MAPPING AQSA 2 (Minggu, 1 Agustus 2021)

No Nama DPJP Kamar Jumlah

1.
dr. M. Fuad Sp.PD. KHOM K1B5, K3B2, K3B1 3

2.
Dr.dr. Fauzi Yusuf Sp.PD, KGEH K2B4, K5B2 2

3.
dr. Mahriani Sylvawani, SpPD-KR K1B4, K5B3 2

4.
dr. Cut Mela Yunita, Sp.PD-KGH K4B3 1

5.
dr. M. Riswan, Sp.PD- KHOM -

6.
Prof Dr dr Kurnia F Jamil Sp.PD-KPTI K1B2, K2B1, K4B5 3

7.
dr. M. Diah, Sp.PD-KKV K1B1, K2B3, K5B4 3

8.
dr. Azzaki Abubakar, Sp.PD-KGEH K4B2, K5B1 2

9.
-

10. dr. Desi Salwani, SpPD-KGH K2B2 1

K1B1 K1B2 K1B3 K1B4 K1B5

DPJP : dr. M. Diah DPJP : Prof. Dr. dr.
Sp.PD-KKV Kurnia F Jamil, SpPD
COW: dr Irwandi / dr KPTI
Saddam COW: dr Irwandi / dr
Ruangan: dr Umar / dr Saddam
Aidil Ruangan : dr Merizka /
dr Fahmi
Nama : Saiful bin Adam Nama : Darmawi bin Al
NRM: 1-27-28-07 Rasyid
TTL: 10/08/1976 (45 th) CM : 1-28-02-87
TTL : 01-07-1962 (59 th)
Ass/ Ass/
1. Dyspepsia tipe like ulcer 1. PSMBA (perbaikan) ec
dd tipe mixed dd -ulcus gaster -ulkus
  duodenum-gastritis erosif-
Th/ malignancy
- Bedrest 2. Anemia sedang NN ec
- Diet MII 1700 kkal/hari dd -pendarahan -penyakit
- IVFD RL 20 tpm kronis
- IV Omeprazole 3.Pneumonia dd infeksi
20mg/12jam paru spesifik, tb paru
- IV Ondansetrion 4.Hipoalbuminemia berat
40mg/8jam 5.benigna hyperplasia
- Sucralfat syrup 3xCII prostate
- Kaltropen supp 6. Selulitis ar cruris dextra
 
P/ Th/
USG abdomen Bedrest
EKG Diet MII 1700 kkal/hari +
ekstra putih telur
Lab 30/07/2021 IVFD Nacl 0,9%
SGOT/SGPT : 90/103 20gtt/menit
ALP : 248 IV Lansoprazole 30 mg
vial/12 jam
Lab 29/07/2021 Drip Albumin 25%
Hb/L/T : 13,1/11,6/251 100cc/24jam
MCV/MCH/MCHC : IV Cefepime 1gr
79/27/34 vial/8jam (H7, 26/72/1)
Diftel : 2/0/0/75/20/3 Sukralfat syr 3x CII
SGOT/SGPT/ALP : Fluimucyl 3 x 200 mg
90/103/248 Drip Albuminar 25% 100
GDS :119 cc/24 jam
Ur/Cr : 21/0,80 Paracetamol 500mg/8jam
Ca/Na/K/Cl : Clindamycin 300mg/8jam
9,5/144/3,90/109 Transfusi PRC : 3 kolf prc
Kompres NaCl 0,9%
dengan kasa steril pada
daerah selulitis
 
P/
USG abomen divisi GEH
EGD dan Kolonskopi
(2/8/21)
Kultur darah dan STAB,
sputum BTA (susul hasil)
Swab PCR
Lab 31/07/2021
Albumin : 2,90
Lab 29/07/2021
Hb/l/t : 10,6/5/158
Mcv/mch/mchc: 85/29/34
Diftel : 13/1/0/62/17/7
 
