Management Sepsis Terkini

PENEGAKAN DIAGNOSA SEPSIS

Dr. Franciscus Ginting, Sp.PD – KPTI

 Outline
• Introduction
• Pathogenesis of sepsis
• SIRS, SOFA Score & qSOFA
• Cases
 I. Introduction

• Sepsis and septic shock  high rates of morbidity and mortality.

• United States, incidence of sepsis is 3 cases per 1000 population
with mortality of 28.6% (215,000 deaths from 750,000 patients
diagnosed) per year.
• Septicemia was listed as the 10th leading cause of death in the
United States in 2007.
• Early and appropriate antimicrobial therapy the predominant factor
for reducing mortality
• DATA FROM ADAM MALIK HOSPITAL (2016) : mortality rate 73%
(Ginting F, ICID 2018, Vienna)
 Definisi lama Sepsis
1991 : Sindrom respon inflamasi sistemik (SIRS) host terhadap infeksi
2001 : Kriteria diagnostik sepsis

Infeksi+ ≥ 2 gejala SIRS

 suhu >38ºC atau <36 ºC

 denyut jantung ≥ .90/men
 pernapasan >20x/menit
 PaCO2 <32 mmHg (4.3kPa)
 Leukosit >12000/mm3 atau <4000/mm3 atau >10% immature bands
S

Sepsis is now defined as “a life-threatening organ dysfunction

2
causedby a dysregulated host response to infection” (Singer et al., 2016)
0

1 …the host response resulting in organ failure from an infection is

6 stressed, while the inflammation stage known as SIRS in sepsis-1
and -2 has been removed
  Sepsis as infection and 2 or
more SIRS is now just an
infection
 Severe sepsis is now sepsis
 Septic Shock: Subset of
sepsis with circulatory and
cellular/metabolic
dysfunction associated with
higher risk of mortality : Blood
lactate > 2 mmol/L despite volume
resuscitation; Hypotension that persists
after fluid resuscitation and requires
vasopressors

JAMA. 2016;315(8):801-810. doi:10.1001/jama.2016.0287

II. PATHOGENESIS of SEPSIS
Patofisiologi Sepsis

 ‘Final common
for death from infection
• Hotchkiss 2013
 Infection
Patofisiologi SEPSIS

Inflammatory Endothelial
Vasodilation
Mediators Dysfunction

Hypotension Microvascular Plugging Vasoconstriction Edema

Maldistribution of Microvascular Blood Flow

Ischemia

Pathophysiology of Sepsis- Cell Death

Induced Ischemic Organ
Injury
Organ Dysfunction
R,perempuan, 61 tahun

 KU: penurunan kesadaran

 Hal ini dialami secara perlahan lahan sejak 1 bulan yang lalu memberat dalam 2 hari
ini. Awalnya pasien masih bisa dipanggil dan membuka mata namun 2 hari ini pasien
sudah cenderung tidur. Riw kejang tidak ada, riw muntah menyembur tidak ada.
Kelemahan tungkai tidak ada. Demam dijumpai 2 hari ini. Pasien pernah rawat
sebelumnya dengan diagnosa NHL
 Sesak nafas dialami 1 hari ini. Demam dijumpai 2 hari ini. Batuk dijumpai 1 minggu ini
namun dahak sulit keluar.
 Riwayat pemasangan kateter dijumpai, riw urin keruh tidak ada
 Luka di bokong dijumpai 2 minggu ini
 RPT: DM (-) HT (-), NHL (+) RPO: kemoterapi
Pemeriksaan fisik
 Sens: somnolen
 TD: 90/50
 HR: 102x/menit
 RR: 28 x/menit
 T: 38,3
 Terpasang O2 2-4 liter via nasal canule
 Mata:
 Anemis (-/-), ikterik (-/-), pupil isokor
 Thorax:
 SP: bronkial
 ST: ronkhi di seluruh lapangan paru
 Abdomen: simetris, soepel, H/L/R ttb, peristaltik N
 Posterior: dijumpai ulkus dengan diameter 3-5 cm, pus (-)
 Ekstremitas: lateralisasi (-)
Jenis Satuan Hasil
Pemeriksaan AGDA Satu Hasil Rujukan
an
Hb g/dl 8,7
Leukosit /μl 3650 pH 7,370 7,35 –
7,45
Ht % 23
pCO2 mm 26 38 – 42
Trombosit /μl 125.000 Hg
pO2 mm 140 85 -100
Jenis Satuan Hasil Hg
Pemeriksaan
HCO3 U/L 12,7 22 – 26
Ureum mg/dL 68
Total CO2 U/L 13,4 19 – 25
Kreatinin mg/dL 3,4
BE U/L -8,9 -2 - +2
Natrium mEq/L 138
Saturasi % 99,0 95 - 100
Kalium mEq/L 3,8 O2

