MAPPING AQSA 3

Senin, 9 Agustus 2021

Tabulasi DPJP

No Nama DPJP Kamar Jumlah

1. dr. Vera Abdullah Sp.PD-Kpsi K3B2, K5B5 2

2. dr. M. Riswan Sp.PD-KHOM K5B3 1

3. dr. T. Mamfaluti Sp.PD K2B3, K2B4, K3B4 3

4. Dr. dr. Fauzi Yusuf, SP.PD KGEH K2B2 1

5. dr. Hendra Zufry SpPD KEMD K1B1, K4B1, K5B2 3

6. Dr. dr. Azhari Gani, Sp. PD, KKV K1B2, K1B4, K3B3 3

7. dr. M. Fuad, SpPD KHOM K5B4 1

8. dr. Azzaki Abubakar, SpPD KGEH K2B1 1

9. dr. Mahriani, SpPD KR K4B2 1

Total 16

Tabulasi RABER

No Nama DPJP Kamar Jumlah

1. dr. M. Riswan Sp.PD-KHOM K4B4 1

2. Dr. dr. Fauzi Yusuf, SP.PD KGEH K1B4, K2B4 3

3. dr. Desi Salwani, SpPD, KGH K1B1 2

4. dr. Cut Mela Yunita, SpPD, KGH K1B3 1

5. dr. M. Fuad, SpPD KHOM K2B2 1

6. dr. Mahriani, SpPD KR K5B2 1

7. dr. Islamuddin, SpPD K5B2 1

8. Dr. dr. Azhari Gani, Sp. PD, KKV K5B5 1

K1B1 K1B2 K1B3 K1B4

DPJP : dr. Hendra Zufry, Sp. PD, DPJP: dr.Azhari Gani SpPD DPJP : DPJP UROLOGI DPJP : dr.Azhari Gani SpPD KKV
KEMD KKV COW : dr. Eko
COW : dr. Irhash Ruangan: dr. Rossyta
Ruangan : dr. Jupri Raber GEH : dr. Fauzi Yusuf, SpPD-
Raber GH : dr. Desi Salwani, KGEH
SpPD-KGH Raber Bedah Toraks Kardiovaskuler
Nama : Asmariati binti Umar Nama: Ansari M Syam Nama : Hamdiah Binti Ahmad
Cm : 1-28-11-76 CM: 1253508 TTL : 10/12/1962 ( 59 th)
TTL : 08-11-1962 (58 th) TTL: 30/11/1964 (59 th) CM : 1-25-05-63
Tgl Masuk : 2/8/2021 Tgl Masuk: 7/8/2021 TM : 27/07/2021
Ass/ K1B2 [14.05, 7/8/2021] Vera Ferina Melani
1. CKD stg V dengan uremic Ass/ NR: Ass/
syndrom ec dd (1) HN (2) PNC (3) 1.CKD Stage 5 dengan Uremic 1. Anemia berat HM ec Penyakit kronis
PGBI Syndrome ec dd/ 1 DN 2. PNC 2. Efusi pleura (perbaikan) post WSD
2. Hidronefrosis dextra dengan 2..Ulkus diabetikum a/ankle sinistra ec dd/ 1. Sirosis hepatis
hidro ureter 3.DM type 2 NM 2. Pleuro pneumonia
3. DM tipe II NW 4.Dispepsia dd/ gastropati 3. Malignancy
4. Hipertensi stg II diabetikum 3. Sirosis hepatis std. DC
5. Efusi pleura sinistra ec dd (1) 5. Hipotermia, Hipoosmolar, 4. DM Tipe 2 NW 
pleuro pnoumonia 5. Hiponatremi, Hipoosmolar,
(2) pleuritis TB Th/ hipovolemik
(3) related CKD -bedrest
-Diet ginjal 1700 kkal/hari + 0,8 g Th/
protein /kgBb hari Bedrest
Th/ -IV meropebem 500mg/12 jam Diet makan lunak 1700 kkal/hari +
Bedrest -IV Lansoprazole 30 mg/12 jam Hepatoselola
O2 2-4 L/hari -IV Metoclopramide 10 mg/8 jam Threeway
Kateter terpasang -Asetil cysteine 3x200 mg IVFD Aminofusin Hepar 1 fls/24 jam
Diet MB 1700 kkal/hari + protein - valsartan 1x80mg IVFD NaCL 0.9% 500 CC/24 jam
1g/KgBB IV Ceftriaxone 2 g/24 jam (30/7/2021)
Valsartan 1x160 mg P/ SC Lantus 0-0-0-22 IU
Lenal ace 2x169 mg KGDP/hari SC Apidra 10-10-10 IU
Flumycin 3x 200 mg Cek PT,APTT,... IV Omeprazole 40 mg/12 jam
IV Ca glukonas 1 amp/12 jam Cek kultur darah +STAB IV.Furosemid 20 mg/12 jam
Bicnat 3x 500mg kultur pus + STAB = susul hasil IV parasetamol 1000 mg (k/p)
As folat 3x04 -USG urologi Spironolakton tab 100 mg/12 jam
Lenal ace 2x1 - susul hasil Ro thorax PA dan Ro Curcuma 3x1
Transfusi on HD pedis Lactulac syr 3xIC
Amlodipin 1x5mg
Bicnat 3x500 mg Lab 6/8/2021  
Allupurinol 1x100 mg Hb/L/T: 10,7/23/156 P/
Diftel: 0/0/89/3/8 KGDP/hari
P/ SGOT/SGPT: 36/40 Pantau produksi cairan pleura
HD 2 kali (Selasa dan Kamis ) HD Albumin: 3,1 Rencana pleurodesis
selanjutnya konfirmasi GH Ur/Cr: 147/3,2 Susul hasil analisis kultyr, dan sitolofi
kultur urine susul hasil Na/K/Cl: 123/4,2/100 cairan pleura
Balance cairan Calcium: 9,1 Susul hasil ro thorax …
Konsul urologi [14.08, 7/8/2021] Vera Ferina Melani
NR: K2B1
Lab 5/8/2021 Ass/
Hb/ Ht/ erit/ trom/ leu 1. sirosis hepatis std decompensate
9,1/ 25/ 3,2/ 275/ 15,7 releted hepatitis B
Mcv/MCH/MCHC 78/28/37 2. asites massif ec releted SH
Netrofil batang 0 3. hepatitis B kronik
Netrofil segmen 89 4. hipoalbumin berat
Limfosit 5 5. anemia sedang NN ec penyakit kronis
Monosit 6
Albumin 2,8 Th/
ca 5,3 Bedrest
Ureum 186 Threeway
Kreatinin 15,8 Iv Omeprazole 40g/12 jam
Na/K/Cl 145/3,6/115 IV furosemide 20mg/8jam
Spironolakton 2x100g
Lab 3/8/2021 Lactulac syr 3 x CII
Asam urat 8,1 curcum 3x1
IV aminofusin hepar 1fls/hari
Urinalisis Drip albumin 25% 100cc/hari
Warna kuning IV ceftriaxon 2g/24 jam (H7)
pH 5,5 KSR 1x600
Protein +2 Fase enema (klp)
Glukosa +1
Leukosit 2-5 P/
Epitel 0-1 EGD
Keton positif USG+ Pansintesis
Bilirubin negatif
Darah negatif Th/
Bakteri positif
Lab 5/8/2021
Lab 1/8/2021 K/Ca/Cl/Na: 3,5/9,3/106/146
Hb /Ht/ erit/ trom/ leu Ur/Cr: 1/40
5,9/ 17/ 2,1/ 293/ 11,1
Mcv/MCH/MCHC 80/29/36
Netrofil batang 0 Lab 5/8/2021
Netrofil segmen 87 PT 23,30
Limfosit 9 APTT 51,60
Monosit 4 D-dimer 4480
PT/APTT 17/38,1
Albumin 3,10 Lab 4/8/2021
ca 4,2 Hb/Ht/erit/ L/T:
Ureum 223 9,8/ 28/3,2/10,3/ 202
Kreatinin 18,20 MCV/MCH/MCHC : 87/30/35
Na/K/Cl 138/4,80/111 Diftel : 1/1/0/70/20/8
Anti HCV negatif
HBsAg reaktif
Albumin 1,3
Globulin 3,9
Kgds 133
Ur/ cr: 19/ 0,7
Na/ K/ Cl/ Ca: 135/ 3,2/ 107/ 7,2