Lab 26/07/2021
Hb/ht/l/t : 6,4/19/6,0/142
Mcv/mch/mchc : 86/29/33
Diftel : 0/8/6/0/69
Ur/Cr : 26/0,78
Na/K/Cl : 140/3,50/111
Albumin :  2,23
K2B1 K2B2
DPJP: dr. Mahriani DPJP : dr. M. Fuad,
Sylvawani, SpPD-KR SpPD-KHOM
COW: dr. Irwandi / dr. COW: dr Irwandi / dr
Irhash Saddam
Ruangan: dr. Merizka / Ruangan : dr Merizka /
dr. Fahmi dr Fahmi
Nama : Firmansyah Nama : A. Rahman
Aulia Prasetya CM :1-24-13-67
CM : 1-28-10-85 TL : 01-03-1960 (61 th)
TL : 14-03-2001 (20 th)
Ass/ Ass/
1. Bisitopenia ec dd 1.Cancer Pain
1. Limfoma maligna 2.Non Hodgkins Lymfoma
2. Anemia aplastic relaps post kemoterapi
3. MDS siklus ke 5 dengan
2. Pneumonia dd infeksi regimen ICE MESNA
paru spesifik dengan karnofsky score 80
3. CHF fc NYHA III-IV 3. Anemia ringan NN ec
4. LBP ec dd metastase dd penyakit kronis
tulang 4. hipokalemia sedang
5. Kontraktur genu dextra  
6. Jaundice ec dd Th/
1. Metastase hepar Bed rest
2. Hepatitis viral Diet MII 1700kkal/hari
7. Anemia berat IVFD NaCl 0,9% 20gtt/i
makrositer ec dd MST 2x10mg
1. Def. asam folat KSR 2 x 600 mg
2. Def. B12 Drip KCl 1 fl dlm 500 cc
8. Mikrotrombosis NaCL 0,9% 20 tpm
sistemik Curcuma 1 tab/8jam
9. DIC IV Omeprazole 40 mg/
10. Hipoalbuminemia 8jam
berat Tracetat 2x1tab
Th/ Lab 31/07/2021
Bedrest Hb/L/T : 9,5/10,8/115
O2 2-4 lpm via Nasal MCV/MCH/MCHC :
Canule 82/30/36
Threeway Diftel : 1/1/0/75/12/11
IV Lansoprazole 30 mg/12 Na/K/Cl : 149/2,70/115
jam Ca : 10,0
IV Ceftriaxone 2g/24 jam
(H3) Lab 29/7/2021
IV Vit. K 1 amp/12 jam Hb/Ht/Eri/Tr/L:
IV Furosemid 20 mg/12 8,9/24/3/116/11,8
jam MCV/MCH/MCHC:
Drip HCl 2 flacon dalam 81/30/37
500 cc NaCl 0,9 10 tpm Diftel;0/1/0/72/16/11
Curcuma 1 tab/8 jam Na/K/Cl: 145/2,3/108
Ur/cr: 33/1,5
P/
Transfusi PRC dengan
target Hb ≥10
Transfusi
Konsul divisi HOM
Lab 31/07/2021
Hb/L/T : 2,7/20,8/75
MCV/MCH/MCHC :
105/32/30
Diftel : 0/0/0/87/7/6
PT/aPTT : 86,7/134,6
D-Dimer : 8390
Anti HCV : negatif
HBsAg : non reaktif
Bilirubin tot/dir/indir :
7,92/5,51/2,41
SGOT/SGPT : 31/10
Albumin : 1,20
GDS : 136
Ur/Cr : 8/0,20
Na/K/Cl : 123/2,10/97
K2B3 K2B4 K2B5
DPJP : Prof. Dr. dr.
Kurnia F Jamil, SpPD
KPTI
COW: dr Irwandi / dr
Saddam
Ruangan : dr Merizka /
dr Fahmi
Nama : Verry Andre
CM : 1-08-34-72
TTL : 19/12/1977 (43 th)
Ass/
1. Hipokalsemi ec dd
- Hiperparatiroid Primer
-Hiperparatiroid sekunder
2.Grave Disease
3. Diare kronik ec dd
chrone disease, kolitis
infeksi
4. LBP ec -spondilolistasis
-spondiloartrosis
- fraktur lumbal
5. Hipoalbumin berat
6. Hipomagnesia
7. Hipokalemia sedang
 
Th/
-Bedrest
-Diet MB 1700 kkal/hari
-IV Lansoprazole 30 mg/
12 jam
-drip Ca Glukonas  1g
dalam dextrose 5% selama
1 jam dilakukan setiap 6
jam dengan target ca darah
7g/dl
-thyrozol 2x10mg tab
-Propanolol 2 x 10 mg
-Synbio 3 x 1 sachet
-Nystatin drip 2cc/ 6 jam
-PCT 3 x 500 mg
-drip Albuminar 25%
100cc/hari
-mecobalamin 500 mg/12 j
- Drip KCl 25mcg dalam
nebul 250 cc NaCl 0,9%
dalam 3 jam
Antasida syrup 30 mg/8jam
Na-diclofenac 50mg/12j
Drip MgSO4 64 mcg dalam
500 cc nacl 0,9%
Drip MgSO4 32 mEq
 
