K2B4

K2B3 K3B5
DPJP: Islamuddin, Sp.PD Dpjp: Prof. Dr. dr. Kurnia Fitri Jamil, DPJP : dr. Desi Maghfirah Sp.PD
COW: dr. Andri BK Sp.PD-KPTI COW: dr. Irhash Hasballah
Ruangan: dr. Ira COW: dr. Abdullah Hambali Ruangan: dr. Arif rahman
Ruangan: dr. Erick Sebastian
Nama: Azhari bin abdul manaf Nama: Radiman Nama: M. Nasir Suib
TL: 201090 No cm: 1300444 CM: 1262933
CM: 1300285 TL: 17/08/1944 TL: 14/04/1967
TM: 17/08/1994
Ass/ Ass/ Ass/
1. Acute on CKD dd AKI stage III Post 1.CKD stage V ec dd: 1. Efusi pleura dextra ec dd/
renal -HN 1). Pleuritis pneumonia
2. Anemia berat makrositer ec dd -PGOI 2). Pleuritis TB
1. Perdarahan -PNC 3). Malignancy paru
2. Def. Asam folat 2. Hipertensi stage I 2. CKD stage V on HD reguler ec dd
3. Def. Vit. B12 3. CAP dd infeksi paru spesifik 1. DN
4. Hematuria ec dd 4. Anemia sedang HM ec dd: 2. HN
1. Tumor buli -penyakit kronis 3. PNC
2. Vesikolithiasis -def.besi 3. HT stage II
3. ISK 5. ISK 4. Katarak grade II OD
4. ISK 5. Neuropati DM
5. Hiperkalemia ringan TH/
Bedrest Th/
Th/ Diet ginjal 1700 Kkal + Protein 0,8 - Bedrest
-Bedrest gram/kgbb/hari - Diet Ginjal 1700 kkal/hari
- O2 2-4 Lpm via NC Drip Levofloxacin 500mg/24jam - IV Ceftriaxone 1 gr/8 jam
-Diet ginjal 1700kkal/hari + protein 0,6 Iv Furosemid 20mg/12jam - Candesartan 8mg/24 jam
gr/kgbb/hari Iv Omeprazol 40mg/12jam - PO amlodipin 1 x 10 mg
-IVFD NaCl 0,9% 10 tpm Po Amlodipin 10mg tab 1x1 - As. Folat 1x1
-IV Ceftriaxone 1g/8 jam Po Bisoprolol 5mg tab 1x1 - Lenal Ace 1x169/12 jam
-IV Omeprazole 40mg/24jam Po Asam folat tab 2x1 - Ambroxol 3x1
- IV Kalnex 1 amp/8 jam Po Fluimucyl 200mg tab 3x1 - Nitrocaf 2x ½ tab
- IV Vit Kn amp/8 jam - HD
-Lenal Ace 2x169 mg Lab (20/02/22)
- Kalitake /8 jam Hb/leu/tromb: 8.1/13.49/316 P/
- As. Folat 2x1 Mcv/mch/mchc: 74/26/35
Diftell: 0/0/0/73/15/12 Lab 19-02-2022
P/ PT/APTT: 1.2/1.2 Hb/L/T: 10,2/5,03/122
HIV R1: non reaktif MCV/MCH/MCHC: 86/30/35
19/2/2022 Anti HCV/HBsAg: negatif/non reaktif Diftel: 7/0/0/59/23/11
Hb/L/T : 5,5/15,07/256 Albumin: 3.4 Na/K/Cl : 142/2,80/107
MCV/MCH/MCHC : 93/30/32 GDS: 79 Ca : 10,1
Diftel : 1/0/0/81/7/11 Ur/Cr: 212/14.40 Ur/Cr: 48/4,40
HIV : Non reaktif Na/K/Cl/Ca: 146/4.2/105/4.6
Anti HCV : Negatif Ph/PCO2/PO2/HCO3/BE: 7.3/22/147/12.5/- Lab 15-02-2022
HBsAg : Non rekatif 10.8 Hb/L/T: 9,6/3,25/127
Albumin : 3,2 MCV/MCH/MCHC: 88/31/35
Ca : 7,5 P/ Diftel: 5/0/0/56/31/8
Ur/Cr : 450/20,00 Balance cairan Ur/Cr : 94/5,80
Na/K/Cl : 142/5,50/104 Urinalisa Na/K/Cl : 144/380/107
Ca : 10,2

Lab 18/02/2022 Analisa cairan pleura

Hb/L/T : 3,5/20,70/259 Warna : kuning
MCV/MCH/MCHC : 112/34/30 Kejernihan : keruh
Diftel : 1/0/0/79/10/10 Bekuan : negative
HBsAg : Non reaktif PMN sel : 13
GDS; 116 Mn sel 87
Ur/Cr : 403/18,30 Leukosit 845
Na/K/Cl : 147/5,80/102 Total protein : 4,5
Albumin 1,8
Glukosaa 181