K2B1 K2B2 K2B3 K2B5 K2B4

DPJP : dr. Azzaki DPJP : Dr. dr. Fauzi Yusuf, DPJP : dr. T. Mamfaluti, DPJP : dr. T. mamfaluti, DPJP : dr. T. mamfaluti,
Abubakar, SpPD KGEH SpPD-KGEH
COW : dr. Eko COW : dr. Eko
Ruangan: dr. Rina Ruangan: dr. Rina
Raber HOM : dr. M. Fuad,
SpPD-KHOM
Nama : fatimah binti abdulullah Nama : Rukaiyah
CM : 0-82-85-66 CM : 1-28-05-17
TTL : 11/03/1969 (52 th) TTL : 03/08/1979 (41 th)
Tgl Masuk : 04/08/21 Tgl Masuk : 27/07/21
Ass/ 1. AML
1. sirosis hepatis std 2. ADHF tipe wet and warm ec
decompensate releted hepatitis dd
B (1) HD
2. asites massif ec releted SH (2)HHD
3. hepatitis B kronik (3) PPCM
4. hipoalbumin berat 3. Peningkatan enzim
5. anemia sedang NN ec transminase ec dd
penyakit kronis 1. Iskemia liver
2. Drug induce
Th/ 3. Infeksi viral
Bedrest 4. Peningkatan enzim
Threeway transaminase
Iv Omeprazole 40g/12 jam 5. Pneumonia bilateral dd
IV furosemide 20mg/8jam infeksi paru spesifik
Spironolakton 2x100g 6. Hipoalbuminemia
Lactulac syr 3 x CII 7. AKI stage I ec dd
curcum 3x1 (1) Sindroma lung tumor
IV aminofusin hepar 1fls/hari (2) Infeksi
Drip albumin 25% 100cc/hari (3) Sindroma hipertensirenal
IV ceftriaxon 2g/24 jam tipe 1
KSR 1x600
Fase enema Th/
Bedrest
P/ O2 nasal canul 2-4 l/i
Susul hasil foto thorax IVFD NaCl 0,9% 30 gtt/I
EGD Diet jantung 1700 kkal/hari
USG+ Pansintesis rendah garam
IV Ceftriaxone 24 gram/24 jam
Th/ (27/7/2021) (HD)
Ramipril 1x2,5 mg
Lab 5/8/2021 SC Heparin 3000 unit/12 jam
K/Ca/Cl/Na: 3,5/9,3/106/146 KSR 2X600 mg
Ur/Cr: 1/40 IV furosemide 20mg/12 jam
CPG 1x75mg
Atorfastatin
Lab 5/8/2021 Curcuma 3x1
PT 23,30 Allupurinol 1x 300mg
APTT 51,60 Recolfar 2x0,5mg
D-dimer 4480 Bicnat 3x500mg
Flumucyl 3x200 mg
Lab 4/8/2021 IV ca glukonas 1g/12 jam
Hb/Ht/erit/ L/T: Drip kcl 2 flacon +NaCL 0,9%
9,8/ 28/3,2/10,3/ 202 500 CC 13gtt/i
MCV/MCH/MCHC : 87/30/35 Spironolakton 1x25mg
Diftel : 1/1/0/70/20/8 Cetirizine 2x10mg
Anti HCV negatif
HBsAg reaktif P/
Albumin 1,3 BMP, CML fase kronis
Globulin 3,9 Rencana hari ini BCR
Kgds 133
Ur/ cr: 19/ 0,7 Lab 5/8/2021
Na/ K/ Cl/ Ca: 135/ 3,2/ 107/ Na/ K/ Cl/ Ca:
7,2 146/ 3,5/ 106/ 9,3
Ur/ Cr: 40/ 1,0
Lab 4/8/2021
Albumin:2,6
Anti HCV:neg
Lab 3/8/21
Hb/Ht/Eri/Trom/Leu=
8,2/28/3,2/346/189,6
MCV/MCH/MCHC/RDW/PD
W/MPV/LED=
87/26/30/22,7/9,5/9,2/23
Diftel= 2/2/2/86/5/5
PT=1,03
APTT=37,40
D-dimer= 730,00
SGOT/SGPT= 42/287
Alb=3,74
Ca=8,6
Ur=33
Foto lumbosacral 2/8/2021
SpPD
Nama : Samsinar binti
CM: 1-28-18-23
TTL : 01/07/1070 (51 th)
Tgl Masuk: 8/8/2021
Ass/
1. PSMBA ec dd
(1) gastritis erosif
(2) ulcus gaster
(3) ulkus duedenum
2. Hiponatremia hipoosmolar
hipovolemik
3. hipokalemia sedang ec dd
1) low intake 2) renal loss
5. Hipertensi grade II
6. Iskemik antero septal
 
