MAPPING AQSHA 2 (Minggu, 05/09/ 2021)

Tabulasi DPJP
No Nama DPJP Kamar Jumlah

dr. M. Fuad Sp.PD. KHOM K3B1, K2B5, K4B4 3

Dr. dr. Fauzi Yusuf Sp.PD, KGEH K1B4, K3B5 2

dr. Mahriani Sylvawani, SpPD-KR

dr. Cut Mela Yunita, Sp.PD-KGH K4B1 K4b5 2

dr. M. Riswan, Sp.PD- KHOM K1B1,K4B4 2

Prof. Dr. dr. Kurnia F Jamil Sp.PD-KPTI K1B5 1

dr. M. Diah, Sp.PD-KKV K4B5, K5B3 2

dr. Desi Salwani, SpPD-KGH

dr. Azzaki Abubakar, SpPD-KGEH K3B3, K3B2 2

dr. Desi Maghfirah, SpPD K1B3, K2B2, K2B4, K4B3 4

Dr. dr. Azhari Ghani Sp.PD KKV

dr. Alfi Syahrin, SpPD

dr. Suheir Muzzakir, Sp.PD

dr. Islamuddin, Sp.PD

Total 18

K1B1 K1B3 K1B4 K1B5

DPJP : dr. M Riswan, SpPD- DPJP : dr. Desi Salwani, SpPD-KGH DPJP : dr.Fauzi Yusuf Sp.PD DPJP: Prof. Dr. dr.Kurnia
KHOM COW : dr. Irwandi KGEH Sp.PD-KPTI
COW: dr. M Firdaus Kamil Ruangan: dr. Marcell COW : dr. Irhash COW: dr. Saddam Emir
Ruangan: dr. Thaifur Ruangan: dr. Merizka
Ruangan: dr. Rahmat Z
Nama : M Diah Nama: Sayuti Nama : Adli Nama : Alfian Erdiyus
CM : 1284350 CM: 1-28-05-53 CM :1284780 CM : 1-28-41-59
TTL : 31/12/1974 (46 th) TTL: 07-05-1980 (41 th) TTL :1/7/1960
Tgl Masuk : 30/08/2021
TTL : 09/06/2986
Tanggal Masuk : 27/08/21