Klorida mEq/L 101

 III.1
Sequential Organ Failure Assessment
(SOFA) Score
 Sequential Organ Failure Assessment (SOFA) Score

The SOFA score predicts mortality risk for patients in the intensive care unit
based on lab results and clinical data on the degree of dysfunction of 6 organ
systems.
• The score is calculated at admission and every 24 hours until discharge
• The SOFA score is not designed to influence medical management
• An initial SOFA score of < 9 predicted a mortality of < 33%, SOFA > 11 predicted
mortality of 95%
• Adam Malik Hospital (2018) SOFA score >7, kematian >>(Andrew, Ginting F KONAS PETRI
2019)
 5
4

S
1
S 6
C
2
0
1 3
6 2
SOFA SCORE
Variable
0 1 2 3 4
Respiratory :PaO2/FiO2, > 400 ≤400 ≤300 ≤ 200 ≤ 100
mmHG
Coagulation : Platelet x 103μl >150 ≤150 ≤ 100 ≤50 ≤20
Liver : Bilirubin, mg/dl <1,2 1,2 – 1,9 2,0 – 5,9 6.0 – 11,9 >12
Cardiovascular : Hypotension No MAP : <70 DOP ≤ 5 or Do ( DOP >5, Epi ≤ 0,1, Dop >15,
hypotension mmHg any dose) or Nor - epi ≤ 0,1 Epi >0,1 or
Nor – Epi
>0,1
Central Nervous System : 15 13 – 14 10 - 12 6-9 <6
GCS Scale
Renal :Creatinine/Urine <1,2 1,2 – 1,9 2.0 – 3,4 3,5 – 4,9 or UOP : >5 .0 or
 Why to Use
The SOFA score can be used to determine the level of organ dysfunction and
mortality risk in ICU patients.

When to Use
• The SOFA can be used on all patients who are admitted to an ICU.
• It is not clear whether the SOFA is reliable for patients who were transferred from
another ICU.

Instructions
Calculate the SOFA score using the worst value for each variable in the preceding
24-hour period.
“the major gap is the difficulty to apply current sepsis case definitions, especially in LMIC settings when
the main tests are not available”

“90% of cases with poor outcome in the Australian sepsis database, inadequate recognition was found
to be the most common feature”
The SOFA scoring system is useful in predicting the clinical outcomes of critically ill patients.
According to an observational study at an Intensive Care Unit (ICU) in Belgium the mortality
• least 50% when the score is increased regardless of initial score in the first 96 hours
• 27% to 35% if the score remains unchanged
• less than 27% if the score is reduced.
III.2.q SOFA
 SSC 2016

QSOFA
 The qSOFA
• a rapid, bedside clinical score to identify patients with suspected infection
who are at greater risk for poor outcomes.
• The primary outcome was in hospital mortality, and the secondary outcome
was an ICU length of stay of ≥ 3 days.
• The qSOFA was meant to replace the systemic inflammatory response
syndrome (SIRS) criteria.
• qSOFA has also been found to be poorly sensitive for the risk of death with
SIRS possibly better for screening
• Sepsis HAM Hospital 2018: 16,7% under diagnose (Maruli,Ginting F, KONAS PETRI 2019)

-Angus, Derek C.; Seymour, Christopher W.; Coopersmith, Craig M.; Deutschman, Clifford S.; Klompas,
Michael; Levy, Mitchell M
.; Martin, Gregory S.; Osborn, Tiffany M.; Rhee, Chanu. Williams JM, Greenslade JH, McKenzie JV, et al. -
SIRS, qSOFA and organ dysfunction: insights from a prospective database of emergency department patients
with infection. Chest 2017;151:586-596.
• The qSOFA score predicts mortality but does not diagnose sepsis
• no prospective studies have demonstrated that clinical decisions based
on the qSOFA lead to better patient outcomes.