Th/
Bedrest
Diet MII 1700 kkal/hari +
redah garam
IVFD NaCl 0,9% 20 gtt/i
IV lansoprazole 30mg/12j
IV ondansetron 4mg/8 jam
Valsartan 1x80mg
Lactulose syrup 3xCII
Fossen enema extra
Rebamipide 3x100 gr
P/
-KGDP/hari
Cek ulang
DR,Elektrolit,PT,aPTT,HbSA
g, anti HCV
Albumin
Foto thoraks
Lab 5/8/2021
Hb/Ht/Eri/L/T:
11,7/30/4,0/7,6/375
MCV/MCH/MCHC ;
74/29/39
Diftel : 1/0/0/82/8/9
GDS : 108
Ur/Cr : 33/1,9
Na/K/Cl : 112/2,9/83
SPPD
COW : dr. Irhash
Ruangan: dr. Rossyta
Nama : seri mulyani
CM: 1-25-16-05
TTL : 12/01/1983 (38 tahun)
Tgl Masuk: 7/8/2021
Ass/
1. Syok sepsis
2. Sepsis ec dd - ulcus
diabetik4/5 cruris
- urosepsis
3. Post debridement artritis
septik genue sinistra
4 Ulcus diabetik 4/5 cruris
5. Anemia berat normokrom
normositter ec dd - penyakit
kronis
- perdarahan
6. Hipoalbuminemia berat EC
dd -low intake
- renal loss
7. DM tipe 2
8.Hiponatremia hipoosmolar
hipovolemik
Th/
Bedrest
O2 nasal kanul 4 lpm
Diet DM 1700 kkal/hari
IVFD NaCl 0,9% 40 gtt/i
IV meropenem 500mg/12 j
Clindamisin 3x300mg
Drip norepineprin dlm NaCl
0.9% 50cc titrasi dosis
IV omeprazole 40mg/12j
IV albumin 25%100cc/24j
Parasetamol 500mg /8j
IV vitamin K 1A/8jam
Asetyl sistein 3x200mg
Transfusi PRC s/d Hb >10g/dl
P/
Pantau hemodinamik
Cek KGDP/hari
Urinalisa
Cek procalcitosis
Evaluasi DR, ur/cr, elektrolit,
albumin ,ca/hari
Kultur darah + STAB
kultur Pus + STAB
kultur urin +STAB
Konsul bedah plastik
Lab 7 /8/2021
Hb/Ht/E/L/T:
4,8/14/2,3/34,8/375
MCV/MCH/MCHC/RDW/MP
V/PDW:
62/21/35/15,8/10,0/11,2
Diftel : 0/0/0/86/11/3
PT/APTT: 1,51/1,8
Albumin : 1,50
GDS: 127
Ur/Cr: 156/2,20
Ca: 6,8
SPPD
COW : dr. Irhash
Ruangan: dr. Rossyta
Nama : Mariawati
CM: 1269275
Tl; 22-04-1970 (51 thn)
Tanggal masuk
Ass/
1.Acute on CKD dd nefrotik
sindrom
2. Anemia sedang HN ec (1)
Def. besi (2) Penyakit kronik
3. Hiponatremia hiperfolemik
4. hiperkalemia ringan
5. Microtrombosis sistemik
6. Hipertensi stg 1
7. DM tipe 2 NW
Th/
Bedrest
O2 2-4l/menit
Diet lunak 1700kkal/hari
Threeway
IV ceftriaxon 2g/24j
IV lansoprazole 30mg/12j
IV Furosemid 400mg/8j
Drip parasetamol 1g 8j
Asam folat 250mg
Lenal Ace 2x 69mg
Kalitaki 3x1
SC novorapid 6+6+6 UI
Flumucyl 3x200mg
SC heparin 5000/12j
Curcuma 3x1 tab
Lab
Hb/HT/E/ L/ T :
8.6/24/3.2/15.3/175
MCV/MCH/MCHC : 76/ 27/35
MPV: 12.9
Diftel : 0/0/0/84/8/8
Ratio PT/APTT : 1,43/ 1.14
Anti HCV : negative
HbsAg : non reaktif
AST/ALT : 27/33
Ca : 8,5
Ur/Cr : 210/6.60
Na/K/Cl : 126/ 5.50/ 97
Spondylosis lumbalis ringan