Ass/ Ass/ Ass: Ass/

1.Bisitopenia ec dd/ 1. Post Covid 19 1. Hepatomegali ec dd 1) abses hati 2) 1. Penurunan kesadaran
  a.CML
  b.MDS
  c.ITP
  d. Aplastik
Th/
-Bedrest
-Diet MII 1700 kkal/hari
-IVFD NaCl 0,9% 20 tpm
-IV Omeprazole 40 mg/12 jam
-Curcuma 3 x 1
- drip levofloxacin 500mg/24 jam
P/
Konsul BMP
Transfusi PRC 3 kolf premed ( sudah
3)
Lab 3/09/21
Hb/L/T : 8,2/4/185
MCV/MCH/MCHC : 85/30/35
Diftel : 0/1/0/64/22/13
Lab 1/09/21
Hb/HT : 4,2/12
Eri/Leu/Trom : 1,4/2,7/169
MCV/MCH/MCHC : 85/30/35
RDW/MPV/PDW : 19,0/9,0/10
Diftel : 0/0/1/55/19/25
Lab 31/08/2021
Hb/HT : 4,5/13
Eri/Leu/Trom : 1,5/2,9/217
MCV/MCH/MCHC : 87/30/35
RDW/MPV/PDW : 18,8/9,8/9,9
Diftel : 0/0/0/64/25/11
Lab 30/08/2021
Hb/Ht/Leu/Tr : 3,3/10/3,1/226
MCV/MCH/MCHC : 87/30/34
Diftell : 0/0/0/43/34/23
2. Sepsis (perbaikan) HCC 3) Kista hepar (perbaikan )ec dd 1) malaria
3. CKD Stage V 2. Abses hati ec piogenik cerebral 2) uremic ensefalopati
4. Anemia sedang NN ec 3. Anemia sedang ec dd
5. ISK Asimptomatik - Perdarahan
2. Malaria berat
6. HN bilateral - penyakit kronis 3. AKI stage III dd acute on CKD
7. Extrofi bladder ec defect kogenital 4. Trombositopenia ec dd 1)
Th: Related Malaria 2) DIC
Bedrest 5. Status hipokoagulasi
Th/
Diet hati 1700 kkal/hari
- Bedrest
O2 2-4 liter/menit
- Diet ginjal 1700 kkal/hari, protein 0,8 Th/
IVFD NaCl 0,9% 20 tpm
gram/kgBB/hari
IV Ceftriaxone 1 g/ 12 j (H1) -Bed Rest
- IV Paracetamol 1g/8jam
IV Lansoprazole 30 mg/12 j -Diet Cair 1700 kkal/hari
- IV Omeprazole 40 mg/24 jam
Vomitus 3x1 -IVFD NaCl 0,9 % 15 gtt/i
- IV Asam traneksamat 500 mg/8 jam
- Curcuma 3 x 1 tab -Drip paracetamol 1 gram/ 8 jam
P/
- Vitamin C 2 x 500 mg -IV. Meropenem 1 gram / 8 jam
pantau hemodinamik
- Ostriol 2 x 0,25 mg -iv. Omeprazole 40 mg / 12 jam
Susul hasil rontgen thorax dan MDT
- Vitamin E 2 x 1 tab
CT scan abdomen 3 fase - IV phenitoin 100 mg/ 8 jam
- Nystatin drop 4 x 2 cc
(tunda diberikan bila kejang >2x)
- Luka yang merembes darah ditutup
Lab 3/9/2021
dengan kassa yang sudah dicelupkan -Sc. Heparin 5000 iu/12 jam
Hb/Ht/L/T : 7/22/10,7/336
kedalam 1 ampul adrenalin dan NaCl - curcuma tab 3x1
Diftel :1/1/0/82/10/6
0,9%. - erdostein tab 3x1
MDT : Anemia NN
MCV/MCH/MCHC : 81/26/32 - transufusi PRC kebutuhan (10-
P/ 7,9) x 60 x 4 cc = 504 --> 2 Kolf
Cek Ur/Cr,elektrolit,albumin Lab2/9/2021
PRC (200 cc)
Hb/L/T : 7,5/12,1/379
Lab 31/08/2021 Diftel :1/1/1/81/11/5 - transfusi PRC 1 kolf/hari
Hb/L/T : 15,1/8,3/212 Mcv/Mch : 81/26
Diftel : 0/1/0/68/16/15 Pt/Aptt : 1,08/1,2 P/
Albumin : 4,40 Albumin : 2,50 Evaluasi hemodinamik perhari
GDS : 137 GDS : 135 Balance cairan perhari
Ur/Cr : 22/1,2 Ur/Cr : 22/0,80
Na/K/Cl : 134/3,7/106 Na/K/Cl : 131/4,10/99 Cek ulang RFT dan LFT tiap 3hari
Kalsium : 9,1 Cek ulang DR post transfusi 2 kolf
Lab 26/8/2021
Hb/L/T : 6,2/6,9/261 diagnostik
Diftel : 7/0/0/65/16/12
Evaluasi pemeriksaan malaia
PT/aPTT : 1,06/1,2
Fibrinogen : 1,5 malam harike 3,7,14,21,28
Albumin : 2,61
Ca : 7,9 Lab 03/08/21
GDS : 102 Urinalisa
Ur/Cr : 84/5,60
Nitrit/Urobili/Darah : (+)
Na/K/Cl : 139/4,30/111
Leukosit : 2-5
Swab RT PCR : 11 /8/ 2021 : positif Eritrosit : 10-25
Swab RT PCR : 16/ 8/ 2021: positif Epitel : 0-1
Swab RT PCR : 18/ 8/ 2021 : positif
Hematologi
Ro Thorax (9/8/2021)
Cor dan Pulmo dalam batas normal Malaria : Negatif
Lab 21/8/2021 Lab/01/08/21
Hb/L/Tr : 8,2/9,7/385 Hb/HT/Eri/Trombo/Leu :
Mcv/mch/mchc : 81/27/34 7,9/22/3.0/142/7.4
Diftel : 3/1/0/75/10/1
MCV/MCH/MCHC : 76/27/35
Rdw/MPV/pdw: 18,0/10,1/10,9
Diftel : 7/1/0/52/30/10
PT/:APTT : 12,60/ 39,90
Bilirubin T/D/IND : 5,36/3,14/2,22
AST/GOT : 173
Ur/Kr : 140/3,70
Na/K/Cl :145/4,0/113
Lab 31/08/21
Na/K/Cl/Ca/ mg :
140/4,1/107//8,0/2,2
Ur/ Cr : 4,1/ 156
Lab 30/08/21
Na/K/Cl/Ca/Mg :
137/3,7/105/7,9/2,4
Ur/ Cr : 172/ 4,3
Hb/L/T : 8,8/9,6/78
MCV/ MCH/MCHC ; 73/28/38
Diftel : 3/1/0/64/23/9
 MDT : anemia normokrom
normositer, trombositopenia
Malaria : negatif

K2B1 K2B2 K2B4 K2B5

DPJP PARU DPJP : dr. Desi Salwani, SpPD- DPJP : dr. Mahriani DPJP : dr. M Riswan, SpPD-KHOM
KGH Sylvawani,, SpPD-KR COW: dr. M Firdaus Kamil
COW : dr. Irwandi COW:dr. Fadhila Ruangan: dr. Thaifur
Ruangan: dr. Marcell Ruangann : dr. Julia

Nama : Jumaidi bin A Majid Nama: Joni Fazi Nama : M Ali Budiman
CM : 0-95-26-51 CM: 1284632 CM : 1284457
TM : 2-9-2021 TTL: 31/16/1969 TTL : 01/07/1951 (70 th)
TTL : 11/06/1972 Tgl masuk: 02/09/2021 Tgl Masuk : 31/08/2021