P/
Monitor tanda-tanda vital
dan kesadaran
Elektrolit dan kalsium post
koreksi
USG thyroid sudah ada
hasil  D-dimer : 460
Foto LS AP /lateral susul
hasil
Paratiroid hormon susul
hasil
Vit D 25 OH susul hasil
Kalsium dan kalium urine
Lab 31/07/2021
Albumin : 1,90
Na/K/Cl : 138/3,30/115
Ca : 6,0
Lab 30/07/2021
Albumin : 2,4
DPJP : dr. Desi Salwani, dr. M. Diah, Sp.PD-KKV DPJP : dr. Fauzi Yusuf,
SpPD-KGH COW : dr Irwandi / dr SpPD-KGH
COW: dr Irwandi / dr Saddam COW: dr Irwandi / dr
Saddam Ruangan : dr Umar / dr Saddam
Ruangan : dr Merizka / Aidil Ruangan : dr Merizka /
dr Fahmi dr Fahmi
Nama: Sayuti Nama : Muhammad Nama : Zahrul Fauzan
CM: 1-28-05-53 Ridha TTL : 07/08/1981 (39th)
TTL: 07-05-1980 (41 th) TTL : 28/11/1988 CM : 1-28-09-42
CM : 1-15-27-35
Ass/ Ass/ Ass/
1. CKD Stage V dengan 1. Febris ec dd bacterial 1.Dyspepsia type like
uremic sindrom ec dd/ 1) infection, viral infection ulcer
PNC 2) HN  2. PSMBA ec dd variceal 2.Hepatosplenomegali
2. Anemia Berat NN ec bleeding, nonvariceal  
dd/ 1) Penyakit kronik 2) bleeding Th/
Perdarahan   IVFD NaCl 0,9 % 20
3. Defek Suprapubik Th/ gtt/hari
dengan anomaly genetik Bed rest IV Lansoprazole 30mg/12
4. ISK asimtomatik Diet  hati sonde bertahap jam
  mulai 50 cc sampai 200cc Liver Prime 2x1 cap
Th/ IVFD Nacl 0,9% 20 tpm  
-Bedrest Iv Ceftriaxone 2 gr/24 jam P/
-Diet ginjal 1700 Iv Paracetamol 40mg/12j AFP
kkal/hari, protein 0,8 Iv Ondansentron 4mg/ 8 USG Abdomen
gram/KgBB/hari jam CT-SCAN abdomen 3
-IV Omeprazole 40 mg/12 Drip Lansoprazole 6,25 cc fase
jam Surcralfat syr CII/8jam  
-IV Ondansetron 4 gram/8 30/7/2021
jam P/ PT/aPTT: 14,1/34,5
-IV Ceftriaxone 2 gram/24 Usg abdomen, foto thoraks, AFP: 0,5
jam (27/7. H3) EKG 29/7/2021
IV Parasetamol 1000mg / Hb/Ht/E/T/L :
8j 30/07/2021 14,7/41/4,7/204/9,1
-Transamin 1am/8jam Anti-dengue IgG/IgM : MCV/MCH/MCHC/RD
  negatif W/MPV/PDW
P/ 87/31/36/13,3/9,2/10,4
USG urologi dan doppler Lab 30 /07/2021 Diftel :
Kultur urin Hb/Ht/E/l/t: 5/0/0/46/41/8
Kultur Pus 13,4/41/6,0/4,7/50 Ca: 9,3
Ronsen thoraks susul hasil MCV/MCH/MCHC/RDW/ GDS: 144
Rencana CT scan PDW/MPV: Ur/Cr: 37/1,1
abdomen 68/22/33/13,5/12,9/10,4 Na/K/Cl:
  Diftel: 0/0/1/44/48/7 146/4,4/115
Lab 30/07/2021 Ur/Cr : 43/1,10 Anti HCV:
Hb/HT/E/L/T : Na/K/Cl: 142/5,3/106 Negative
10/28/3,5/10,4/347   HbsAg: non reaktif
MCV/MCH/MCHC/RDW Albumin : 4,3
/MPV/PDW: Globulin: 2,20
80/28/35/10.3/10.4/10.4 SGOT/SGPT:
Diftel : 1/1/0/93/2/3 43/108
Na/K/Cl : 131/3,3/104 Protein total: 6,5
Ca : 6,5
Ur/Cr : 304/13,1
Lab 30/7/21
Na/K/Cl/Ca
120/6,10//90/6,8
PT/INR/Fibrinogen/Fibrin
ogen (pasien) :
1,30/272/783
APTT pasien/control
37/32,2
Feritin : 430
Lab 27/07/2021
Na/K/Cl : 115//5,90/95
Ca : 6,9
 
Urinalisa
Kuning kemerahan
Lekosit (+)
Ca: 6,3 Protein (+1)
Na/K/Cl : 143/2,3/115 Darah (+)
Leu 5-10
Lab 29/07/2021 Eri 400-500
Hb/Ht/E/L/T Epitel 0-1
13.2/39/5,0/7.8/227 Bakteri (+)
MCV/MCH/MCHC/RDW/  
MPV/PDW:
78/27/34/16.9/9.8/11.9
Diftel : 11/0/1/69/10/9
Albumin : 1,71
Na/K/Cl : 143//2,30/112
Ca : 5.5
Kimia klinik
Ca: 5.1
Na/K/Cl: 140/2.70/114
  
Lab 27/07/2021
Hb/HT/E/L/T
14,1/42/5,3/12,2/254
MCV/MCH/MCHC/RDW/
MPV/PDW:
79/27/34/18.1/10.3/12.1
Diftel : 6/0/0/77/8/9
Na/K/Cl : 143//2,30/114
Ca : 4,7
Imunoserologi
(26/07/2021)
Free T4 : 36.41
TsHs: 0.005
Kimia klinik
Albumin: 1.42
Ca/Mg: 4.4/ 1.0
 
Analisis Tinja: Dalam batas
normal
Urinalisis : Dalam batas
normal.