Lab 2/08/2021
D-dimer: 670
PT/APTT: 1.06/37,3

Lab 1/08/2021
Ca: 8.1
Na/K/Cl : 144/3.00/107

Lab 31/07/21
Hb/Ht/E/L/T :
8,6/27/3,3/211,9/257
MCV/MCH/MCHC : 81/26/32
RDW : 22,7
Diftel : 2/10/0/81/5/2
Ur/Cr : 48/1,20
Na/K/Cl/Ca : 146/2,40/108/8,4

Lab 30/07/21
Hb/Ht/E/L/T :
8,9/27/3,4/219,7/228
MCV/MCH/MCHC : 80/26/33
Diftel : 1/10/1/83/3/2
Anti HCV : negatif
HBsAg : non reaktif
Bilirubin total : 0,24
Bil. Direct : 0,07
Bil. Indirect : 0,17
SGOT/SGPT : 338/912
Troponin T : <0,04
CK-MB : 9
Ur/Cr : 62/1,40
K/Ca/Cl/Na : 2,30/7,8/109/145
LDH : 1051
D-Dimer : 1550,00
PT/APTT: 1,04/34,10
 
Echo 30/7/21
Fungsi sistolik menurun EF
37%
MR, AR, TR Moderat
LV Dilatasi
Disfungsi diastolic LV
Regional wall motion
hipokinetik
 
Lab 29/07/2021
Urinalisis
Warna: kuning muda jernih
Berat jenis : 1,007
pH : 6,0
Leukosit/Protein/Glukosa/Keto
n/Nitrit/Urobilinogen/
Bilirubin/Darah : Negatif
Leukosit : 0-2
Eritrosit : 0-2
Epitel : 0-1
 
Lab 27/07/21
Hb/L/T : 6,8/246,2/236
Ht/E : 19/2,6
MCV/MCH/MCHC : 74/26/35
RDW 22,5
Diftel : 2/5/1/88/2/2
SGOT/SGPT : 3130/9984
Albumin 3,1
Ur/Cr : 97/1,9
Na/K/Cl/Ca : 138/4,1/109/6,2
PT/APTT : 1,28/36,60
Fibrinogen : 302
D-dimer : >20000
Anti HCV : negatif
HBsAg : non reaktif
Asam urat : 14,3
 
Urinalisa 29/07/21
pH : 6,0
Protein : negatif
Urobilinogen : negatif
 K3B1 K3B2 K3B3 K3B4 K3B5
DPJP : DPJP : dr. Vera Abdullah, SpPD- DPJP : dr.Azhari Gani SpPD DPJP : dr. mamfaluti, SPPD DPJP : dr.M Fuad, SpPD-
NEURO KPsi KKV COW : dr. Irhaash KHOM
COW : dr. Irhash COW : dr. Eko Ruangan: dr. Rossyta COW : dr. Irwandi
Ruangan : dr. Rina Ruangan: dr. Rossyta Ruangan: dr. Merizka