The most recent Surviving Sepsis Campaign guidelines, published in March

2017, do not integrate the qSOFA into recommendations for screening or
diagnosis of sepsis.

A positive qSOFA score clinicians to further investigate for the presence of organ
dysfunction or increase the frequency of patient monitoring.

Emergency Medicine Practice • October 2018

 III.3.
SIRS compare to SOFA score in sepsis
 The SIRS Criteria definitions of sepsis
• are being replaced as they were found too many limitations;
• the "current use of 2 or more SIRS criteria to identify sepsis was unanimously considered
by the task force to be unhelpful.”

Audit pasien sepsis Tahun 2016 RSUP HAM

• SSC 2012: 2 SIRS + infected  Over diagnosed: 33,7%

• 78 data infection with SIRS < 2
• 75 data >2 SIRS without infection (Chronic disease)
• 30 data Increased Procalcitonin in CKD (Ginting F, submitted journal process)
• 124 data sepsis in resume medic only
Only 94 out of 142 cases ( 66,2 %) were
judged to meet the diagnosis criteria for
sepsis.

Out of the 94 patients, 77 ( 82%) were

appropriately classified for sepsis
severity.

19 patients (20%) met criteria for severe

sepsis/ septic shock.
 Among critically ill patients with suspected sepsis, the
predictive validity of the SOFA score for in- hospital mortality
was superior to that of the SIRS criteria (area under the
receiver operating characteristic curve 0.74 versus 0.64)

 SIRS, qSOFA and new sepsis definition

 Paul E. Marik, Abdalsamih M. Taeb

 Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA, USA
Correspondence to: Paul Marik, MD. Eastern Virginia Medical School, 825 Fairfax Av, Suite 410, Norfolk VA 23507, USA. Email:
marikpe@evms.edu. Provenance: This is an invited Editorial commissioned by the Section Editor Zhongheng Zhang (Department of
Emergency Medicine, Sir Run-Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China).
Comment on: Williams JM, Greenslade JH, McKenzie JV, et al. SIRS, qSOFA and organ dysfunction: insights from a prospective database of
emergency department patients with infection. Chest 2017;151:586-596.
 Submitted Feb 05, 2017. Accepted for publication Mar 06, 2017. doi: 10.21037/jtd.2017.03.125
View this article at: http://dx.doi.org/10.21037/jtd.2017.03.125
Evaluated the presence of SIRS criteria in 109,663
patients with infection and organ failure. In this study,
12% of patients were classified as having SIRS-negative
sepsis (i.e. <2 SIRS criteria)
Kaukonen KM, Bailey M, Pilcher D, et al. Systemic inflammatory response syndrome criteria in de ning severe sepsis. N Engl J
Med 2015;372:1629-38.

Over diagnose
 A new large retrospective cohort analysis among 184,875 patients in
182 Australian and New Zealand intensive care units (ICUs) found
SOFA score had superiority in prediction of in-hospital mortality but it
showed SIRS criteria has greater prognostic accuracy for in-hospital
mortality than qSOFA score

Raith EP, Udy AA, Bailey M, et al. Prognostic accuracy of the sofa score, sirs criteria, and qsofa score for in-hospital mortality among adults with
suspected infection admitted to the intensive care unit. JAMA 2017;317:290-300.
The discrimination of in-hospital mortality for SOFA (75.3% AUROC; 99% confidence interval (CI): 0.750–0.757) was significantly
higher than that of qSOFA (60.7% AUROC; 99% CI: 0.603– 0.611) or SIRS (58.9% AUROC; 99% CI: 0.585–0.593).

Of the study population, 90.1% (165,103 patients) had an increase in SOFA score from baseline to at least
two points; 86.7% (158,710 patients) met two or more SIRS criteria, and 54.4% (99,611 patients) had a qSOFA score
of at least two points .