K3B1 K3B2 K3B3 K3B4 K3B5

DPJP : dr. M. Fuad, DPJP : dr. M. Fuad,

SpPD-KHOM SpPD-KHOM
COW: dr Irwandi / dr COW: dr Irwandi / dr
Saddam Saddam
Ruangan : dr Merizka /
dr Fahmi

Nana : Muhammad Nama : Amiruddin

Hasan CM : 1-28-02-03
CM : 1280690 TL : 31-12-1976 (44 th)
TTL : 31-12/1937 (83 th)
Ass/ Ass/
1. Sups ca paru dextra 1. Pansitopenia ec. dd
2. Anemia sedang NN ec   a. Anemia aplastic
dd -penyakit kronis   b. MDS
-perdarahan 2.PSMBA ec. dd
    a. Ulkus gaster
Th/   b. Ulkus duodenum
Bedrest   c. Gastritis erosive
Diet MB 1700kkal/hari 3. Ulkus pedis sinistra
Iv omeprazole 40mg/12jam  
PCT 2x1000mg Th/
Lactulac syr 3x2c/hari - Bed rest
Fosen enema sup dsm - Diet sonde 6x200 kkal
Ceftriaxone 2gr/12jam IV - O2 2-4 lpm
Fumucyl 200mg/8jam - IVFD NaCl 0,9% 20 tpm
  - Drip omeprazole 80mg
P/ dalam 50 cc NaCl 0,9%
CT-Scan Thoraks kec. 5 cc/jam
Foto thorax susul hasil - Sucralfat syr 3x 3c
Urinalisis -Tranfusi PRC sd Hb
>10g/dl
Lab 28/07/2021 -Levofloxacin
Foto thorax PA 500mg/24jam
Aortosklerosis -Vit K 1 amp/8jam
Massa paru kanan dengan -Mupirocin cream ue 1 x
destruksi costae 2 kanan, 12 jam
kesan pancoast tu mor -albuminar 25%
Nodul di parahiler kanan 100cc/24jam
-transamin 500mg/8jam
Lab 28/07/2021 IV
Hb/l/t : 10,7/8,3/448  
Mcv/mch/mchc : 82/28/34 P/
Diftel : 6/0/0/78/9/7 - diagnostik BMP
Albumin : 3,50 -egd dan colonoscopy
Gds : 93
Ur/cr : 27/1,00 Lab 31/07/2021
Na/k/cl : 142/4,20/108 Ur/Cr : 13/0,50
Na/K/Cl :141/3,10/108
Ca : 8,2

Lab 30/7/2021
Hb/L/T/Ht/E :
8,2/2,6/26/24/2,8
MCV/MCH/MCHC :
83/29/35
RDW/MPV/PDW :
15,2/9,5/8,9
Diftel : 0/1/0/43/51/5
 
Lab 29/7/2021
Hb/L/T/Ht/E :
8,9/2,3/8/26/3
MCV/MCH/MCHC :
29/35/84
RDW : 15,1
Diftel : 0/1/0/47/40/12
 
Lab 26/07/2021
Hb/L/T/Ht/E :
5,7/17/2.0/17/1,2
MCV/MCH/MCHC :
85/29/34
RDW/MPV/PDW :
16.3/11,5/10.6
Diftel : 0/1/0/55/39/5
Kimia klinik
 Albumin : 2,80
Ur/Cr: 14/0.60
Na/K/Cl/Ca :
136/3.10/109
 
Lab 22/07/2021
Hb/L/T/Ht/E :
1,3/2,3/7/4/0,4
MCV/MCH/MCHC :
98/30/31
Diftel : 0/0/0/52/44/4
MDT:
Eritrosit: Normokrom
anisositosis
Laukosit: menurun, sel
muda (-), blast (-)
Trombosit: mrnurun, giant
(-)
Kesimpulan: pansitopenia,
periksa retikulosit
Anti HCV : Negatif
HBsAg : Non Reaktif
Bilirubin
total/direk/indirek :
0,35/0,17/0,18
SGOT/SGPT : 9/4
Albumin : 2,50
Na/K/Cl/Ca :
141/4,0/115/7,3
GDS : 106

