Mapping Aqsha 3

Senin, 14 Maret 2022

K3B1 K3B2 K3B3 K3B4 K3B5

DPJP : dr. Mahriani DPJP : dr. Desi Salwani, DPJP : dr. Alfi Syahrin, DPJP : dr. M Fuad, Sp,
Sylvawani, Sp PD-KR Sp PD, KGH Sp. PD PD-HOM
COW : dr Fadhilah COW : dr Irhash COW : dr. Muhsin COW : dr.Fadhila
Ruangan : dr. Imam Ruangan : dr. Fitrah Ruangan : dr. Novita Ruangan : dr.Imam

Nama : Eliana Binti Nama : Masyitah binti Nama: Resta Juli Nama: Atika yahya
Abu Bakar M. Rubi TL: 01/07/1997 TL: 10/11/1960
NRM : 0797661 NRM : 1294168 CM: 1301908 CM: 1300620
TL : 03/05/1972 TL : 10/10/1990 TM: 13/03/2022 TM: 11/03/2022
TM: TM: 24/02/2022

Ass/ Ass/ Ass/ Ass/

1. Sepsis ec dd 1). 1. CKD stage V On HD 1. Jaundice ec dd - vomitus ec induce by
Selulitis ar cturis sinistra 2. post repair CAPD 1.) Related chemotherapy
2. Selulitis Cruris 3. efusi pleura bilateral ec tirotoksikosis - NHL stadium III B post
3. AKI stage III dd acute dd 1). Renal failure, 2.) Hepatitis autoimun kemoterapi siklus ke I
on CKD 2).shunt difragma 3). 3.) Cholelithiasis - Febril neutropenia
3. DM tipe II obese Malignancy 4). CHF 2. Status hipokoagulasi ec
grade II unwell controled 4. Anemia sedang NN ec dd/ Th/
PGK dd 1). Perdarahan. 2) 1.) Liver disease - Bedrest
Th/ PGK 2.) DIC - Diet DM 1700
Bedrest 3.Grave disease dengan kkal/hari
Diet DM 1700 kkal/hari Th/ impending tiroid storm - IV Omeprazole 40
IVFD NaCl 0,9 % 20 - 4. hipoalbuminemia berat mg/24 jam
gtt/i ec dd/ - IV Ondancetron 4 mg/8
SC Lantus 0-0-0-10 1. liver disease jam
SC apidra 8-8-8 unit P/ 2. Low intake - Drip levofloksasin 500
IV ceftriaxone 2gr/24jam - pantau cairan pleura 3. Renal loss mg/24 jam
IV Omeprazole - hold dan evaluasi CAPD 5.Hipokalemia Berat ec dd/ - SC leucogen iural extra
40mg/12jam 2-3 bulan 1. related tirotoksikosis (ANC <1500)
IV ondancetron Lab 13/3/2022 2.GI loss - Paracetamol 500 mg/8
4mg/8jam Hb/Ht/E/L/T: jam
Fluimucil 200 mg/8 jam 10,3/30/3,6/11,4/188 Th/ - Sucralfat syr CII/8 jam
Clindamicin 300mg/8 MCH/MCHC/MCV: Bedrest
jam 29/35/83 IVFD NaCl 0,9% 20 tpm P/
Bicnat 500 mg/8 jam MPV : 9.7 IV omeprazole - Cek Dr post koreksi
Heparin 5000/12 jam PDW : 10,2 40mg/24jam ANC
Diftel : 3/0/0/85/7/5 Iv vit k 1amp/8jam
P/ Cl : 101 Drip albuminar 25% Lab 13/3/2022
- USG Doppler cruris Ur/Cr 93/6 1fls/hari Hb/Ht/E/L/T:
dextra 23/03/2022 GDS 80 Drip KCL 1fls dalam nacl 10,4/30/3,9/0,83/211
- susul USG urologi Na/K/Ca/Mg 0,9% 10 tpm MCH/MCHC/MCV:
(11/03/2022) 135/4,2/8,7/1,9 Propanolol 3x10mg 27/35/76
- KGDP/ hari Albumin 2,5 Ksr 2x600mg RDW : 12,6
- elektrolit Ur/Cr /3 hari Tyrozol 2x10mg MPV : 9,6
- PT/APTT, Lab 11/3/2022 Curcuma 3x1 PDW : 10,2
fibrinogen /3 hari Hb/Ht/E/L/T: IV Aminofusin Hepar 1 Diftel: 0/0/0/23/61/16
8,5/24/2,9/10,92/165 fls/24 jam
Lab 12/3/2022 MCH/MCHC/MCV: N Acetilcysteine 200 mg/8 Lab 12/3/2022
Ur/Cr : 37/0,60 29/35/83 jam Hb/Ht/E/L/T:
Na/K/Cl :133/4,00/103 RDW : 15,4 10,5/30/3,9/1,72/284
Lab 10/3/2022 MPV : 9,5 P/ MCH/MCHC/MCV:
H/L/T: 12,7/11,36/537 PDW : 9,4 Tf FFP 500cc 27/35/76
MCV/MCH/MCHC : Diftel: 2/0/0/88/6/4 Urinalisa RDW : 12,6
77/27/35 Lab 8/3/2022 Usg abdomen (hari ini) MPV : 9,1
Diftel : 0/0/0/85/10/5 Hb/Ht/E/L/T: EKG PDW : 9,6
PT/APTT : 1,04/1,0 9,5/27/3,3/9,37 Konsul GEH, EMD Diftel : 1/2/0/71/22/4
Albumin : 2,70 MCH/MCHC/MCV: Cek Mg, alp, gamma GT
GDS : 180 29/36/81 Lab 13/02/20222 Lab 11/3/2022
Ur/Cr : 253/4,2 Diftel: 1/0/0/82/9/8 Hb/l/tr: 10,5/.9,76/227 Hb/Ht/E/L/T:
Na/K/Cl : 122/5,3/91 GDS : 93 MCV/MCH/MCHC: 11,2/ 33/ 4,3/ 2,09/ 392
Ca : 7,5 Ca/Mg : 7,4/1,0 74/28/37 MCH/MCHC/MCV:
Ur/Cr: 104/6 DIFTEL: 2/0/1/71/17/9 26/34/77
Analisa gas darah Na/K/Cl: 138/4,20/106 Pt/APTT: >6/5,4 RDW : 12,8
PH ; 7,461 DDMER: <100 MPV : 8,9