Nama : Hamamah Binti Salam Nama : Yulisna Rukmana Nama : Asmar Binti Baharuddin Nama : Zuryati
TTL : 1/7/1950 (71 th) TTL : 01/07/1968 CM : 1-28-15-41 CM : 1281174
CM : 1-28-11-37 CM : 1281525 TL : 01/07/1962(59 th) TL : 17/06/1986(35 th)
Tgl Masuk 4/8/2021
Tgl Masuk 2/8/2021 Tgl. Masuk : 05/08/2021 Tgl. Masuk : 01/08/2021
Ass/ Ass/ Ass/ Ass/
1. Penurunan kesadaran  ec dd 1. HE grade 1 dengan pencetus 1. CKD stage V ec 1. DN dengan 1.CHF FC NYHA III ec dd/
- Sepsis Susp imbalance elektrolit uremic syndrome perbaikan 2. PNC a.HHD
-  imbalance elektrolit 2. Serosis hepatis stadium 2. Trombositopenia ec dd b.IHD
-SDA dekompensata CTP C Related (1) TTP-HUS c.DCM
2. Sepsis ec dd (1) pneumonia, (2) hepatitis B (2) DNS induced koagulopati 2.Pnemonia dd/infeksi paru
urosepsis (3) Artritis sorhc 3. Hepatitis B kronik 3. Hiponatremi hipoosmolar spesifik
  4. Hipokalemia sedang hipervolemik 3.Mikrotrombosis sistemik
3. Pneumonia CAP dd  infeksi paru 5. DM tipe 2 dd relatif 4. Pneumonia  dd infeksi paru 4.Ascites ec dd/
spesifik Hiperglikemia spesifik a.CHF
4.ISK simptomatik   5. DM tipe 2 b.Hipoalbuminemia
5. Anemia sedang HM ec dd Th/ 6. Hipertensi stage 2 c.Sirosis Hepatis
    1. perdarahan Tirah baring 7. Hipoalbuminemia berat 5.AV Block derajat
    2. Def. Besi Diet hati ll 1700kkal/hari 8 DD/ Myelohepatis, urelititis 6. Susp emboli paru
6. PSMBA ec dd Threeway 9. Iskemik anterior
    1. Stress ulkus IVFD comafusin hepar 1 fls/24   Th/
    2. Ulkus duodenum jam Th/ -Bedrest
     3. gamran NSFIID Inj Furosemid 20mg/8j Tirah baring -Threeway
7. geriatric problem Drip Albumin 1 fls/24 jam O2 nasal canul -IVFD Coamfusin hepar 1 fls/hari
    1. Infeksi IV vitamin K A/8jam Diet ginjal 1700 kkal/hari protes 1 -Diet jantung II 1700 kkal/hari +
    2. Instabilitas dan jatuh Spironolakton 2x100mg gram/kgbb/hari diet rendah garam
    3. Immobilisasi KSR 2X600 mg Treeway -IV Ceftriaxone 2 g/24 jam (H7)
    4. Inanisasi Curcuma 1tab /12j IV Levofloxasin 500 mg/24j -Drip furosemide 2 cc/jam
    5. Haring of viktion Lactulac 3x2 Iv furosemid 20mg/ 8j -Drib dobutamin titrasi 6 meq/jam
8. hipoalbuminemia Sucralfat syr 3x I C IV lansoprazol 30 mg/ 12j -Spironolacton 1 x 25 mg
9. Contracted genu ec dd/ OA, RA, gout   IV Ondasetron 4 mg/12 jam -Clopidogrel 1 x 75 mg
10. Osteoporosis P/ Bicnat 50mgx3 -SC Heparin 5000/12 jam
11. Hipertensi stage II Ukur LP dan BB /hari Asetilsistein 3x200mg /8j -Lactulac syr 3 x CII
12. Artritis Sepsis dengan OA genu dex KGDP/hari Asam folat 0.4/12j -Comafusin hepar fls/24 jam
IV Susul hasil sitologi dan kultur Clopidogrel 1x75mg/12j -Curcuma 3 x 1 tab
  cairan asites Atorvastatin 2pmg/ 24j
  Persiapan EGD Lenal Ace 2x16g g Lab 4/8/21
Th/ Cek DR, Elektrolit, Albumin, Valsartan 1x40 mg Hb/Ht//Leu/Tr : 12,8/39/236/8,7
Bed rest PT, APTT susul hasil HD free Heparin MCV/MCH/MCHC : 83/28/33
Diet Sonde 6x200 mg/hari   Lactulac syr 3xII C Diftell : 0/0/0/79/13/8
Pasan NGT dan kateter Urinalisa 6/8/2021   PT/APTT : 1,65/1,18
Drip albumin 100cc /24j Warna: Kuning P/ D-dimer : 8340
IV lansoprazole 30mg/12j Protein: - Usg urolasi AntiHCV : negatif
IV meropenam 1g/8j pH: 6 Kgdp/hari HbsAg : Non Reaktif
Valsartan 1x80 mg Leukosit: 0-2 HD sesuai jadwal Bil tot/dir/indir : 2,69/1,99/0,70
Amlodipine 1x10 mg Glukosa: - Cek DR, ur, cr, elektrolit Protein total : 6,94
Calporosit D500 Eritrosit: 2-5 EKG/hari Albumin/Glo : 3,31/3,63
IVFD NaCl 0,9 % 1 fls/8 jam Darah + Kultur urine+ STAB Ca : 8,4
Paracetamol 2x100 mg Bilirubin - Foto thorax Ur/Cr : 58/0,97
Sucralfat syr     Na/K/Cl : 131/4,0/98
  Lab 5/8/2021 Urinalisa 5/8/2021
P/ Protein Total: 6,6 Warna: Kuning
Evaluasi hemodinamik LDH: 267 Protein: +2
Susul hasil kultur darah, kultur urin Alb: 2,23 pH: 5
STAB GDS: 117 Leukosit: 10-25
Evaluasi DR/hari Hb-A1c: 5,2 Glukosa: -
G-scan tnmx kontras non   Eritrosit: 25-50
Feces rutin   Darah +
Cek asam urat Lab 3/8/2021 Bilirubin -
Foto genu bilateral Hb/ L/ T : 10,1/5/55  
Kultur sendi sitologi dan kultur MCV/MCH/MCHC : 97/35/36  
  Diftel : 1/1/0/70/15/13 Lab 4/08/2021
Lab 4/8/2021 PDW/RDW: 11,8/14,2 Hb/Ht/E/ L/ T : 8.0/ 22/
Hb/L/T: 9,9/14,8/305 Protein Total: 6,5 3.0/125/12.6
Diftel: 1/0/0/89/4/6 K/Ca/Cl/Na: 2,8/7,9/108/137 MCV/MCH/MCHC : 74/ 27/36
LED: 130 PT/APTT: 2,36/0,73 Diftel : 0/1/0/94/4/1
K/Ca/Cl/Na: 2,8/7,4/96/137 HbsAg: Reaktif Ratio PT/aPTT : 1.43/ 1,14
Alb: 2,74 Alb/Glo/GDS: 2,4/4,1/220 D-dimer: 4950
Ur/Cr: 30/0,44 Anti HCV: negative HIV : non reaktif
  SGOT/SGPT: 31/57 Anti HCV : negative
Lab 3/08/2021 Bil.Dir/Bil.Ind/Bil.Tot: HbsAg : non reaktif
Ferritin: 409.30 2,44/2,24/4,68 AST/ALT: 42/30
FE: 14 GDS : 95
LTIBC: 163 Ur/Cr : 296/17.10
  Na/K/Cl : 131/ 4,8/ 107
Lab 2/8/2021
Urin Rutin
  Darah : POS
  Eritrosit : 25-50
  Keton : POS
   Leukosit : POS
  Leukosit : 5-10
 
