash/dr.Eko COW : dr. Irhash/ COW : dr. Irhash/dr.
Irhash/dr.Eko Ruangan : dr. Rossyta/ dr. dr. Eko Eko
Ruangan : dr. Rossyta/ dr. Rina/dr.julia/dr.Jupri Ruangan : dr. Ruangan : dr.
Rina/dr.julia/dr.Jupri Jupri/dr. Julia/ dr. Jupri/dr. Julia/dr.
Rossyta/ dr. Rina Rossyta/ dr. Rina
Nama : Maryam Binti Nama :Atina binti Zainal Nama : Mayasari Nama : Cut Badri
Majid Abidin Binti Nurdin Yunus TTL : 17/08/1967
TTL : 08/0/1958 TTL : 18/05/1976 TTL : 16/1/1992 CM : 1070771
Tgl masuk: 14/07/2021
CM: 1264786 CM: 1279771 CM 1279281
Tgl masuk : 16/7/2021 Tgl masuk : 16/7/2021 Tgl masuk : 13/7/2021
Ass/ Ass/ Ass/ Ass/
1. Ca buli post kemoterapi 1. dd/ 1. Massa intra Abdomen 1. Penurunan kesadaran
siklus 4 -parotitis supuratif e.c dd: ec dd:
2. Anemia sedang NN ec -parotitis viral - Ca Colon - hiponatremia
penyakit kronis -mastoiditis - Ca colorectal - uremic encephalopati
3. Dyspepsia type 2. AKI stage III dd/ diabetik - Metastase proses - sepsis
dysmotility nefropati 2. Metastase paru - stroke
3. Pneumonia 3. Candidiasis oral 2. Akut on ckd ec
Th/ 4. Severe Headache -DN
Bed rest 5. DM Tipe 2 NW Th/ -Cardio renal syndrome
Diet MB 1200 kkal/hari 6. Hipertensi stg 1 Bedrest 3. ISK dd BSK
IVFD Nacl 0,9% 20 gtt/i Diet lunak 1500 4. Efusi pleura sinistra
IV omeprazole 40 mg/12 Th/ kkal/hari ec dd
jam Bed rest IV lansoprazole 40mg / -pneumoni
IV ondansentron 4 mg/8 Diet DM 1700 kkal/hari 12 jam -TB paru
jam IVFD Nacl 0,9% 20 gtt/i IV ondancentron 4 mg/8 5.Hiponatremia
Curcuma 2x1 IV lansoprazole 30 mg/12 jam hipoosmolar
Transfuse PRC s/d Hb > 10 jam Attalpulgite 1 tab/ hipovolemik
Azitromicin 1x500 mg mencret max 10 tab k/p 6. DM tipe 2
P/ IV ceftriaxone 2 gr/ 24 jam Sucralfat syr 3xCI 7. CHF NYHA II ec dd
Cross match Amlodipine 1x10 mg Zink 1x20 mg -HHD
Transfuse PRC s/d Hb > 10 Flumucyl 3x200 mg Lactulac syr 3xCI -DCM
Persiapan kemoterapi SC lantus 0-0-0-14 Lacbon 1 tab/12 jam 8. PSMBA ec dd:
SC apidra 8-8-8 Nystatin drop 4x2cc - stress ulcer
Lab 14/07/2021 Balance cairan Kaltropen supp 100 mg - uremic bleeding
Hb/Ht/Eri/L/Tr: (k/p)
8,0/24/2,7/7,3/291 P/ Transfusi PRC Target Th/
MCV/MCH/MCHC: Evaluasi NRS Hb>=10g/dL Bedrest
87/30/34 Susul hasil Ro Thorax O2 nask Kanul 4 l/i
RDW/MPV:18,6/9,3 Urinalisa P/ Diet sonde ginjal 6x200
Diftel: 1/1/0/56/20/22 Cek KGD/hari susul hasil Ro Thorax CC via NGT
Ur/Cr: 29/ 1,00 Cek KGD2P Urinalisa IVFD NaCl 0,9% 500
Cek Lipid profile, PT APPT Colonoskopi + GA + CC/12 jam
1. D-Dimer, HbA1C EGD (persiapan)
Kultur Darah + STAB CT- scan abdomen dan NGT -> diet sonde 6 x
Ro Cervical Lateral Thorax kontras 200 CC/hari
IV Ceftriaxone 2 g/24
Lab 16/07/2021 jam (14/07/2021)
Hb/Ht/Eri/L/Tr: Lab 16/7/2021 Fluimucyl 200 mg/8 jam
10,0/29/3,5/23,4/394 Hb/Ht/Eri/L/Tr: Bicnat 500 mg/ 8 jam
MCV/MCH/MCHC: 9,4/31/3,8/9,9/580 Ondancetron 4 mg/8
82/28/35 MCV/MCH/MCHC: jam
RDW/MPV/PDW:13,3/10,6 80/25/31 IV furosemid 25 ampul
/13,1 RDW/MPV/PDW: +50 cc NaCl 0,9%
Diftel: 0/1/0/86/8/5 18,1/8,5/7,7 IV ondansetron 4 mg/8
GDS: 578 LED: 129 jam
Ur/Cr: 73/ 3,00 Diftel: 2/0/0/73/16/9 Lenal Ace 169 mg/12
Na/K/Cl: 138/4,20/103 Ur/Cr: 5/0,24 jam
IV lansoprazole 2 ampul
+ 50 CC NaCl 0,9% 5
Lab 15/7/2021 CC/jam
PT:1,01 IV lansoprazole 1 ampul
APTT:1,06 extra
AFP:1,18
CA125:5,4 P/
Anti HCV:Negatif Pantau hemodinamik
HBsAg:Non Reaktif Susul hasil kultur urin +
Albumin:2,86 STAB
GDP:75 Susul hasil kultur darah
+ STAB
Enchocardiografi jika
transportable
Lab 14/7/2021 USG urologi
Hb/Ht/L/T Cek darah rutin,
8,8/27/10,8/540 elektrolit
MCV/MCH/MCHC Cek Ca. Albumin, Ur/Cr
 78/25/32 per 3 hari
Diftell 2/1/0/70/17/10
Lab 17/7/2021
Hb/Ht/Eri/Leu/Tr
9,8/27/3,6/7,8/67
MCV/MCH/MCHC
75/27/36
RDW: 19,1
Diftel 2/1/0/78/13/6
K/Ca/Cl/Na :
3,60/9,1/94/124
Ur/Cr : 73/3,40