Ass/ Ass/ Ass/

1. Post Covid-19 dengan gejala 1. PSMBB ec dd Hemoroid Dvt + infeksi sekunder
sedang Interna grade 2 Ht stage 2
2. CKD stg V on HD regular 2. Anemi sedang ec dd Hipoalbumin sedang ec dd : related
3. Anemia sedang ec peny. Kronis perdarahan infection
4. Efusi pleura sinistra   AKI stage 2 pre renal ec dd :
  Th/ - related infection
-Bed rest - dehidrasi
Th/
-Diet MII 1700 kkal/hari rendah  
- tirah baring
garam Th /
- Diet ginjal 1700 kkal/hari + protein -IVFD NaCl 0,9% 20 gtt Bed rest
60 g/kgBB/hari -IV transamin 500mg/8j Diet 1700 kkal / hari
- O2 4 lpm nasal canul -anti hemoroid syrup IV Ceftriaxon 2gr / 24 jam
- Threeway -transfusi PRC 1kolf Sc lovenox 0,6 cc / 12 jam
- IV Levofloxacin 500 mg/24 jam(h-   Drip albumin 100 cc / 24 jam
3)   Curcuma 3x1 tab
- Favipirapir 2x1600 mg (H1) P/ N-acetylsistein 3 x 200
- Favipirapir 2x600 mg (H2-H5) Cek darah post transfusi Kalitake 3 x 1 sachet
- Asam folat 2 x 0,4 mg   Clindamicyn 3x300mg
- Lenal ace 2 x 169 mg Lab 3/9/2021  Parasetamol 3x500mg
- Flumucyl 3 x 200 mg Hb/L//Tr : 8,4/7,6/258 Amlodipun 1x10mg
- Curcuma 3x1 MCV/MCH/MCHC : 80/25/31
- Zinc 1x20 mg Diftell 4/1/0/58/30/7 P/
- Vitamin C 2x500mg PT/APTT : 0,94/0,82 Balance cairan
- Ostriol 2x0,25 mg  
   
- Valsartan 1x160 mg
Lab/01/09/21 Lab 3/9/2021
- Amlodipine 1x10mg Hb/Ht/ eri/ trombo/ leu: Hb/L//Tr : 8,3/8,6/133
  10,1/32/4,1/ 302/ 7,6 MCV/MCH/MCHC : 94/34/36
P/ MCV/MCH/MCHRDW/RDWP : Diftell : 2/1/0/74/14/9
Lab 3/9/2021 80/25/31/18,1/10,1/11,8 PT/APTT : 1,45/2,17
Hb/L/T : 7,3/9,6/181 Ditell: 4/1/0/43/43/9 D-dimer : 2960
Diftel :27/1/0/47/16/9 Ur/Cr/Na/K/Cl : 40/ Albumin: 2,17
Fibrinogen : 1,04 0,80/14/4,00/116 Ur/Cr : 51/1,92
D-dimer : 2690 HbsAg : NN REAKTIF Na/K/Cl : 150/4,2/105
Albumin : 3,76 PT/APTT : 14,10/28,40  
GDS : 69 Albumin/ Ca : 3,30, 8,3  
Ur/Cr : 108/12,29 GDS : 97 Lab 31/08/2021
Na/K/Cl : 146/5,30/112 Hb/Ht/Leu/Tr : 11,4/31/14,0/97
Kalsium : 8,8 MCV/MCH/MCHC : 91/33/36
  Diftell : 3/0/0/66/13/16
Lab 2/9/2021 PT/APTT : 1,32/1,01
D-dimer : 7060
Hb/L/T : 7,8/11,1/244
Anti HCV : Negatif
Diftel : 24/1/0/51/16/8
HbsAg : Non Reaktif
Fibrinogen : 294 Bil tot/direct//indirect : 4,36/2,67/1,69
SGOT/SGPT : 47/24
Alb/Ca : 2,10/8,4
GDS : 88
Ur/Cr : 92/2,60
Na/K/Cl : 141/5,80/117
 
Lab 30/08/2021
Hb/Ht/Leu/Tr : 11,4/31/14,0/97
MCV/MCH/MCHC : 91/33/36
Diftell : 3/0/0/66/13/16
PT/APTT : 1,32/1,01
D-dimer : 7060
Anti HCV : Negatif
HbsAg : Non Reaktif
Bil tot/direct//indirect : 4,36/2,67/1,69
SGOT/SGPT : 47/24
Alb/Ca : 2,10/8,4
GDS : 88
 Ur/Cr : 92/2,60
Na/K/Cl : 141/5,80/117

K3B1 K3B2 K3B4 K3B5

DPJP: dr. M. Fuad, DPJP: dr. Azzaki DPJP: Prof. Dr. dr. DPJP: Dr. dr. Fauzi
Sp.PD-KHOM Abubakar, SpPD-KGEH Kurnia F Jamil Yusuf Sp.PD, KGEH
COW: dr. COW : d.r Fadhilla Sp.PD-KPTI COW: dr.Irhas
FadhillaRahmi
Ruangan : dr. Iqbal COW: dr. Sadam Ruangan: dr. Meriska
Ruangan: dr. Julia Sari
Ruangan: dr.
Zuaidi