Lab 1/8/2021
Hb/Ht/L/Tr : 7,7/23/9,1/382
Mcv/mch/mchc : 78/26/34
Diftel : 0/0/0/93/3/4
Pt/aPTT : 0,91/1,12
Hbsag anti hcv : non reaktif
Albumin 2,3
GDS 136

K4B1 K4B2 K4B3 K4B4 K4B5

DPJP : dr. Hendra Zufry, Sp. DPJP : dr. Mahriani DPJP : dr. Vera Abdullah, DPJP : dr. Alfi Syahrin, DPJP : Dr. dr. Fauzi
PD-KEMD Sylvawani, SpPD-KR SpPD-KPsi SpPD Yusuf, SpPD-KGEH
COW : dr. Irhash COW : dr. Saddam COW : dr. Irhash COW : dr. Suprinardi COW : dr. Eko
Ruangan : dr. Jupri Ruangan : dr. Rina Ruangan : dr. Julia S/dr. Ruangan: dr. Rina
Raber HOM: dr.Riswan Ruangan : dr. Fahmi Murdia
SpPD-KMOM

Nama: Raudhah Nama : Dahliani Binti Dahlan Nama: Nurmala Nama: Masna Saleh Adri Nama: Sri Purwaty
CM : 1-17-64-71 CM : 1-27-03-20 CM: 1267741 CM: 0769924 CM: 1280722
TTL : 31/12/1990 (30 th) TL: 29-08-1988 (32 th) TL: 04/02/1965 TL: 19/11/1945 TL: 24/10/1969
Tgl Masuk : 1/8/2021 TM: TM: 06/08/2021 TM: 07/08/2021 TM: 08/08/2021

Ass/ Ass/ Ass/ Ass/

Ass/ 1. SLE derajat berat dengan 1. Sepsis ec dd 1.Penurunan kesadaran ec dd/ 1.Dyspepsia tipe like ulcer dd/
1. Trombositopenia ec dd manifestasi neuropsikiatri, - pneumonia a.Sepsis tipe mixed
    1. APS hemologik - urosepsis b.SDA 2.Konstipasi
    2. ITP 2. Anemia berat NN ec dd 2. Pneumonia dd infeksi paru c.Stroke
2. SLE Related SLE spesifik 2.Pneumonia geriatri dd infeksi Th/
3. Dyspepsia tipe like ulcer dd 3. Hipoalbuminemia 3. Syok sepsis dd syok paru spesifik -Bedrest
mixed   kardiogenik 3.Anemia sedang NN ec dd/ -Diet bubur kecap
3. DM Tipe 2 Th/ 4. Ckd st V on Hd reguler a.penyakit kronik -IVFD NaCl 0,9% 20 tpm
4. Leukositosis ec dd Bedrest 5. Diare akut b.perdarahan -IV Lansoprazole 30 mg/12 j
    1. Pneumonia (CAP) Diet MB 1700 kkal/hari 6. Dm type II NW 4.Hipoalbuminemia berat ec dd
5. Menoragia ec Susp mioma Treeway 7. Status hipokoagulasi a.low intake Lab 28/7/2021
uteria IV Lansoprazole 30 mg/inj 8. Hipoalbuminemia sedanv b.renal loss Hb/Ht//Leu/Tr :13,3/42/7,1/304
6. Anemia sedang normokrom IV Methylpresnisolon 250 5.Stroke iskemik MCV/MCH/MCHC : 79/25/32
normositer dd/ perdarahan gr/inj Th/ 6.HT Terkontrol Diftell : 0/0/0/70/25/5
akut, penyakit kronis IV Furosemide 20 mg/jam Ivfd d10 10tpm 7.Dispepsia tipe like ulcer PT/APTT : 1,02/0,88
    Drip Albumin 25% 100 cc/24 Drip Vascon amp dlam 50 cc 8.Geriatri problem (inanisi, HbsAg : Non Reaktif
Th/ jam NaCl 0,9% (dosis titrasi) infeksi, instabilitas dan jatuh, GDS : 98
Bed rest Kalfonosy D-500 2x1 Iv Meropenem 1g/8jam impairment of vision) Ur/Cr : 23/0,71
Diet 1700 kkal/hari Myfortic 2x720 mg Iv Lansoprwzole 30mg/12jam Na/K/Cl : 146/3,70/108
SC Lantus 0-0-0-12 IU Asam folat 2x400 mg SC Heparin 500 IU/12jam Th/
Sandimun 25 mg/12 jam HCQ 1X200 mg Lenal ace 2x169mg -Bedrest
Inj omeprazole 40mg/hari   Asam folat 2x400mg -02 2-4 lpm
Paracetamol 3x500mg P/ Iv vit k 1amp/8jam -Diet sonde 6 x 200 cc via
Kalsium lactat 2x1   Attapulgite NGT + ekstra putih telur
Drip Levofloxacin 500 mg/12 Lab Synbio 3x1 -IVFD NaCl 0,9% 20 gtt/i
jam (H5) Urinalisis 6/8/2021 Paracetamol drip 1000mg -IV Cetriaxone 1 g/12 jam
Valsartan 1x80mg Warna kuning Bicnat 3x500mg -Drip Albumin 100 cc/24 j
Hidroklorokuin 200mg/24j pH 5 Flumucil 3x200mg -IV Omeprazole 40 mg/12 jam
  Protein +2
P/ Glukosa -
IV Asam tranck/8 jam Leukosit 5-10 Lab 06/07/2021
MRI kamis Epitel 0-1 Hb/l/t: 7,7/26, 3/76 Lab 4/8/21
ANA profil daftar Keton: - Mcv/mch/mchc: 86/29/33 Hb/Ht//Leu/Tr :8,4/24/7,2/356
  Bilirubin negatif Diftel: 0/0/0/91/6/3 MCV/MCH/MCHC : 82/29/35
  Darah positif Pt/aptt: 2,275,29 Diftell : 0/1/1/76/17/5
Lab 6/8/2021   Albumin:2, 1 HIV : Non Reaktif
Hb/L/T:  7,2/21/36 Lab 5/8/2021 Ca:7, 6 Bil tot/dir/indir :0,31/0,14/0,17
Diftel: 1/1/0/82/11/5 Hb/ Ht/ erit/ trom/ leu Gds:20 SGOT/SGPT : 36/17
  8,5/ 25/ 3,1/ 181/ 3,5 Ur/Cr:43/3,3 Alb : 1,0
Urinalisis 5/8/2021 Mcv/MCH/MCHC 80/27/34 Na/k/cl:131/4, 0/104 Ca : 6,1
Warna kuning kemerahan Diftel 1/1/0/55/38/5 GDS : 86
pH 5,5 Albumin 1,7 Ur/Cr : 34/0,70
Protein +1 Kgds 102 Na/K/Cl : 133/4,10/112
Glukosa +1 Ureum 23
Leukosit 10-25 Kreatinin 1,1
Epitel 0-1 Na/K/Cl 143/2,5/110
Keton: + SGOT/SGPT: 24/9
Bilirubin negatif
Darah positif
 