Lab 15/07/2021
Hb/Ht/Eri/Leu/Trombo:
9,6/27/3,5/8,6/61
MCV/MCH/MCHC:
77/27/35
Diftel: 0/0/0/84/9/7
Ur/cr: 61/2,7
Na/K/Cl: 123/3,7/94

Lab 14/07/2021
Hb/HT/Eri/Leu/Trom:
10,3/28/3,8/4,0/110
MCV/MCH/MCHC:
75/27/36
Diftel: 2/0/0/70/21/7
Albumin: 3,00
Ca 9,1
Na/K/Cl: 122/4,6/90
GDS : 143
Ur/Cr: 56/2,1

K3B1 K3B2 K3B3 K3B4 K3B5

DPJP dr.Hendra DPJP Dr. dr. Fauzi DPJP dr. Vera DPJP dr.Hendra DPJP: dr. dr. M.
Zufry,SpPD-KEMD Yusuf, SpPD KGEH Abdullah, SpPD Zufry,SpPD-KEMD Riswan SpPD KHOM
COW:dr.Irhash/ dr. Eko COW : dr. Irhash/ dr. COW:dr.Irhash/ dr. COW : dr. Irhash/ dr.
Ruangan: Eko Eko Eko
dr.Rossyta/dr.Jupri/dr.Ri Ruangan : dr. Jupri/dr. Ruangan: Ruangan : dr.
Julia/ dr. Rossyta/ dr. dr.Rossyta/dr.Jupri/dr. Rossyta/dr. Jupri/ dr.
na/dr.julia
Rina Rina/dr.julia Julia / dr Rina