In adults admitted to the ICU with suspected infection, an increase in SOFA score of at least two points had superior prognostic
accuracy for in-hospital mortality followed by qSOFA and finally SIRS criteria.
With SOFA score demonstrating significantly greater discrimination for in-hospital mortality, the authors highlight that this may
suggest that SIRS criteria and qSOFA may have limited utility in predicting mortality in an ICU setting .
• The definition of SIRS, although sensitive to detect sepsis, was rather unspecific.
• In addition, the SIRS criteria performed badly in identifying patients significant morbidity
and mortality.
• These issues led to a recent new consensus definition for sepsis and septic shock
• This international task force
o defined sepsis as ‘life-threatening organ dysfunction
o Using large datasets (>1 million patient records),
o increase in 2 points or more for a patient suspected to have infection using the
Sequential Organ Failure Assessment (SOFA) best predicted in-hospital mortality.
• The SOFA is well known within the intensive care community, but is not so well known
generally.
• The task force developed a simpler clinical screening tool that performed very well in
identifying adult patients with suspected infection who were likely to have poor
outcomes, which they termed ‘quick SOFA’ (qSOFA).
PPK SEPSIS PERMENKES 2017 - > SSC 2012
 MENGHITUNG RASIO PAO2/ FIO2

Perhitungan rasio PaO2 / FiO2 dilakukan untuk mengetahui status oksigenasi pasien.
• Rasio paO2 / FiO2 yang normal adalah > atau =300.
• Apabila rasio paO2 / FiO2 < 300 maka pasien mengalami acute lung injury ( ALI)
• Apabila rasio PaO2 / FiO2 < 200 maka pasien mengalami acute respiratory distress syndrome (ARDS)
Cara menghitung rasio paO2 / FiO2 pasien diatas adalah:
1. cari nilai FiO2: misal, pasien menggunakan O2: 3 l/mnt  FiO2 adalah : 33% atau 0,32
2. hasil AGDA didapat paO2 pasien diatas adalah 82 mmHg
3. masukan ke rumus berikut:
AO2 100% (l/mnt) FiO2
PaO2 / FiO2
82 / 0,3 = 273,3 Kanul nasal Sungkup O2
1 0,24 5-6 0,40
2 0,28 6-7 0,50
3 0,32 7-8 0,60
4 0,36 Sungkup reservoar

5 0,40 6 0,60
6 0,44 7 0,70
8>= 0,80
 qSOFA Score
qSOFASOFA SSC 2016
 STEP 1
Inflammation or Bacterial or viral?
infection?

• Leukocytosis : MCI, • CRP, Procalcitonin

CHF, Pancreatitis, (CKD?)
burn injury, post • Neutrophil/ limphocyt
operative? • Total eosinophil
• SIRS not cause by
infection
• Fever?
• SIRS correlation with
infection? Acute?
 STEP 2
• Sepsis (SSC 2016)
– Quick Sofa

The scoring/condition happened in acute condition and due to by infection

SOFA Score
Kasus Pasien
Sepsis
dr. Fransiscus Ginting SpPD, K-PTI
 Kasus 1
Tn E, Laki-laki 38 tahun
 Anamnesa
Sesak nafas dialami 2 hari. Sesak nafas tidak berhubungan
dengan aktivitas dan cuaca, disertai batuk.
Demam dialami sejak 2 hari, sepanjang hari .Penurunan kesadaran
terjadi sejak 2 hari ini. Tidak ada riwayat trauma atau kejang.
Pasien sudah berbaring sejak > 1 bulan ini karena tangan dan kaki
pasien mengalami kelemahan. Pasien juga tidak dapat diajak
berbicara lagi.
pasien baru mengetahui menderita HIV selama 2 minggu.
 Vital Sign

Sens : TD : 90/60 HR 104x/i RR : 24x/i T : 39

somnolen mmHg
 Pemeriksaan Fisik
Kepala : Konj palpebra anemis (-), sklera ikterik (-), oksigen terpasang
4 l/I nasal canul. NGT terpasang
Leher : TVJ R-2 Cm H20
Thorax : simetris, SF ki=ka. Sonor, SP: bronchial, ST : Ronchi basah
diseluruh lapangan paru
Abdomen : simetris, soepel, peristaltik N
Extremitas : oedema (-)
 Apakah ini sepsis?
1.Fokus infeksi : paru
2.Hasil scanning : Toxoplasma encephalopathy
3.Quick sofa score = 3 (>2)
• GCS : 5 ( <15)
• RR : 24 ( >22x/i)
• TD : 90/60 (<100)
1 1 1