Lab 4/8/2021
SGOT/SGPT:8/32
Bil
tot/bil.direk/bil.indirek:2,08/1,5
6/0,52
 
Lab 1/8/2021
Hb/L/T : 7,1/14,7/195
Mcv/mch/mchc : 72/23/32
Diftel : 2/1/1/77/15/4
PT/aPTT : 0,94/1,25
GDS : 336
Ca : 8,4
Ur/Cr : 28/0,5
Na/K/Cl : 135/4/104

K5B1 K5B2 K5B3 K5B4 K5B5

DPJP NEURO DPJP : dr. Hendra Zufry, SpPD- DPJP : dr. M. Riswan Sp.PD- DPJP : dr. M Fuad, DPJP : dr. Vera
KEMD KHOM SpPD-KHOM Abdullah, SpPD, KPsi.
COW : dr. Irhash COW : dr. Eko COW : dr. Irwandi COW : dr. Irhash
Ruangan : dr. Jupri Ruangan: : dr. Jupri Ruangan : dr. Merizka Ruangan : dr. Rina
Raber Rheumato : dr. Mahriani, Raber Bedah Onkologi Raber KKV : dr. Azhari
SpPD-KR Gani, SpPD-KKV
Raber Pulmo : dr. Islamuddin, SpPD
Nama : Juliana binti Kalpiah Nama : Suhadani binti M.Amin Nama : Nursami binti Nama : Elyana Ismail
CM : 1-10-09-13 CM : 1-28-11-84 Husni CM : 1-15-54-27
TL : 01/07/1987 (34 th) TL : 10/07/1975 (46 th) CM : 1-28-11-27 TL : 17/05/1979 (42th)
Tgl. Masuk : 03/08/2021 Tgl masuk : 2/8/2021 TTL : 01/07/ 1972 Tgl masuk : 30/7/2021
Tgl Masuk : 01/08/ 2021
1. Efusi pleura bilateral ec dd/ 1) related 1. Bisitopenia ec ITP dengan Ass/ Ass/
SLE 2) hipoalbuminemia 3) perdarahan 1.Cancer Pain 1. PSMBA ec dd
bronkopneumonia 2. Susp. Ca mamae sinistra (1)stres ulcer
2. SLE derajat sedang dengan manifestasi Th/ 3. Anemia berat NN EC dd (2)induced xarelti
konstitusional paru, hematologik, ginjal Bedrest peyakit kronik, perdarahan (3) varises esofagus
stadium lll Diet 1700 kkal/hari 4. Dyspeosia tipe like ulcer 2. Acute chronic right heart
3. Nefritis lupus grd lll IV Transamin 500mg/8 jam dd type mixed failure ed cc
4. Hipoalbumin sedang EC dd renal loss IV omeprazole 30mg/24 jam (1) intertisial lung
dan low intake IV metilprednisol 125mg/12j Th/ destruction (fibrotik paru)
5. MCTD Domperidon 3x10mg -Tirah Baring (2) IPC
6. Efusi pericard Paracetamol 3x500mg -Diet MB 1700 kkal/ hari (3) Ht
-IVFD NaCl 0,9% 20 gtt/ 3. DM tipe 2 NW
Th/ P/ -IV Ceftriaxone 2 5. Scabies
Bedrest Transfusi TC 10 kolf target gram/24jam 6.ph moderate
Diet MII 1700 kkal/hari >20000 -Clindamycin 3x300mg 7. Asites grade lll ec dd
Inj omeprazole 40 mg/12 jam Transfusi PRC 2 kolf hari -Paracetamol 2x1000mg congestive liver
Inj Furosemid 40mg/8j dengan blood set khusus premed Transfusi PRC s/d Hb 10  
Myfortek 2x720mg dexa Sukralfat 3xcll Th/
Inj Metilprednisolon 125mg/12 jam (H1) Pantau perdarahan Omeprazole 40mg/12j Bedrest
Lenal ace 2x1 Diet DM 1700 kkal/hari
Ostriol 2x1 Lab 6/8/2021 P/ IVFD NaCl 0,9% 20 gtt/i
Asam folat 2x1 Hb/L/T: 4,1/10,7/6 Daftar echo IV lansoprazole 30mg/12j
Hcq 1x200mg Diftel: 0/0/0/83/11/6 Protoleransi kemotrapi IV cefoparazole 1 g