Nama:Sumiati Sulaiman Nama : Sarifah Sofia Nama : Syarifah Tauhida Nama : Hasimah Nama : Irma Dewi
TTL: 01/07/1966 TTL : 14/05/1981 (40) TTL: 7/10/1977 TTL : 01/07/1959 Kusuma Nengsih
CM:1171102 CM : 1272209 CM : 1279880 CM : 1279682 CM : 1261455
Tgl masuk 10/07/21 Tgl Lahir : 05/07/1975
Tgl masuk:15/07/2021 Tgl Masuk : 17/7/2021 TM : 17/7/2021
Tgl masuk : 16-7-2021
Ass/ Ass/ Ass/ Ass/ Ass/
1. Sepsis ec dd/ 1.Arthritis septic a/r genue 1. Pansitopenia ec dd/ 1.Dyspepsia tipe like 1. ca mamae post
-pneumoni sinistra - anemia aplastic ulcer dd tipe mixed kemoterapi siklus ke 3
-urosepsis 2. Post Hipoglikemia ec dd - Leukimia 2. Pneumonia CAP dd dengan regimen TAC
2. Pneumoni HAP dd infeksi -drug induced - MDS infeksi paru spesifik 2. Neutropenia ec
paru spesifik -low intake 2. Menoraghia kemoterapi induced
3. Efusi pleura dextra ec dd/ 3. Kontraktur genue sinistra 3. Hipernatremia ringan Th/
-pneumoni pleura 4. Trombositosis reaktif dd 4. Hiperchlorida -IV Ceftriaxone 2 g/24jam Th/
-TB pleura trombositosis esensial - IV Omeprazole Bedrest
4. DM tipe 2 NW 5. Hipertensi stg 2 on Th/ 40mg/8jam Diet MB 1700 kkal/hari
5. Anemia berat NN ec dd/ therapy Diet MB 1700 kkal/hari - Domperidone 3x10mg IVFD NaCl 0.9% 20 tpm
- penyakit kronis 6. DM tipe 2 NW IVFD NaCl 0,9% 20 tpm - Sukralfat syr 3XC1 IV omeprazole 40 mg/ 12
- perdarahan 7. ISK dd BSK IV. Omeprazole 40 jam
mg/12 jam Lab 17/07/2021 IV ondansentron 4 mg/8
Domperidone 3x10 mg Hb/L/T : 13,6/13,4/182 jam
Th/
Th/ Transfusi Trombosit Jika Diftel 0/1/0/92/3/4 Curcuma 2x1
Bedrest Bedrest -trombosit < 20.000 PT/APTT : 1,0/1,5 Sc leucoge 1 vial/hari s/d
O2 nasal kanul 3-4 lpm Diet DM 1700kkal/hari terjadi perdarhan Fibrinogen 1152 ANC > 1500
Diet MII 1700 kkal/hari IVFD NaCl 0,9% 20tpm - trombosit < 10.000 Ddimer 8210
IVFD NaCl 0,9% 10gtt/i IV Ceftriaxone 2g/24 jam GDS 203
IV paracetamol 1gr/8jam P/
Valsartan 1x80mg UR/CR 45/0,9 Evaluasi klinis +
IV meropenem 1gr/8jam Paracetamol 3x500mg Na/K/Cl : 137/3,5/106
IV furesemide 20mg/12jam hemodinamik
Drip tramadol 1amp/8jam Troponin T <0,04 DR/ hari
IV lansoprazole 30mg/12jam Meloxicam 2x75mg CK MB 27
N-Acetilsystein3x200mg
Transfusi PRC s/d HB > Lab 17/07/2021
P/ Hb/Ht/Eri/Leu/Tr
10g/dl KGDP /hari
SC Lantus 0-0-0-8 IU 7,4/22/3,2/0,7/62
Konsul rehab medik MCV/MCH/MCHC
69/23/34
P/ Lab 15/7/2021 RDW
Ro thorax PA susul hasil LED:130 25,8
Urinalisa RF:Negatif Diftel 0/1/0/12/48/39
Kultur urin + STAB GDP:184
Kultur darah + STAB Lab 14/07/21
Cek D-dimer, MDT, Lab 15/7/2021 Hb/Ht/E/L/trom
Prokalsitonin, retikulosit LED: 130 9,2/28/4,0/0,8/194
Sputum BTA jika ada dahak Factor rheumatoid: negative MCV/MCH/MCHC
Gen expert GDP: 184 70/23/33
USG thorax didivisi pulmo RDW: 26,8
Pungsi cairan pleura Urinalisa 13/7/2021 Diftell : 0/3/0/19/74/4
Cek KGDP/hari Makraskopik/
Pantau hemodinamik Leukosit : positif
Rivalta test Glukosa : positif (+2)
Darah : positif
Lab 17/7/2021 Mikroskopik/
Analisa Cairan Otak/Tubuh : Leukosit: 50-60
Protein Tot : 5,60 Eritrosit: 25-50
Epitel: 5-10
Bakteri: positif
Protein Total :
Albumin : 2,50 Lab 12/7/2021
Globulin : 3,10 Hb/T/L: 11,7/754/11,7
LED: 130
Lab 16/07/2021 Diftell: 0/0/0/80/17/3/1,1
Hb/Ht/Eri/L/Tr: HbA1c: 8,6
Kol.HDL/LDL
7,0/22/2,3/17,8/343
42/123
MCV/MCH/MCHC:
95/30/32 Lab 10/07/21
RDW/MPV/PDW: Hb/L/T : 8,8/11,8/840
14,7/10,6/11,7 MCV/MCH/MCHC :
LED: 130 82/26/32
Diftel : 1/0/0/77/18/4
Diftel:1/0/0/86/9/4 Albumin : 3,2
Retikulosit: 3,4 GDS 66
Morfologi darah tepi; Na/K/Cl/Ca :
146/4,6/113/9,4
Eritrosit: normokrom
UR/CR : 39/0,70
normositer
Leukosit: jumlah meningkat,
bentuk normal, neutrofilia (+)
Trombosit: jumlah cukup
bentuk normal, tersebar (+)
Kesimpulan: anemia
normokrom normositer,
leukositosis
D-dimer: 2050
HbA1c: 8,4
Procalsitonin: 1,26