Nama : juni irwansyah Nama : Herman bin warni Nama : zainuddin Nama: zulfikar bin amin
Cm : 0986422 CM : 1-18-73-71 Cm : 1284585 CM: 1-11-06-36
Ttl : 26/03/1966 TTL 23-11-1983 Ttl : 23/03/1996 Ttl: 05-01-1980
Tm : 01/09/21 TM : 04/09/2021 Tm 01/09/21 Tgl masuk: 02/09/21

Ass/ Ass/ Ass/ Ass/

Udem paru acute pada 1. CKD stage 5 ec dd sirosis hepatis 1. Asites ec dd
-sindrom nefrotik stadium -TB Peritoneal
acute on CKD dd CHF
-GNC decompensata -Non sirotik
PPOK eksaserbasia -Ig A Nefropaty related hepatitis C
cute ec SOPT 2. Pneumonia (HAP) PSMBA (perbaikan) Th/
Hipokina perifer ec 3. Anemia berat NN ec.dd ec dd : Bedrest
mikrotrombosis -perdarahan - varises esofagus Threeway
-penyakit kronik bleeding Diet mb 1500. Kkal/hari
sistemik 4.mikrotrombosis sitemik - varises Fundus Iv lansoprazole 30 mg/12
DM tipe 2 nw 5. hiperkalemi sedang (6,40) bleeding jam
Ht stage 2 6. hipoalbuminemia berat - gastropati Ht portal
AKI Stage 3 acute on (1,60) anemia sedang
hipokrom mikrositer P/
ckd -Pantau hemodinamik
Th/ ec dd:
Hiperkalemia -bedrest - pendarahan -Balance cairan dan
  -diet ginjal 1700 kkal/hari - penyakit kronik lingkar perut
-threeway Hipoalbuminemia -ADA Test
Th/
-iv ceftriaxone 1gr/12 jam related sirosis -SAAG 0,8
Bed rest -Senin parasintesis
-iv furosemide 40 mg/8 jam hepatis
Diet 1700 kkal / hari -drip albumin 25% 100cc/24j Hepatitis C kronis -Selasa CT Scan abdomen
Drip IV Levofloxacin -sc heparin 5000iu
700 mg / 24 jam -bicnat 500mg/8jam Th/ Lab 02/09/21
Drip heparin 700 mg -fluimucyl 200mg/8jam bed rest Hb/Ht/e/t/l:
-asam folat 400mg/12jam kateter 11,6/34/4,0/216/4,0
Drip furosemid 30 mg /
-lenal ace 169mg/12jam diet 1700 kkal/hari Mcv/mch/mchc 85/29/34
24 jam -kalitake 1 sachet/8jam Diftel 8/1/0/71/11/9
IVFD Aminofusin
Drip NTG -novorapid 10iu hepar Albumin 2,70
Sc novorapid 10-10- -dextrose 40% extra IV Ceftriaxone Ca/Ur/Kr 8,2/26/0,80
10iu -nebule fentolin extra 2g/24jam Na/K/Cl 136/3,80/107
-ca gluconax extra IV Omeprazol 40 mg
IV Omeprazole 40 mg/
/ 12 jam Analisa Cairan Asites
24 jam Lab 03/09/21 IV Furosemid 20 mg Albumin : 1,9
IV gluconase 1gr Hb/Ht/e/t/l: 4,0/6/0,6/498/6,8 / 12 jam
Curcuma /8jam Mcv/mch/mchc: 112/70/63 Spironolacton 2 x
PDW/MPV:8,6/8,7 Lab 31/08/21
kalitake 3 x 1 sachet 100 mg Hb/ht/l/t : 13/39/5,3/272
Diftel 2/0/0/71/23/4 Propanolol 2 x 10
Nebule combucorf 1 Albumin 1,60 Mcv/mch/mchc : 85/28/33
mg Diftel : 4/1/0/76/12/8
fl/8j GDS:96 Curcuma 3 x 1
Ur/Kr 219/6,20 Albumin: 3,32
Nebule pulmocrof 1 Lactulac Syr 3x1
Na/K/Cl 138/6,90/120 Globulin: 3,89
fl/12j Transfusi PRC Na/k/cl : 147/4/109
D-dimer:9170 1kolf/hari
Tanaps 5mg/24j HVC: (-) Ur/cr : 27/109
Adalatoros 1x30ng HBsAg: non reaktiv
Zink 1x20mg P/ Hasil USG Abdomen:
evaluasi Asites non sirotik
Dex 40% 2fl + 10iu hemodinamik GDS: 71
insulin bolus 10 meq Evaluasi Balance
Nebule fentolin 4fl cairan
Renal ace 2x1mg ukur lingkar perut
dan bb
Fluimucyl 3x200 mg
cek dr post transfusi
 Iv metilprednisolon 2 kolf prc
40mg/12jam susul hasil Ro
Ostriol 2x0,5mg thoraks
Herbesser cd 2x250mg USG Abdomen +
parasintesis
Bicnat 3x500mg
EGD (6/9/21)
Konsul anestesi
P/
Pantau hemodinamik
Balance cairan Lab 01/09/2021
Pantau hasil usg Hb/ht/e/t/l
Pantau hasil ro thorax 7,0.22/2,9/110/3,7
Susul hasil kultur darah Mcv/mch/mchc
77/24/31
+ STAB Rdw 20,2
Susul hasil Kultur urin + Diftel
STAB 10/1/0/58/20/11
Kultur Sputum PT/APTT
18,60/37,30
Gun expert
Bilirubin total 1,82
Check DR ur/cr Bilirubin direct 0,72
elektrolit ulang, Bilirubin indirect
screening HIV 1,10
hd hari ini Albumin 3,10
Ca 8,0
GDS 106
ECHO 3/9/21 1.
Disfungsi Diastolik
grade 3
LVH Konsentrik
Wall motion
normokinetik
 