Quick Sofa : 3
 Laboratorium
Hb : 9,6 AGDA :
PLT : 22.000 pH 7,46 IgG anti toxoplasma 157
WBC : 12.300 pCO2 : 21 IgM anti toxoplasma 2,72
Ureum : 75 pO2 : 167
Creatinin : 1,63 HCO3 : 14,9
Total Co2 : 15,5
Bilirubin total : 2,3
Base Excess : -6,9
SO2 : 100
Natrium : 130
Kalium 3,2
Chlorida 102
 Sofa score:
1. Kesadaran :

1
1 3
2. Tekanan darah

TD : 90/60 mmHg
MAP > 70
(score = 0)
Pernafasan
AO2 100% (l/mnt) FiO2
Kanul nasal Sungkup O2
1 0,24 5-6 0,40
2 0,28 6-7 0,50
3 0,32 7-8 0,60
4 0,36 Sungkup reservoar
5 0,40 6 0,60
6 0,44 7 0,70
8>= 0,80
167/0,36= 463
PO2 : 167 FiO2:0,36

0 1 2 3 4
>400 <400 >300 <200 <100
Trombosit : 22.000 ( score 3)
Bilirubin : 2,3 ( score 2)
pO2/FiO2 : AGDA pO2 167/FiO2 0,36= 463 ( score : 0)
Trombosit :22.000 ( score 3)
Bilirubin : 2,3 ( score 2)
MAP : 73 ( score 0)
GCS :5 ( score 4)
Creatinin : 1,63 ( score 1)
Total Score : 10
 DX
Sepsis ec pneumonia
Pneumonia HAP dd CAP
HIV stadium IV
Toxoplasma Encephalopathy
Kas us 2
Tn L, pria 54
tahun
 Anamnesa
Sesak nafas dialami sejak 1 hari sebelum rumah sakit. Sesak
nafas memberat dengan aktivitas disertai dengan batuk.
Pasien di diagnosa dengan acute lung oedema oleh dept
cardiologi. Demam dialami sejak 4 hari dirawat di CVCU.
Demam terjadi sepanjang hari .Pasien menggunakan
ventilator sejak berada di cvcu.
 Vital Sign

Sens : DPO TD : 90/60 HR 54 x/i RR : 16x/I T : 38,9

mmHg
terpasang
Dengan
ventilator
support
norepinefrin
 Pemeriksaan Fisik
Kepala : Konj palpebra anemis (-), sklera ikterik (-), terpasang
ventilator. FiO2 50%
Leher : TVJ R+3 Cm H20
Thorax : simetris, SF ki=ka. Sonor, SP: bronchial, ST : Ronchi basah
diseluruh lapangan paru
Abdomen : simetris, soepel, peristaltik N
Extremitas : oedema (-)
Diagnosa infeksi
Pneumonia HAP?
 ? ? ? ?