Lab 15/07/2021
Hb/Ht/Eri/L/Tr:
6,7/21/2,2/321/19,9
MCV/MCH/MCHC:
92/30/33
RDW/MPV/PDW:
15,0/10,1,12,1
Diftel:0/0/0/87/8/5
Analisa Gas Darah
-PH:7,492
-pCO2:41,00
-pO2:127
-HCO3:31,6
-Total CO2:32,9
-BE:8,3
-Sat.02:97,2
Albumin:2,5
Ca:8,2
GDS:94
Ureum:36
Kreatinin:0,6
Na:143
K:4

K4B2 K4B3 K4B4 K4B5

DPJP : dr. Azhari Gani, DPJP: dr. T. Mamfaluti, DPJP : dr. M. Fuad, DPJP: dr. M. Riswan, SpPD
Sp.PD-KKV Sp.PD SpPD-KHOM KHOM
COW : dr. Irhash/ dr. Eko COW : dr. Irhash/ dr.Eko COW : dr. Irhash/ dr.Eko
Ruangan : dr. Jupri/dr. Julia/ Ruangan : dr. Rossyta/dr. Ruangan : dr. Rossyta/dr.
dr. Rossyta/ dr. Rina Jupri/ dr. Julia / dr Rina Jupri/ dr. Julia / dr Rina

Nama : Hasanah binti Yahya Nama : Murni Jalidin (HD)