Lab 2/9/1
Anti HCV/HbSag (-)
Albumin : 2,93
Koltot/HDL/LDL/TG
155/24/110/152
Na/K/Cl = 142/5,7/118
Ca : 7,9
 
Urinalisa
Protein : +2
Glukosa : +2
Darah : +
Granular cast : -
Bakteri : -
 
Lab  01/09/21
Albumin 2,93
Kolestrol Total 155
Hdl 24
Ldl 110
Ca/ur/kr/asam urat
7,9/91/6,74/7,9
Na/K/Cl 142/5,70/118
Urinalisis
Protein +2
Glukosa +2
Granular Cast +
Bakteri +
 
Analisa gas darah
Ph 7,325
Pco2 30, 10
 Po2 217
Hco3 15,8
Total co2 16,8
Be -8,5
 
Lab  01/09/21
Hb/l/t : 10,4/14,2/245
Mcv/mch/mchc :
90/30/33
Diftel : 0/1/0/95/3/1
Pt/aptt : 0,,97/1,08
d-dimer : 2220
sgot/sgpt : 6/12
na/k/cl/ca:
145/6/119/7,8
ur/cr : 90/119

K4B1 K4B3 K4B4 K4B5

Dpjp : dr. Cut Mela DPJP : dr. Desi Salwani, DPJP : dr. M Riswan, Dpjp : dr. Cut Mela
Yunita Sp.PD KGH Sp. PD-KGH SpPD-KHOM Yunita Sp.PD KGH
Cow : dr. Saddam Emir COW : dr. Irwandi COW: dr. M Firdaus Kamil Cow : dr. Saddam Emir
Ruangan: dr. Thaifur
Pratama Ruangan : dr. Marcel Pratama
Dr. Ruangan : dr. Dr. Ruangan : dr.
Suhaimi Suhaimi
raber : bedah urologi Raber: GEH

Nama :Samsul Bahri Nama : Adam Nama : Ibrahim bin Nama : Selamat
Tgl lahir: 11/7/1960, 61 NO. CM : 1-28-44-07 Abdussalam Pasaribu
tahun TL : 07/10/1929 NO. CM : 1-27—91-17 CM : 1284890
Tgl masuk: 27/8/2021 Tgl Masuk : 01/09/21 TL : 11/03/1963 TL : 03-10-1952
No.CM : 1011174 Tgl Masuk : 03/09/21