K4B1 K4B2 K4B3 K4B4 K4B5

DPJP : dr. Azzaki DPJP : dr. Cut Mela DPJP : DPJP : Prof.Dr.dr.
Abubakar, SPPD-KGEH Yunita Sp.PD KGH COW: Kurnia F Jamil Sp.PD
COW: dr Irwandi / dr COW : dr. Irwandi / dr. Ruangan : KPTI
Saddam Saddam COW : dr. Irwandi / dr.
Ruangan: dr. Umar / dr Ruangan : dr. Umar / dr. Saddam
 Aidil Aidil Ruangan : dr. Merizka /
dr. Fahmi
Nama:Sastrawan Nama : Abu Bakar Saidi Nama: Nama : Sumardi Bin
Nurman TTL : 01/07/1953 Ttl: Salimin
CM:1-27-65-43 CM: 1-06-95-44 TTL : 6/6/1968 (53)
TL:14/5/1974 (47 th) CM : 1-19-16-80
Ass/ Ass/ Ass/
1. Right upper quadran pain 1. Penurunan kesadaran ec 1. Low back pain ec DD
ec dd kolesistitis akut dd -sepsis -imbalance -spondilosisthmosis
2. Multiple ulkus gaster a/r elektrolit -stroke -Spondilosis lumbalis
autrum 2. sepsis ec dd -Skoliosis lumbalis
3. PSMBA ec dd -pneumonia -urosepsis – 2. Post PSMBA ec DD
-multiple ulcus diabetikus -Kolitis Ulceratif
ulkus(operdarahan) 3. pneumonia -Kolitis TB
-peny.kronik 4.ulcus diabetkus -Chron Disease
4. Polip gaster 5. hiperkalemia -Ca Colorektal
5. Anemia Berat NN ec dd 6. AKI stage III dd akut 3. Anemia ringan NN ec
1) Perdarahan, 2) Penyakit on HD dd 1)perdarahan 2)
Kronis 7. Anemia sedang NN penyakit kronik
4.diare akut ec dd
Th/ Th/ 1)Intoleransi motonasi
Bedrest Bedrest 2) infeksi virus
Diet MII 1700 kkal/harii NGT, kateterr urin
Drip octreodie 200mg/8jam Ivfd sol 2:1 Th/
IV ketorolac 1 amp Iv ceftriaxone 2g/8jam Bed rest
IV omeprazole 40 mg/12 Iv lonsoprazole Diet Lunak 1700 kkal/hari
jam 30mg/12jam tinggi serat
Sucralfat sy 3xc1 Drip revat 1,2g IVFD RL 20 tpm
Azitromocin 1x500 mg Drip pct 1g IV Lansoprazole 30mg/12
Amoxicillin 2x1000 mg jam
Kaltropen supp extra P/ IV Ondansetron 4mg/8
Drip omeprazole 80 mg Kultur darah & urin (susul jam
dalam 50 cc nacl0,9% hasil) Mecobalamin 500mg/8
Kaltropeb supp Balance cairan jam
As traniksamar amp/8jam Susul hasil foto thorax PCT 2x1000 mg
IV octretide 50mg extra Cek lab ulang (senin) Attapulgit 2 tab awal dan
Continues drip octretide USG Urologi (daftar 2 tab tiap Diare, maksimal
200mg senin) 12 tab /hari
IV vitamin K 1 amp/8j
IV Novalgin 1 amp /8j Lab 30/07/2021
P/
Transfusi PRC 2 kolf /hri Anti HCV : negatif
Foto thoraks
dengan target Hb> 10g/dl HBsAg : Non reaktif
Rencana EGD dan
kolonoskopi
Lab 29/07/2021
P/
Hb/ht/l/t : 8,2/23/31,6/160
Pantau hemodinamik Lab 27/07/21
Mcv/mch/mchc : 79/28/36
EGD dan kolonoskopi Hb/L/T/HT :
Diftel : 0/1/095/3/1
CT scan abdomen susul 10,8/8,2/484/31
Pt/aptt : 17,80/43,80
hasil MCV/MCH/MCHC:
Albumin : 2,70
Cek DR post transfusi 1 87/31/35
GDS : 118
kolf RDW : 14,4
Ur/cr : 226/5,60
Ca/na/k/cl : Diftel : 3/1/0/73/14/9
Lab 31/07/2021 7,1/150/4,20/125 Normokrom Normositer
Hb/L/T/Ht/E : SGOT/SGPT : 39/23
4,1/17,6/323/13/1,6 Albumin : 2,90
MCV/MCH/MCHC : Ca : 8,9
82/26/32 GDS : 104
Diftel : 1/1/1/86/5/6 Ur/Cr : 49/1,50
Na/K/Cl : 134/4,50/110
Lab 27/7/2021
Urinalisa
Dalam batas normal.