CM : 0972946 CM : 1279329 Nama : Nurmala Nama : Marlina binti usman
Tgl Lahir : 01/07/1956 TTL : 16/11/1987 CM : 1274982 CM : 1279846
TTL : 06-07-1976 (45) TTL : 16/06/1980
Tgl masuk : 13/07/2021 Tgl masuk : 16 Juli 2021 Tgl masuk: 17/ 07/ 2021
Ass/ Ass/
1. Acute on CKD dgn uremic 1.CKD stage V dengan uremic Ass/ Ass/
syndrome (mual, muntah) ec syndrome ec dd 1.Multiple limfadenopati ec
dd/ -DN dd 1. Limfoma maligna 2. 1. PSMBA ec dd/
- DN -GNC Malignancy -Ulkus gaster
- HN 2. DM tipe 2 normoweight 2, Bisitopenia ec dd 1. AML - ulkus duodenum
2.Geriatri problem (inanisi, 3. Ulcus diabeticum ar plantar 2. CML 3. MDS 2. Anemia berat makrositer ec
instabilitas dan jatuh, impaired pedis dextra 3.Tumor Paru T2N3M1 dd/ -perdarahan
of hearing and vision) 4. Hipoalbuminemia ringan stadium IV A - autoimun
3. Hipoalbuminemia ringan 5. Hipocalsemia ringan 4. Pneumonia
4. Anemia sedang NN ec dd/ 6. Anemia ringan HM ec 5. Sindroma obstruksi Th/
penyakit kronis penyakit ginjal kronik Bed rest
5. Hipertensi stage II 7. Hipokalemia ringan Th/ O2 nasal 4 lpm
6. DM tipe II -IV Omeprazole 40mg/12 Diet lunak 1700 kkal/hari
Th/ jam IVFD NaCl 0,9% 20 gtt/i
Th/ - Tirah baring - Ventolin 4x1 respul IV Omeprazole 40 mg/12 jam
Tirah baring - O2 nasal kanul 4 lpm - Fluxotide 1respu/12 jam IV Cefotaxime 1 gr/8 jam
Diet Ginjal - Diet Ginjal 1700kkal/hari Asam folat 3x400mg Transfusi PRC s/d Hb > 1 g/dl
1700kkal/hari+protein 0,6-0,8 - Threeway -SF 3X1 dengan bloodset khusus,
g/kgbb/hari - IV Ceftriaxone 2g/24jam Kaltrofen sup premedikasi diberikan IV
O2 nasal canul 4 lpm - IV Omeprazole 40 mg/12 jam Ciprofloxacin 200mg/12 dexametason 1 amp
Catheter -Lenal ace 2x169mg jam
Threeway -Asam folat 2x0,4mg Methlprednisolon 125/12 P/
Iv ceftriaxone 2 g/24 jam -Bicnat 3x500mg jam Transfusi PRC sampai Hb > 10
Iv Lansoprazoe 30mg/12jam -Albuminar 20 % Ciprofloxacin 200mg/12 jam g/dl dengan bloodset khusus
Fluimucyl 3x200mg -IV Ca gluconas 3x1ampul -Ostriol 2x0,25mg Premedikasi 1 amp
Valsartan 1x80mg - Valsartan 160 mg/24j -Flumicort 2x12 respul Dexametason
Transfusi PRC s/d Hb > 9 - domperidone 10 mg/8jam -Duralgesic patch
P/ - Amlodipin 10mg/24jam Lab 17/7/2021
Pantau hemodinamik Lab 13/07/2021
Balance cairan/hari P/ Hb/L/T : 6,0/9,3/6 Hb/Ht/Erit/leu/trombo:
Urinalisa Cek KGDP/hari Diftel : 1/1/0/69/22/1 2,1/5/0,4/13,3/261
Feses rutin Cek DR,Ur, Cr, Elektrolit/ MDT : Hipokrom mikrositer MCV/MCH/MCHC:127/57/45
Cek KGDP/hari 3hari Anisopoikilositosis, PDW/MVP: 11,9/15,2
USG urologi AV Shunt: jadwal konfirmasi hipersigmentasi, Diftel: 0/0/0/73/19/8
Susul hasil Ro thorax HD selanjurnya senin (19 Juli anisopoikilositos, ovalosit, PT/ APTT: 1,42/ 0,81
Konsul GH 2021) sel target Anti HCV: negative
Lab 16/7/2021 Ddimer 2580 HBsAg: non reaktif
Hb/Ht/Eri/Leu/Tr Lab 17/07/2021 LDH 1785 Bilirubin total 3,17
7,3/22/2,8/6,5/239 Hb/Ht/Eri/Leu/Tr 2. Bilirubin direct 1,21
MCV/MCH/MCHC 11,8/33/4,4/11,7/98 3. Bilirubin indirect 1,96
78/26/34 MCV/MCH/MCHC
RDW/ PDW 76/27/35 SGOT: 113
15,7/14,2 RDW: 14,6 SGPT: 65
Diftel 7/1/0/69/16/7 Diftel 4/1/0/72/16/7 Protein total: 6,10
PT :1,17 K/Ca/Cl/Na : 2,90/7,1/109/138 Albumin 3,60
APTT :34,20 Albumin : 2,40 Globulin 2,50
Ur/Cr : 105/4,6 Ur/Cr : 66/6,70 4. Kalsium 8,7
Lab 15/7/2021 5. Ur/ cr: 32/ 0,70
HbA1c:4,8 Lab 14/07/2021 Na/k/cl: 142/4,6/112
Ferritin:271,50 Hb/Ht/E
Besi:28 9,5/27/3,7
TIBC:207 MCV/MCH/MPV
Lab 13/07/2021 74/26/12,9
Hb/Ht/L/E/Tr: Diftell: 3/1/0/67/20/9
7,1/20/8,5/2,6/275 Albumin : 3,3
Diftel: 2/1/0/60/28/9 K/Cl/Ca
MCV/MCH: 77/27 3,4/107/6,7
Albumin 3,2
GDS : 127 Urinalisa 14/07/2021
Ur/Cr: 114/4,5 Makroskopis/
Na/K/Cl/Ca: 136/4,6/109/8,6 Keruh
HbsAg/AntiHCV/HIV: negtif Leukosit : positif
Swab PCR : negatif Protrin : positif +2
Keton: positif 6.
Darah: positif
 Mikroskopis/
Leukosit: 5-10
Eritrosit: 2-5
Epitel: 1-3
Hyalin cast: positif
Ca oksalat: positif
Sel ragi: positif

Lab10/07/2021
Hb/L/T : 6,8/6,2/190
MCV/MCH/MCHC : 75/27/36
Diftel : 1/0/1/76/16/6
HIV : non reaktif
AntiHCV : negative
HbsAg : non reaktif

AGDA
Ph 7,3
Pco2 20,80
PO2 74
HCO3 11,2
Total CO2 11,8
BE -12,6
Saturasi 90,7
Albumin 2,4
Na/K/Cl/Ca : 127/4,2/103/4,2
GDS 103
UR/CR : 156/11,9

K5B1 K5B2 K5B3 K5B4 K5B5

UROLOGI DPJP : dr. Azhari Gani, DPJP SPOT

Sp.PD-KKV
COW : dr. Irhash/ dr. Eko
Ruangan : dr. Jupri/dr.
Julia/ dr. Rossyta/ dr. Rina