Ass/ Ass/ Ass/ Ass/

Penurunan kesadaran 1.Rhabdomiosarkoma 1.penurunan kesadaran ec 1 1.penurunan kesadaran
(perbaikan) ec dd : 2.AKI stage III prerenal dd Ec dd
- sepsis dd Acute on CKD -syok sepsis - SDA
-imbalance elektrolit
- imbalance elektrolit 3.Pneumonia -imbalance elektrolit
-sepsis
- SDA 4.Efusi pleura dextra ec -krisis hiperglikemi Stroke
Sepsis ec dd: dd (perbaikan)
- abses renal dekstra -Pleuropneumonia 2.Syok sepsis ec dd/ 2.PSMBA Ec dd
- pneumonia -Pleuritis TB -pneumoni -ulkus gaster
PSMBA ec dd: -Metastase proses -urosepsis - ulkus duodenum
- ulkus gaster 5.Geriatri problem 3.Pneumonia CAP dd/ 3.Anemia sedang NN e dd
perdarahan
- ulkus duodenum   infeksi paru spesifik
Penyakot kronik
- keganasa Th/ 4. Krisis hiperglikemi 4.Hipertensi stage ll 
post PAD renal dextra hari -Bed Rest ec/dd Th/
ke 4 -NGT- diet sonde -KAD Bedrest
Pneumonia AP post infeksi -kateter folley -HHS (perbaikan) O2 nasal canul k/p
paru spesifik -Diet ginjal 1700 kkal/24 5. Ca. Buli prokemoterapi IVFD RL 20 tpm
Anemia berat ec dd : jam siklus 2 dengan reg. Diet sonde 6x200 cc/hari
- perdarahan -IVFD NaCL 0,9 % 20 Gem+c15 Drip omeprazole 80
-peny. Kronis -gtt/i 6. Hematuri ec dd mg/jam
DM tipe II nw on therapy -Iv. Meropenem  1g/12 -Ca buli IV ceftriaxone 2 g/24jam
-Hiponatremia hipoosmolar jam -trombositopeni Sucraalfat syr 3xC1
hipovolemik -iv. Omeprazole 40 mg/ Amlodipine 1x10 mg
-Status hipo koagulasi 12 jam 7. Trombositopeni ec dd Valsartan 1x80 mg
-iv. ondansetron 4 mg/ 12 -induce kemotrapi  
Th / jam -perdarahan
Bed rest -Bicnat 3 x 500 mg -consumptive coagulopaty Lab 4/9/21
Diet MB 1700kkal + putih -N-acetyl sistein 3 x 200 8. AKI stage III dd acute Hb/L/T : 7,0/5,0/104
telur/hari mg on CKD Diftel :1/0/1/77/12/9
Pt/Aptt : 1,18/1,2
IVFD NaCl 0.9% 20 gtt/i -kalitake 3 x 1 sach  
Na/K/Cl : 146/2,60/107
Drip albumin 25% 1 fls/h -Lactulac syr 1 x 30 cc Th/ Ur/Cr 86/2,50
(h2) -Allopurinol 1 x 100 mg -O2 NRM 15 l/i Albumin 2,10
IV meropenem 1gr / 8 jam   -NGT
IV Toursamin 500mg/ Lab 3/9/21 -IVFD Nacl 0,9% 20 tpm
8jam -drip norephinefrin mulai
IV Lansoprazol 30 mg / 24 Hb/ht/e/l 9,6/29/3,7/30,6 0,05 meq/kgbb
jam Mcv/mch/mchc 79/26/33 -IV cefepime 1 gr/8k
Drip PCT 1 gr / 8 jam k/p Diftel 0/0/0/93/3/4 -IV omeprazole 40 mg/12j
IV Metoclopramid 10 -Drip novarapid 10 iu
mg/8jam MDT: Leukositosis dalam 50 cc Nacl 0,9%
Lantus 0-0-0-16 sc D-dimer : 8600 (tunda)
Flumucyl 200 gr / 8 jam PT/APTT : 1,09/1,14 -Curcuma 3x1 tab
Sucralfat syr C2 / 8 jam Urinalisa -Fluimucyl 2x200
Apidra 6-6-6 Darah/Lekosit/Sel ragi (+) -Vit K 1 amp/8j
Herbesser 100 mg/24 jam Nitrit (-) -Drip parasetamol 1gr/8j
Eperison 50mg/12 jam Na/K/Cl/Ca -Mupirocine Zalf ue a/r
Mecobalamin 139/6,10/110/7,7 inguinal
500mg/12jam   -Sc insulin carbocounting
Lab 2/9/21 3-3-3-3-3-3
P/ HIV/Anti HCV/HbsAg (-)
Susul hasil Kultur darah + Na/K/Cl : 137/6,9/108 P/
STAB AU : 14,1 -Balance cairan
Susul hasil kultur pus + Na/K/Cl : 136/6,5/110 -Transfusi tc 10 kolf
STAB   -cek ulang dr, ur, cr,
Cek DR, albumin, ur/cr, Lab 01/09/21 elektrolit
elektrolit, kalium Hb/Ht/L/T :
Kgdp/hari 11,4/35/37,7/356 Lab 3/9/21
Cek PT/APTT, HBSAG, MCV/MCH/MCHC : PT/APTT: 15,6/37,3
anti HCV, LFT 79/26/33 Ddimer: 4240
Ct scan abdomen kontras Diftel : 0/0/1/94/2/3
dan non kontras- post PAD Prot Tot/Alb : 5/2,8 Lab 2/9/21
Transfusi PRC 1 kulf/hari Na/K/Cl/ Ca : Hb/Ht/eri/tromb/leu
s.d Hb>10 mg/dl 134/7,5/105/7,5 7,5/21/2,9/4/28,4
Ur/Cr : 134/7,4 MCV/MCH/MCHC/RDW
Lab 3/9/2021 72/26/36/14,7
K/Ca/Cl/Na Diftel: 0/0/0/96/3/1
4,10/8,1/107/133 MDT: menyusul hasil
Diftel:1/0/0/7/23/5
MCV/MCH/MCHC Lab 1/9/21
80/26/33 Hb/ht/eri/tromb/leu
TDW/RDW:8,4/18,4 10,3/29/4,0/5/31,2
LED:59 MCV/MCH/MCHC/RDW
Hb/Ht/erit/Trom/Leuko 73/26/36/14,6
4,6/14/1,7/531/14,3 Diftel: 0/0/0/96/3/1
Albumin:1,79 pH: 7,404
Kr/Ur: 0,89/69 pCO2: 36,00
pO2: 58
Lab 01/08/21 Bikarbonat: 22,7
Hb/Ht/erit/Trom/Leuko Total CO2: 23,8
4,6/16/1,7/531/14,3 BE: -1,0
MCV/MCH/MCHC Saturasi O2: 84,2
80/26/33 Albumin: 2,7
TDW/RDW:18,4/8,8 Ca: 7,7
LED: 59 GDS: 952
Diftel: 1/0/0/71/23/5 Ur/cr: 172/3,1
Albumin : 1,79 Na/K/Cl
Ca/ Ur/ Kr : 8,1/69/0,89 130/3,3/92
Na/K/Cl : 133/4,10/107