Lab 26/7/2021
PT/APTT: 1,08/32,80
Urinalisa 26/7/2021

K5B1 K5B2 K5B3 K5B4

DPJP : dr. Azzaki Abubakar,
SPPD-KGEH
COW: dr Irwandi/ dr
Saddam
Ruangan: dr Umar/ dr Aidil
DPJP : dr. Fauzi Yusuf, SpPD-
KGEH
COW: dr Irwandi/ dr Saddam
Ruangan : dr Merizka / dr Fahmi
DPJP : dr. Mahriani
Sylvawani, SpPD-KR
COW : dr. Irwandi / dr.
Saddam
Ruangan : dr. Merizka / dr.
DPJP : dr. M. Diah Sp.PD-KKV
COW: dr Irwandi/ dr Saddam
Ruangan: dr Umar/ dr Aidil
 Fahmi
Nama: Hasanudin Nama : Baharudin bin Parni Nama : Muhammad Nur Nama: Zaini Muhammad
CM:1276543 CM : 1-27-89-06 Ibrahim CM: 0927340
TL:14/5/1974 (47 th) TL : 12-12-1952 (68th) Laki-laki TL: 01/07/1965 (56 th)
CM : 1-27-47-32
TL : 31-07-1958 (63 th)
Ass/ Ass/ Ass/ Ass/
1. NHL 1. Sirosis hepatis stadium 1. CKD stage V dengan 1.CKD Stg V on HD reg
2. Dyspepsia tipe like ulcer dekompensata uremic syndrom ec dd -PNK 2.Dyspepsia type like ulcer dd tipe
3. Hidrokel 2. PSMBA ec dd -DN -HN mixed
4. Pneumonia cap dd infeksi - Varises esofagus bleeding 2. Pneumonia
5. Diare akut ec dd infeksi virus - Varises fundus bleeding 3. HHD Th/
dan bakteri 4. DM tipe 2 Bedrest
  Th/ O2 2-4lpm(kp)
Th/ Bedrest Th/ Diet ginjal 1700 kkal
Bedrest Diet hati 1700 kkal/hari Bedrest IV lansoprazole 30mg/12jam
Diet TC58 IVFD NaCl 0,9%:10 tpm Diet ginjal 1700kkal/hari + IV Ondancentron 4mg/8jam
Iv FDNA 0,9% 20tpm IV Lansoprazole 30mg/12jam protein 0,8 gr/kgBB/hari Paracetamol 3x500mg
Iv ondansentron 4mg/8 jam IV Ondansentron 4 mg/8 jam Three way As folat 2x400μg
Drip paracetamol 1g Drip albumin 25% 100cc/24jam Iv furoesmide 40mg/8jam Lenal ace 2x169mg
Attalpugite 1 tab/ bab cair KSR Bicnat 3x500mg N asetil sistein 3x200mg
Sybio 3 X 1 Spironolakton 100mg/12jam As folat 2x400 mg
Flumucyl 3 x 200mg Curcuma 1tab/8jam Lenal ace 169/12jam P/
Ceftriakson 2g/24jam Lactulac syr 3xCII Albuminar 25% 100cc/8jam HD konfirmasi jadwal
Curcuma 3x1 Ceftriaxone 2g/8jam
P/ Omeprazole 40mg/12jam Lab 31/07/2021
P/ EGD-konfirmasi divisi GEH Katilake 1shacet/8jam Urine Rutin
Amlodipin 10mg/24jam Darah : POS
Lab 30/07/2021 30/07/2021 Eritrosit : 50-60
Urinalisa Usg abdomen Lab 28/07/2021 Keton : POS
Keton positif Sirosis hepatis stadium Hb/L/T : 8,8/21,1/341 Leukosit : POS
Pemeriksaan tinja dekompensata Diftel : 0/1/0/93/3/3 Leukosit : 25-50
Warna hijau bau khas Asites derajat sedang HIV : non reaktif Protein : +1
  Hydropp gallbladder Anti HCV : negatif
Lab 30/7/2021 HBsAg : non reaktif Lab 29/7/2021
Bilurubin total/direct/indirect: Lab 31/07/2021 Albumin : 2,30 Hb/Ht/Eri/Tr/L:
0,42/0,22/0,20 Hb/L/T : 7,4/8,9/168 Na/K/Cl : 144/5,70/122 11,8/34/4,3/149/5,8
Sgot/sgpt: 12/5 Diftel : 2/1/0/70/17/10 Ca : 8,1 MCV/MCH/MCHC:
LDH: 256 Protein Total : 4,0 GDS : 101 78/27/35
Kolesterol Albumin/Globulin : 2,30/1,70 Ur/Cr : 147,13,60 Diftel;1/1/0/63/27/8
total/hdl/ldl/trigrilesida: Na/K/Cl : 134/4,0/108 Na/K/Cl: 144/5/100
145/18/87/145 Ca : 7,6 Lab 20/07/2021 Ur/cr: 348/24,1
LED : 12 GDS : 100 Hb/ht/l/t : 8,8/25/21,1/341 GDS 101
Anti HCV : negatif SGOT/SGPT : 219/137 MCV/MCH/MCHC :
HBsAg : non reaktif Bilirubin tot/dir/indir : 91/32/35
Protein total : 5,43 23,34/16,50/6,84 Diftel : 0/1/0/93/3/3
Alb/Glob : 3,49/1,94 Albumin : 2,30
  Lab (28/07/2021) GDS :101
Lab 29/07/2021 Hb/Ht/E/T/L: 9,7/27/3,2/194/11,6 Ur/cr : 147/13,60
Hb/HT/E/L/T : MCV/MCH/MCHC: 84/30/36 Ca/Na/K/Cl :
11,7/38/4,8/30,4/239 RDW : 20,9 8,1/144/5,70/122
MCV/MCH/MCHC/RDW/MP MPV : 10,9
V/PDW: 79/25/31/14/9,6/10,7 diftel : 1/1/0/77/15/6
Diftel : 1/1/0/34/61/3 Pt/Aptt: 2,73/2,79
PT/APTT:15,2/31,6 Anti HCV : negatif
Anti HCV dan HIV : Negatif HbsAg : non reaktif
HBsAg : Non Reaktif Bil tot: 25,83
GDS : 64 Albumin: 2,3
Protein total:5,43 SGOT/SGPT: 208/141
Albumin : 3,49 Ur/Cr : 26/1,1
Globulin: 1,94 Na/K/Cl : 132/3,4/101
Na/K/Cl : 140/4/108
Ca : 8
Ur/Cr : 21/1,2
Asam urat: 8,3