Nama : Hasanah binti Yahya

CM : 0972946
Tgl Lahir : 01/07/1956
Tgl masuk : 13/07/2021
Ass/
1. Acute on CKD dgn uremic
syndrome (mual, muntah) ec
dd/
- DN
- HN
2.Geriatri problem (inanisi,
instabilitas dan jatuh, impaired
of hearing and vision)
3. Hipoalbuminemia ringan
4. Anemia sedang NN ec dd/
penyakit kronis
5. Hipertensi stage II
6. DM tipe II

Th/
Tirah baring
Diet Ginjal
1700kkal/hari+protein 0,6-0,8
g/kgbb/hari
O2 nasal canul 4 lpm
Catheter
Threeway
Iv ceftriaxone 2 g/24 jam
Iv Lansoprazoe 30mg/12jam
Fluimucyl 3x200mg
Valsartan 1x80mg
Transfusi PRC s/d Hb > 9
P/
Pantau hemodinamik
Balance cairan/hari
Urinalisa
Feses rutin
Cek KGDP/hari
USG urologi
Susul hasil Ro thorax
Konsul GH
Lab 16/7/2021
Hb/Ht/Eri/Leu/Tr
7,3/22/2,8/6,5/239
MCV/MCH/MCHC
78/26/34
RDW/ PDW
15,7/14,2
Diftel 7/1/0/69/16/7
PT :1,17
APTT :34,20
Ur/Cr : 105/4,6
Lab 15/7/2021
HbA1c:4,8
Ferritin:271,50
Besi:28
TIBC:207
Lab 13/07/2021
Hb/Ht/L/E/Tr:
7,1/20/8,5/2,6/275
Diftel: 2/1/0/60/28/9
MCV/MCH: 77/27
Albumin 3,2
GDS : 127
Ur/Cr: 114/4,5
Na/K/Cl/Ca: 136/4,6/109/8,6
HbsAg/AntiHCV/HIV: negtif
Swab PCR : negatif
Zamzam 3 K10 Zamzam 3 K 15 Zamzam 3 kamar 18 Zamzam 3 K20
DPJP:dr.Azzaki Abubakar DPJP : dr. M. Riswan, Sp. PD, DPJP : dr. M. Fuad, Sp.PD DPJP : dr. Islamuddin, SpPD
SpPD-KGEH KHOM KHOM

Nama: Siti Kaila Nama : Nurtanty Jambak
TTL: 29-05-2001 TTL : 10/ 08/ 1961
CM: 1228088 CM : 98-81-76
Tgl Masuk: 18-07-2021 Tgl Masuk : 08/ 07/ 2021
Ass/ Ass/
Dyspepsia tipe like ulcer dd tipe 1. Cystitis
mixed 2. Anemia Ringan NN ec dd
- penyakit Kronis
TH/ - Occult Bleeding
-Bedrest 3. LBP
- IVFD NaCl 0,9% 20 tpm 4. Dyspepsia tipe like ulcer dd
- IV Lansoprazole 30 mg/12 jam tipe mixed
- Sukralfat syr 3XCI
- Domperidon 3x10mg
Th/
Lab : - Tirah Baring
Hb/L/T : 13,6/9,6/297 - Diet Lunak 1700kkal/ hari
MCV/MCH/MCHC : 88/29/33 - IVFD NaCl 0,9 % 20 gtt/i
Diftel : 4/0/0/55/33/8 - IV Ceftriaxone 2 gram / 24jam
PT/APTT : 1/1,09 - Drip Tramadol 1 amp/ 8jam
UR/CR : 17/0,62 - IV Lansoprazole 30mg/ 12 jam
- IV Ondansetron 4mg/ 8jam
- IV mecobalamin 1 amp/ 8jam
- Paracetamol 3x 500mg
- Lactulac syr 3x 2C
- gabapentin 1x 300mg
- Kaltropen supp 2x1 supp
Lab 08/ 07/ 2021
Hb/ L/ Tr : 11/ 14,5/ 390
MCV/ MCH/ MCHC : 81/ 28/ 34
Diftel : 0/0/0/78/15/7
Alb : 4
Ca: 12,5
GDS: 103
Ur/ cr : 98/ 2
Na/ K/ cl : 129/ 4/
Nama : Nurhayati Binti Ismail
TTL : 11/5/1983 38 thn
CM : 0842865
Tgl Masuk : 13/ 07/ 2021
Ass/
1.Anemia sedang HM ec dd 1.
Penyakit kronik 2. Def fe
Th/
bedrest
Diet MB 1500 kkal/hari
IVFD nacl 0,9% 20 gtt/I
IV omeprazole 40 mg/12 jam
Transfusi PRC
Lab 12/7/2021
Hb/Ht/L/T 7,7/28/5,7/609
MCv/MCH/MCHC 59/16/28
Diftell 2/1/0/55/36/6
MDT anemia Hipokrom
mikrositer, trombositosis
Feritin 13,78
Ur/Cr 18/0,68
Nama : Raimah
TTL : 03-8-1966 (54)
CM : 1270803
TM : 17-07-2021
1. Diare kronik ec dd 1. Chron
disease 2. Colitis ulseratif 3. Ca
colorectal 4. Ca rectosigmoid
2. Pneumonia HAP dd infeksi
paru spesifik
3. Hipoalbuminemia berat
4. AKI stage II prerenal
5. Anemia sedang HM ec ss 1.
Penyakit kronis 2. Defisiensi Fe
6. Partial MBO
Th/
Bedrest
Diet sonde 6x200cc
IV Cefepime 1g/8jam
IV Omeprazole 40mg/12 jam
IV Metoclopramid 1
ampul/8jam
Albuminar 25% 100cc/24 jam
Attapulgite
Synbio 2x1
Sucralfat 3XC1
Lab 17-07-2021
Hb/L/T : 8,1/12,2/310
MCV/MCH/MCHC : 68/24/35
Diftel : 1/0/0/86/7/6
PT/APTT 1,3/1,3
Anti HCV NNegatif
HbsAg non reaktif
GDS 108
UR/CR 112/2,1
Na/K/Cl : 142/4,0/122