Lab 30/8/2021
Hb: 9,3
Ht: 28
Eritrosit: 3,5
Trombosit: 569
Leukosit: 18,1
MCV: 79
MCH: 27
RDW: 18,3
DIFTELL 1/1/0/78/14/6

Lab 31/8/21
Analisa gas darah
Ph/pco2/po2/hco3/total
co2/BE/saturasi o2
7,551/24,00/62/21,2/22,0/0,
5/92,9

Lab 30/8/2021
Hb: 7,4
Ht: 23
Eritrosit: 2,9
Trombosit: 520
Leukosit: 24,7
MCV: 81
MCH: 26
RDW: 18,9
LED: 130
Hitung Jenis:
0/0/0/83/10/7Lab
27/8/2021
Hb/Ht/L/T 7,5/23/35,1/711
MCV/MCH/MCHC
80/26/33
DIFTELL 0/1/0/87/6/6
PT/APTT 1.17/1.74
FIBRINOGEN 941
SGOT/SGPT 19/15
Alb 2.7
Ca 9.3
Gds 209
Ur/cr 50/1.2
Na/K/Cl 130/4.9/100

K5B2 K5B3 K5B4

DPJP : dr. M. Fuad, SpPD- DPJP : Dr. dr. M. Diah, SpPD- DPJP : dr. M. Fuad, SpPD-
KHOM KKV KHOM
COW : dr. Fadhilla COW : dr. Saddam COW : dr. Fadhilla
Ruangan : dr. Julia Ruangan : dr. Rina Ruangan : dr. Julia