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 Mapping Aqsha 3
Senin, 14 Maret 2022

pCO2: 23,20 Lab 5/3/20 Anti hcv/hbsag: -/- Diftel: 2/3/0/71/22/2

pO2 ; 78 Hb/Ht/E/L/T: Sgot/sgpt: 285/135 PT/APTT : 14,10/33,50
HCO3 ; 16,7 8/22/2,8/5,19/130 Protein total: 4,10 D-dimer : 380
Total CO2 : 17,4 MCH/MCHC/MCV: Albumin/globulin: 2/2,10 Albumin : 3,70
BE : -5,0 29/37/79 Ur/cr: 21/0,3 Ca : 8,8
Saturasi O2 : 91,6 Diftel: 4/0/0/72/16/8 Na/k/cl/ca: 135/2,5/1 GDS : 139
PT/APTT: 14,50/36,70 Ur/Cr: 19/0,20
Fibrinogen: 363 Na/K/Cl: 132/3,60/103
D-dimer: >4000
Albumin: 2,70
Ca: 7,8
Ur/Cr: 106/6,50
Na/K/Cl: 139/4,20/107
Lab 2/3/2022
Hb/HT/E/L/T:
5,3/15/1,8/5,61/114
MCH/MCHC/MCV/
MPV/LED:
30/36/82/10,8/20
Diftel: 2/0/0/62/29/7
PT/APTT: 13,70/36,30
Albumin: 3,29
Ca: 8,4
Ur/Cr: 119/8,61
Na/K/Cl: 134/4,50/108

Lab 27/2/2022
Albumin 2,90
Lab 25/02/2022
Hb/Ht/E/L/T:
8,2/24/2,8/8,23/94
MCV/MCH/MCHC:
84/29/35
Diftel:3/0/1/87/6/3
Alb: 3,20
Ur/Cr: 97/8,70
Na/K/Cl/Ca:
141/6,20/106/8,7
Lab 24/02/22
HIV R1 Non-Reaktif
Anti HCV Negatif
HBsAg Non-Reaktif
Albumin:3,40
Na/K/Cl/Ca:
138/8,30/104/9,4

Lab 22/02/22
Hb/Ht/E/L/T:
8,5/24/2,8/10,49/168
MCV/MCH/MCHC:
85/30/36
Diftel:2/0/0/75/16/7
HbsAg: Non reaktif
GDS: 93
Ur/Cr: 165/13,61
Na/K/Cl: 143/7,60/104

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 Mapping Aqsha 3
Senin, 14 Maret 2022