TITIPAN

RAUDHAH 4 ISO 2 RAUDHAH 4 K5B4

DPJP: dr. M. Fuad, Sp,PD- DPJP dr Alfi Syahrin
KHOM, FINASIM SpPD
Nama : M Yunus Usman Nama : T. Yulizar Putra
Tgl lahir: 20/03/1934 (87 TTl : 08/07/1977 (44 th)
th) CM : 1-21-11-79
No. Rm: 1-28-04-61
Ass/ Ass/
1. Bisitopeni ec dd. - anemia 1. Obs Febri sec dd
aplastik 1) DBD
- MRS 2) Pneumonia
2. Penyakit jantung 2, Trombositopenia ec dd
aneurisma 1)ITP
3.Dispepsia tipe mixed
Th/ 4.Cephalgia
Diet Mll 1700kkal/hari
IV lansoprazol 30mg/hr Th/
Transfusi PRC 1/0 Bedrest
IVFD Frutolit 20 tpm
Lab 26/7/21 IV Omeprazole 40mg/12j
Hb/HT/E/T/L : IV Ceftriaxone 2gr/24j
3.7/14/2.4/209/3.3 IV Ondancentron 1 amp/8j
MCV/MCH/MCHC: Fluimucyl 3x200mg
57/16/27 Curcuma 3x1
RDW : 22.3 Drip Antrain 1 amp/8jam
Diftel : 14/1/0/60/16/9 dalam NaCl 0,9%
Retikulosit: 1.3
morfologi darah tepi Lab 28/7/2021
Eritrosit: hipokrom Hb/HT/E/L/T
anisopoikilositosis, 14,8/41/5,2/7,3/38
teardrop(+), ovalosit(+), MCV/MCH/MCHC
schiztocyt (+) 80/29/36
Leukosit : jumlah kurang, Diftel : 1/1/1/66/25/6
bentuk normal, Na/K/Cl : 138/4,3/108
eosinofilia(+) Ur/Cr : 13/0,90
Trombosit: jumlah cukup,
bentuk normal, teraebar(+)
Kesimpulan : Anemia
hipokrom mikrositer
leukopenia
imunoserologi
HBsAg: non reaktif
Kimia klinik
AST/ALT : 17/7
Ptotein total : 7.38
Albumin: 4.19
Ca : 8,3
GDS : 78
Ur/Cr : 37/1,27
Asam urat: 6.1
Na/K/Cl : 148/4.40/114