Nama : Zulkarnaen bin Ismail Nama : Sulaiman M nur Nama: Azli bin M. Taleb
CM : 1-28-47-84 CM : 1279484 CM: 1-28-29-21
TL : 05/05/1969 (52 th) TL : 06/04/1976 (45 th) TL: 10/11/1974
Ass/ Ass/ Ass/
1. Anemia berat makrositer ec dd : 1. CKD stage V on HD regular 1. Multipel myeloma
2. MDS dengan edema paru akut(Perbaikan) 2. AKI Stage I due to multiple
3. Def. Asam folat
ec.dd 1.PNC myeloma
4. Def. B 12
5. DD 1) ALL 2)CML 2. Ht stage I 3. Hipokalemia ringan ec dd
3. Anemia sedang NN ec PGK - low intake
4. Diare akut tanpa - renal loss
Th/
- Bed Rest dehidrasi(Perbaikan) ec dd
-Diet MB 1700 kkal/hari -infeksi virus Th/
-IVFD RL 20 gtt/i -intoleransi makanan Bedrest
-IV. Ceftriaxone 1 gram/12 jam -infeksi bakteri Diet MII 1700 kkal/hari
-iv. Omeprazole 40 mg 5.Sepsis ec.dd 1.Pneunomia IVFD NaCl 0.9% 20 gtts
-iv. Mecobalamin 500 mg/12 jam
2.Urosepsis Transfusi PRC s.d hb>10g/dl
iv. Dexamethasone 10 mg/h
Asam folat 3 x 1 tablet 6.Pneunomia dd infeksi paru (sementara hari ini cukup)
spesifik Transfusi TC 1 hari ini 10 (jika
P/ ada)
BMP Th/ IVFD Aminopurin 1 fls/24j
Susul hasil MDT Bedrest Asam traneksamat 500mg/8 jam
Leukimia immunolypy Diet ginjal 1700 kkal/hari+60 IV furosemide 20 mg/12jam
gr/hari IV Omeprazole 40 mg/12 jam
Lab 3/9/21 Bicnat 2x1
Urinalisa : dbn O2 nasal kanul 2-4 L/i
Iv Linezolid 600mg/12 jam(3/9/21) Allopurinol 1x10mg
IV furosemide 20 mg/8 jam Cetirizin 1x10mg
Lab 02/09/21 IV Omeprazole 40 mg/12 jam MST 10 g/12 jam
Hb/Ht/L/T : 6,2/4/0,4/293 IV Ondansetron 4 mg/8 jam Kaltrofen supp II (K/P)
MCV/ MCH/MCHC : Drip Heparin 500 unit/jam
105/168/159
Attapulgit 2 tab extra 1 tab tiap P/
Diftel : 0/0/0/22/67/11 Pantau perdarahan dan
PT/APTT : 1,06/1,1 BAB cair max 12 tab
Asam folat 2x0,4 mg hemodinamik
Bil.tot/bil dir/bil indir :
0,82/0,3/0,52 Lenal Ace 2x169 Kemo jika hb>10g/dl,
SGOT/SGPT : 13/13 Zinc 1x20 mg tromb>100.000
Alb : 2,90 Codein 1x10mg (malam)
Na/K/Cl/Cl : 140/4,5/105/2,9 Hemodialisa (rabu,sabtu) Lab  3/9/21
Hb/Ht/L/T : 9,9/3,4/30.000
MCV/ MCH/MCHC : 80/28/36
P/
Diftel : 0/1/0/45/45/9
Kultur darah + STAB (susul hasil)
Pantau Urine output/hari
Lab  1/9/21
Kultur Urine + kultur darah
Hb/Ht/E/T/L : 7,7/22/2,7/35/3,5
Balance cairan
MCV/ MCH/MCHC : 81/28/35
Cek
Diftel : 1/1/0/47/46/5
PT/APTT,Ddimer,Fibrinogen/3hari
PT/APTT : 14,70/51,40
Cek ur/cr,albumin,calsium
Lab 30/08/21
PT/APTT : 1,1/1,53
Lab 01/09/2021 Albumin b
Hb/ Ht/ E/L/ T : Ca/ ca/ Ur/Kr : 2,70/10,2/80/1,70
7,7/23/3,1/25,1/188
MCV/ MCH/MCHC: 74/25/34 Urinalisa 30/08/21
Diftel : 15/1/0/69/7/8 Warna : kuning muda
Alb : 2,70 Kejernihan : keruh
Na/K/Cl/Ca : 143/2,80/104/7,6 Leukosit : positif
Ur/Cr : 87/8,20 Protein : positif (+1)
PT/APTT: 13,50/39 Darah : positif
Bakteri : positif
Lab 30/08/21 Sedimen :
Hb/ Ht/ E/L/ T : Leukosit : 5-10
8,4/25/3,5/29,3/271 Eritrosit : 2-5
MCV/ MCH/MCHC: 72/24/34 Epitel : 0-1
Diftel : 24/1/0/55/8/12
Alb : 2,88 Lab 29/08/21
Na/K/Cl/Ca : 142/3.40/104/7,7 Hb/ Ht/ L/ T : 9/5,2/29
Ur/Cr : 133/11,35 MCV/ MCH/MCHC  82/29/35
PT/APTT: 14,20/36,80 Diftel : 1/1/0/56/34/8
 Alb : 2,5
Lab 27/08/21 Na/K/Cl/Ca : 136/3,40/108/12,1
Hb/ Ht/ L/ T : 6,9/ 21/25,2/294 Ur/Cr: 74/1,80
MCV/ MCH/MCHC 69/23/34 SGOT/SGPT: 73/51
Diftel : 18/1/0/63/10/8 BilTot/BilDir/BilIndr
Alb : 3,27 0,70/0,32/0,38
Na/K/Cl/Ca : 135/4,2/100

Lab 24/08/2021
Hb/L/Tr : 8,2/28,2/435
Diftel : 18/1/0/66/9/6
MCV/MCH/MCHC: 69/23/34
Albumin 3,6
Kgds 120
Ur/cr: 95/11,3
Na/K/Cl/Ca: 141/4,0/110/8,3

Analisa gas darah

pH 7,496
pCO2 27,80
pO2 49
bikarbonat (HCO3) 21,6
total CO2 22,5
kelebihan basa BE -0,2
saturasi O2 87,2

MINA 2

Raber : dr. Desi Maghfirah, Sp.PD

COW : dr. Andri BK
Divisi: dr. Viencensia

Nama: Ny. Fadhilah Sufianti

CM: 2109010418
TL: 24/4/1976
 
Ass/
1. Acute on CKD dd AKI STAGE 3
2. Hiperkalemie sedang
3. Hipertensi stage 2
4. Observasi seizure tipe general onset klonik ec post stroke

P/
Diet ginjal 1700. Kkal/hari + protein 0,5 - 0,8/KG BB/hari
IV Novorapid 10 unit bolus extra
Inj glukosa 1 ampule
Nebule ventoin 1resp extra
Kalikate 3x1 sache
Fumucyl 3x200mgbakane cairan seimbang
Usg urologi
Cek urinalisa, albumin, kalsium, asa murat, HbsA, anti HCV, HIV
Cek ulang elektrolit post koreksi
Cek ur, cr, eektrolit per 3 hari

Passien acc awat bersama dan aakan diikuti divisi IPD GH

Lab 1/9/2021

Hb/ Ht//L/ T : 9,9/29/12,8/444

MCV/MCH/MCHC: 78/27/34
Diftel : 2/1/0/70/21/6
GDS : 142
Ur/Cr : 96/ 7,3
Na/K/Cl : 144/6,4/144