Iv furosemide 40 mg/8 jam Susul hasil Biopsi Spironolacton 2x25 mg
Valsartan 1x80mg Lab 5/8/2021 Urinalisa Lactulac syr 3xCII
Flumucyl 3x2mg Hb/L/T: 3,8/6,1/2 Kultur Pus + STAB Curcuma 3x1 tab
Simark 1x2 mg Diftel: 0/0/0/82/10/8 furosemid 2x 40 mg
Ibuprofen 3x400mg Lab 6/8/2021 Atorvastatin 1x20mg
Silostazol 2x100mg Lab 4/8/2021 Hb/L/T: 7,4/14,6/368 Cetirizin 2x10mg
Calprosis 2x1 Hbsag:nok reaktif Diftel: 2/1/0/78/12/7 Sidenafil 1x 12jam
Miniaspi 80mg/24j AntiHCV:neg  
Cetirizin 2x10mg SGPT/SGOT:5/9 Urinalisis 6/8/2021 P/
Bil.Direk/Bil.indirek/Bil.Tot:0,4 Warna kuning -Gen exspert --> paru
P/ / pH 6 belum ada dahak
- DR, ur,cr, elektrolit, albumin,ca 0.69/1,09 Protein - Kultur dahak +STAB
-gen expert Glukosa - Evaluasi perdarahan
Lab 3/8/2021 Leukosit 2-5 Evaluasi hemodinamik
Hb/L/T : 4,3/7,2/4 Epitel 5-10 -USG abdomen susul hasil
Lab 4/8/2021 MCV/MCH/MCHC : 72/23/32 Keton: - -Balance cairan /24 jam
Urinalisa Diftel : 0/0/1/84/9/6 Bilirubin negatif negatif
BJ:1,029 PT/INR : 1,04 Darah positif -ukur lingkar perut dan BB
Darah:positif aPTT : 26,5
Eri:5-10 Lab 05/08/2021 Lab 5/8/2021
Protein:positif +3 Lab 02/08/2021 Hb/ Ht/ Erit/ L/ T : Hb/L/T: 10,7/6,7/182
Leu:neg Hb/L/T/Ht/E : 7,6/24/3,0/13,1 / 334 Diftel : 6/1/0/64/20/9
PH 5 5,6/11,9/7/18/2,5 MCV/MCH/MCHC/RDW APTT: 0,76
MCV/MCH/MCHC/RDW: : Ur/Cr: 35/0,80
Lab 02/08/2021 73/22/30/22,4/ 80/ 25/32/15.9 K/Ca/Cl/Na:
Hb/Ht/E/L/T : Diftel : 0/0/1/83/9/7 Diftel : 2/1/0/74/14/9 3,8/8,1/101/137
9,0/27/3,3/6,3/201 Ur/Cr: 34/0,70
MCV/MCH/MCHC : 83/27/33 Na/K/Cl: 145/3,50/113 Lab 02/08/2021 Lab 4/4/2021
Diftel : 1/1/0/63/28/7 GDS: 134 ALP : 126 LED:33
Na/K/Cl/Ca: 146/2,90/119/7,5  
Albumin : 2,60 Thorax PA 2/8/2021 Lab 31/07/ 2021 Lab 30/7/2021
Ur/Cr : 35/1,90 Cor normal, pneumonia Hb/ Ht/ Erit/ L/ T : Hb/Ht/L/T :
PT/APTT : 13,90/30,70 7,6/24/3,0/13,1 / 334 11,6/36/7,6/202
Fibrinogen: 384,00 MCV/MCH/MCHC : MCV/MCH/MCHC ;
D-dimer: 1810,00 80/ 25/32 82/27/33
GDS : 92 Diftel : 2/1/0/74/14/9 Diftel : 4/1/1/65/19/10
PT/APTT : 15/32,10
Cairan pleura 03/08/2021 Lab 31/07/ 2021 Anti HCV : negative
Warna: Kuning Hb/ L/ T : 10, 4/ 19.700/ HBsAg : non reaktif
Kejernihan: Jernih 499 Bil tot/direct/indirect
Bekuan: negatif MCV/MCH/MCHC : 81/ 2,41/0,71/1,70
PMN sel: 95 25/32 SGOT/SGPT : 24/15
MN sel: 5 Diftel : 1/0/1/73/18/7 GDS : 224
lain2: hasil menyusul Ratio PT/aPTT : 1,01/ 0,9 Ur/Cr : 21/0,7
Leukosit: 202 Anti HCV : negative Protot/Albumin/Globulin
Total protein: 1,5 HbsAg : non reaktif 6,30/3,20/3,10
Albumin: 0,8 Albumin : 3,2 Na/K/Cl/Ca
Glukosa: 102 Ca : 8,9 138/4,60/107/8,9
GDS : 71
Ur/Cr : 22/0,60
Na/K/Cl : 139/ 4,3/ 104