Zamzam 3 K01 Zamzam 3 K02 Zamzam 3 K11 Zamzam 3 K12 Raudah 1 K7B2
DPJP: dr. Islamuddin, DPJP dr. Desi Salwani DPJP dr. Desi Salwani, Dpjp : dr. Desi Salwani,
Sp. PD SpPD KGH SpPD KGH SpPD-KGH

Nama: Meliana Budiman
TTL: 01/07/1984
CM: 1077299
Tgl Masuk:16/07/2021
Nama: Teuku Cut Din Nama : Nana Diana Nama : M. Hasan AR Nama : Nurjannah
Muska TTl : 05/02/1973 CM: 1227027 No RM : 1.27.96.70
TTL: 24/06/1964 CM : 1190072 Tgl masuk: 09/07/2021 TTL : 01/12/1968
RM: 0-76-22-57 Tgl Masuk : 16/07/2021 Tgl Masuk : 15/07/2021
Tgl masuk: 27-06-2021
Ass/ Ass/ Ass/ Ass/ Ass/
1. cancer pain ec dd MCL 1. HHD 1. Penurunan Kesadaran 1.PSMBA ec dd/ 1. Anemia sedang HM ec
2. hepatomegaly ec dd 2. APS CCS III post PCI ec.dd - gastropati NSID DD 1. Defisiansi besi 2.
● HCC (2minggu yll) 1. Syok Sepsis - ulkus gaster/ dudenum perdarahan
● Metastase proses 3. AKI stge II ec dd/ 2. Uremic 2. Anemia berat MH ec 2. AUB ec susp mioma
3. ca mammae dextra post contrast induce nefropati enchepalopati dd/ uteri
mastektomi dan 4. gangguan psikotik 3. Stroke - penyakit kronik 3. Hipertensi Stage I
kemoterapi organik 2. Sepsis ec Pneumonia dd - defisiensi besi
4. hipokalemia ringan probable covid 19 3. Bradiaritmia ec AV
Th/
Th/ 3. CKD stage V on HD block derajat 2 mobitz 2
Th/ - bedrest regular ec DN 4. CHF NYHA II ec dd/ -Tirah Baring
IV Ceftriaxone 2 gr/24 jam - IVFD NaCl 15gtt 4. Anemia ringan HM ec - HHD -diet MII 1700kkal/hari
IV lansoprazole 30 mg/ 12 - Diet jantung dd - IHD - TVFD Nacl 0,9% 20 gtt
jam 1700kkal/hari 1. Def. Besi 5. Hipertensi on therapy - drip Levofloksasin 750
MST 2x10 mg - IVFD clinimix 1 fls/hari 2. PGK 6. AKI stage 3 prerenal mg/24 jam
N. acetilsistein 3x200 mg - Levofloxacin 750/24 4. DM tipe 2 Overweight 7. Hiperkalemia ringan (K - IV Lansoprazole 30,g/24
Bicnat 3x500 mg - IV meropenem 1 g/8 jam 5,9) jam
KSR 2x600 mg - Drp PCT 1g/8 jam Th - fluimucyl 3x200 mg
- IV lansoprazole 30mg/12 Bedrest, NGT, Folley Th/ -Valsartan 1x80mg
P/ - IV ondansentron 4mg/8j cateter urine - Bedrest -IV Kalnex 500mg/8 jam
- Fluimucyl 1x200mg 02 2-4 liter/menit (canule - NGT -Transfusi PRC s/d Hb > 10