Urinalisis
Hasil normal

Zam-Zam 1

Zamzam 1 K4 Zamzam 1 K6 Zamzam 1 K7 Zamzam 1 K14 Zamzam 1 K19

Dpjp: dr. Alfi Syahrin, DPJP: dr. Islamuddin DPJP : dr. Islamuddin DPJP dr. Desi Salwani DPJP: dr. Islamuddin
Sp.PD SpPD SpPD SpPD KGH SpPD
Nama : Aisyah binti
Ibrahim
TTL:04-04-1966 (55 th)
Tgl msk:23/7/2021
CM:1-03-94-84
Ass/
1. Psmba Perbaikan EC
DD
-varises esofagus bleeding
-varises fundus bleeding
-gastropati hipertensi
portal
2. Anemia Aplastik
3. Sirosis hepatis std
decompensata chilpugh B
Th/
Omeprazole 40mg/12jam
Curcuma 1tab/8jam
Vit k 1amp/8jam
Sandimun 100mg/12jam
Ondansetron 1amp
Lactulac syr CII/8jam
Propranolol 2x10
N asetil sitein 3x200
Lab 30/7/2021
Hb/L/Tr : 6,7/1,1/20
Mcv/Mch/Mchc : Sc lovenox 0,4/12 jam
76/26/34
Diftel : 2/0/0/63/26/9
23/07/2021
Hb/ht/t/l : 7,7/23/28/8,1
Mcv/mch/mchc : 67/22/34
Diftel : 0/0/0/90/8/2
Mdt : anameia hipokrom
mikrositer
Pt/aptt : 16,60/34,60
Bilirubin total : 1,31
Sgot/sgpt : 16/15
Gds : 175
Ur/cr : 75/0,80
Na/k/cl : 141/4,80/109
Cek DR post tranfusi
Target HB 8 boleh PBJ
Nama : Rosmiati binti Nama : Bulan Yunita Nama: Mariana Nama : Nurmalawati
ismail TTl : 24/08/2000 Sauraya TTl : 11/04/1970
TTl : 01-12-1959 CM : 1-22-86-27 TTL : 25/01/1980 CM : 1-28-08-45
CM : 1-28-10-30
CM : 1-27-85-42 Tgl Masuk : 29/07/2021 Tgl masuk 29/7/2021
Tgl masuk 30/7.2021
Ass/ Ass/ Ass/ Ass/
1.CHF FC NYHA III-IV 1. Dispepsia type like 1. Obs. Jaudince ec dd/ 1. PSMBA ec dd
2.DM tipe 2 overweight ulcer dd/ dysmotility 1) Colangiocarcinoma. 2) 1)Ulcus gaster
3.Hipokalemia 2. SLE derajat ringan Ca Caput Pankreas. 2)Ulcus duodenum,
4. Pneumonia dd infeksi 3)Metastase Proses.4) 3)gastritis erosive
paru spesifik Th/ Kolestistitis dengan 2.DM tipe 2 overweight
5.Grave disease Bedrest Kolelithiasis 3.Anemia Berat HM
6. Efusi Pleura bilateral Diet MII 1700kkal
7. LBP IVFD NaCl 0,9% 20tpm 2. Hepatomegali ec dd/ Th/
8.Iskemik Lansoprazole 1)HCC. 2) Metastase -IVFD NaCl 0,9% 20tpm
anteriorekstensif 30mg/12jam proses -Diet cair 6x200 lunak
9. Bone metatase Sukralfat 3xc1 Iv Transamin 500mg/8jam
Calcium laktat 3x1 Th/ Sukralfat 3xc1
Th/ Calcitrol 1x1 Bed rest Lactulac 3x30cc
Bedrest Ketoconazole salep Diet hati D Oral 1700 Vit k 1 amp/ 8 jam
Diet DM 1700kkal Myfortic 2x720 kkal/hari Drip omeprazole 5cc/ jam
IVFD Asering 10tpm Sistenol 3x1 tab IVFD Nacl 0,9% 20 tpm
IV Lansoprazole Clyndamicin 1x300mg Iv Cefoperazone 1 gr/8 P/
30mg/12j Adalat oros 1x30mg jam Hari ini tranfusi kolf 3 dan 4,
IV Cefepime1gr/8j Miniaspi1x80mg Iv omeprazole 40mg/12j cek DR post tranfusi
IV Ondancentron 1 Metilprednisolon 4mg/48 Iv novalgin 1 amp k/p
amp/8j jam nyeri Lab 29/7/2021
IV furosemide 20/ 8 jam Domperidone 3x1 tab Curcuma 3 X 1 tab Hb/HT/E/L/T
Strocain 3x1 3,2/11/1,4/6,4/308
(H7) besok stop gantinya Amoxicilin 2x 1000 30 /07/2021 MCV/MCH/MCHC
dipastikan lagi ke DPJP Azitromicin 1x500 Hb/Ht/E/t/Leu 79/24/30
Ramipril 1x2,5 Attapulgit per Mencret 11,5/33/4,1/392/12,9 Diftel : 4/1/0/76/14/5
Atorvastatin 1x20 Kaltropen sup K/P Na/K/Cl : 144/4,1/115
Propranolol 2x10 MCV/MCH/MCHC: Ca : 8,6
Spironolakton 1x25 Lab 29/7/2021 81/28/35 Ur/Cr : 12/0,60
Sukralfat syp 3xC1 Hb/HT/E/L/T : Diftel: GDS: 162
Clopidogrel 1x75 14,8/42/4,9/257 1/0/0/84/8/7 Protein tot: 6,10
Herbesser CD 1x100 MCV/MCH/MCHC Bilirubin
PCT 1g/8 jam 86/30/35 INR/APTT total/direk/indirek :
Resfar 1200mg / 24 jam Diftel : 3/1/0/72/16/8 2,29/1,46 2,06/0,61/1,45
H3 Na/K/Cl : 144/3,4/110 SGOT/SGPT : 29/7
Tyrozol 2x 5 mg Ca : 9,3 Hepatitis
KSR 2x 600 Ur/Cr : 15/0,60 Anti HCV: negatif
Novorapid 6-6-6 Hbsag : non reaktif
Levemir 0-0-0-10
Alprazolam 1x 0,5 Hati & Empedu
Pct 300+tramadol 25 Bilirubin total/dir/indir :
17,93/12,33/5,06
Lab 29/7/2021 SGOT/SGPT : 238/236
Hb/HT/E/L/T Protein total :5,50
9,6/28/3,4/8,8/308 Ur/Cr : 31/0,50
MCV/MCH/MCHC
84/29/34 Elektrolit
Diftel : 0/0/0/81/10/9 Natrium : 135
Na/K/Cl : 143/2,7/96 Kalium. : 3,20
Ca : 8,5 Klorida : 93
Ur/Cr : 26/0,40
Albumin 3,2 P/ USG abdomen divisi
senin
Echo 28/7/2021 Cek AFP, ALP gamma
EF 69 % GT senin
LV RV normal Daftar CT scan abdomen
Katup normal 3 fase
Fungsi diastolic LV grade
II
Kultur darah susul hasil