Lab 15/07/2021 - ramipril 1x5 nasal) - IVFD NaCl 0,9% g/dl
Hb/Ht/Eri/L/Tr: - atorvastatin 1x40 Diet ginjal 1700 kkal/hari - IV omeprazole 40 mg/12
12,8/36/4,3/13,7/269 - ISDN k/p (Protein 70g/hari) jam Lab 15/7/21
MCV/MCH/MCHC: - CPG 1x75 IV Ceftriaxone 2g/24jam - IV ondansentron Hb/L/T : 8,2/10,6/409
84/30/36 - Risperidon 0,5 (H1) 4mg/8jam Ht :26
RDW/MPV:15,9/11,1 - Kalitake 3x1 Drip NE 1amp dalam 50cc - IV Furosemide 20mg/12
Diftel:2/0/0/81/14/3 NaCL 0.9% dengan Dosis MCV/MCH/MCHV:74/23/
jam 32
PT/APTT: 1,13/ 1,26 Lab 16/7/2021 0.03 mEq/KgBB/menit - IV Sulfas atropin 12mg /
Albumin: 3,40 Na/K/Cl : 133/6,6/106 (titrasi dosis) Diftel : 1/1/0/71/22/5
6jam
Kalsium: 18,5 IV lansoprazole PT/APTT : 0,9/0,7
- Aminofilin 2x200mg
Natrium: 131 Lab 15/7/2021 30mg/12jam SGOT/SGPT : 65/69
- Cilostazol 1x100mg
Kalium: 2,90 Hb/L/Tr : 15/7/210 As. Folat 2x0.4mg - Salbutamol 3x4mg Gds : 118
Klorida: 91 Alb : 2,7 Lenal ace 2x169 mg - Kalitake 3x 1sach Ur/Cr : 17/0,80
GDS: 75 Ur/Cr : 74/2,3 N asetil sistein 3x200mg - Transfusi PRC s/d hb Na/K/Cl : 146/4,20/110
Ur/ Cr: 59/ 3,40 SC Apidra 3-3-3-3-3-3 10g/dl
Lab 11/7/2021 unit - Balans cairan seimbang
Hb/L/Tr : 8,3/8,1/355 HD regular
NS 74
Malaria – Lab 16/07/2021 Lab 09/07/2021
Tubex 6 Hb/L/T : 10.1/11.7/218 Hb/Ht/E/L/T :
Procalcitonn 10,55 MCV/MCH/MCHC : 6,1/20/4/9,1/323
SGOT/SGPT : 89/59 77/27/38 MCV/MCH/MCHC :
ALP 158 Diftel : 1/1/0/90/6/2 50/15/30
Lab 8/7/2021 SGOT/SGPT : 17/9 Diftel : 6/1/0/68/17/8
Hb/L/Tr : 9,3/7,7/279 Albumin : 3.7 MDT :
NS 79 Ur/Cr: 83/6.3 - eritrosit : hipokrom
Ur/Cr : 100/3,2 Na/K/Cl/Ca: anisopikilositosis, target
Alb 2,5 Ca : 7,3 145/4.1/107/9.5 cell, pencil cell,
Na/K/Cl : 127/4,9/102 fragmentosit, teardrop
Lab 3/7/2021 AGDA - kesimpulan : anemia
Hb/L/Tr : 9,3/7,4/240 PH : 7.4 MH
Mcv/mch/mchc : 75/26/35 PcO2 : 34.8 PT/APTT: 1,07/ 1.0
Diftel : 0/0/0/84/11/5 HCO3 : 24.1 Hbsag/ antiHCV : negatif
Lab 2/7/2021 BE : 0.9 SGOT/SGPT : 17/18
Na/k/cl/ca : Sp02 : 97 % Albumin 3,60
144/5,6/113/8,6 Ur/cr : 125/3,3
Na/K/Cl/Ca:
Lab 29/6/2021 139/5,9/114/8,5
Ur/cr : 92/3,1 GDS 138
Lab 27/06/2021
Hb/L/Tr: 15/15,1/270
Diftel: 0/0/0/77/11/12
GDS 144
Ur/Cr: 64/24
Na/K/Cl: 137/5,2,109