Quick Sofa : (sulit dinilai) untuk pasien rawat non ICU

RR : 20 x/I ( ventilator +)
Td : 100/80 (support norepinefrin)
Sens : DPO
 Laboratorium
Hb : 12,3 AGDA :
Natrium : 134
PLT : 206.000 pH 7,42 Kalium 3,2
WBC : 17.440 pCO2 : 32 Chlorida 107
Ureum : 137 pO2 : 87
Creatinin : 2,8 HCO3 : 20,8
Bilirubin total : 1,2 Total Co2 : 21,8
Base Excess : -2,9
SO2 : 97%
 SOFA SCORE
pO2/FiO2 : 87 / 0,5 = 174 ( score : 3)
Trombosit : 206000 ( score 0)
Bilirubin : 1,2 ( score 1)
MAP : support norepinefrin ( oleh karena penyakit jantung? Sepsis? )
GCS : sulit dinilai. Pasien DPO ( score ?)
Creatinin : 2,8 ( score 2)
Total Score : 6
 DX
Sepsis ec pneumonia VAP
Acute Lung Oedema
CAD 3 VD
DM tipe 2
 time
is my time
KASUS 3
 S, perempuan, 42 tahun
Anamnesis:
• Sesak nafas, dijumpai sejak 4 hari SMRS, sesak tidak berhubungan dengan aktivitas dan
cuaca
• Batuk dijumpai sesekali 3 minggu ini, dahak berwana kuning, riw batuk darah (-), penurunan
BB (-), keringatmalam (+), nyeri dada (-) demam (+) 3 hari SMRS.
• Mual muntah (-) mata kuning dijumpai 2 hari SMRS. Nyeri perut tidak dijumpai
• Riw sakit kuning sblmnya (-) riw alkohol (-)
• BAK nyeri (+) 2 hari ini setelah pemasangan kateter, pada kateter dijumpai BAK sedikit keruh.
Volume BAK 1 liter/hari
• BAB tidak ada keluhan
• Pasien merupakan pasien konsul dan dirawat oleh TS Bedah dengan Diagnosa Reynoud
Disease.
• RPT: DM (-) HT (-)
 Pemeriksaan Fisik
• Sens : CM
• Vital Sign:
– TD 90/60,
– HR: 107x/menit,
– RR 32x/menit (terpasang simple mask 6 l/menit)
– T: 37 C
• Mata: anemis (-/-), ikterik (+/+)
• Thorax:
– SP: bronkial
– ST: ronkhi (+/+) di lapangan atas kedua paru
• Abdomen: simetris, soepel, H/L/R ttb, peristaltik normal
• Ekstremitas:
– Sup: menghitam pada digiti III dan IV manus sinistra
– Inferior: edema (-/-)
Jenis Pemeriksaan Satuan Hasil Nilai Rujukan

Hb g/dl 11,2 12-16

Leukosit /μl 34.910 4,000-11,000
Ht % 33 39-54
Trombosit /μl 6000 150,000-450,000
MCV fL 87 81-99
MCH pg 29,2 27-31
MCHC g/dL 33,6 21-37
Neutrofil % 91,8 50-70
Limfosit % 4,0 20-40
Monosit % 3,6 2-8
Eosinofil % 0,3 1-3
Basofil % 0,3 0-1
Kesan : leukositosis, trombositopenia
 Kimia Klinik
Jenis Pemeriksaan Satuan Hasil Rujukan
Ginjal
Ureum mg/dL 96 15-40
Kreatinin mg/dL 5,02 0.6-1.1

AGDA Satuan Hasil Rujukan

pH 7,370 7,35 – 7,45

pCO2 mmHg 22 38 – 42
pO2 mmHg 159 85 -100
HCO3 U/L 12,7 22 – 26
Total CO2 U/L 13,4 19 – 25
BE U/L -10,8 -2 - +2
Saturasi O2 % 99,0 95 - 100

Hasil
Bil. Total 20,70
Bil Direk 11,00
 Apakah ini sepsis?

1. Adakah fokal infeksi?

Diagnosa Infeksi
• Pneumonia dd/ TB Paru
• ISK
• Cholangitis (??)
2. Berapa qSOFA?
TDS 90 mmHg  1 RR 32x/menit  1

TOTAL SCORE : 2
 SOFA score:
• AGDA  PaO2/FiO2 159/0,5= 318 (<300) 1
• Platelet  6000  4
• Bilirubin  20  4
• Cardiovaskular  MAP >70 0
• CNS  GCS >15  0
• Renal  Cr>5,00 4
• TOTAL SCORE 13
3. Berapa SOFA Score?

TOTAL SCORE 14
 Diagnosis
• Sepsis ec dd/ pneumonia dd/urosepsis dd/ cholangitis
• Reynoud Disease
 Treatment
• Cor NaCl 0,9% 30 cc/kgBB  1500 cc
• Kultur darah, sputum, urin
• Cek Procalcitonin  31,89
• Antibiotik  Drip meropenem 1 gram/8 jam dalam 100 cc
NaCl 0,9% habis dalam 3 jam
 Hasil Kultur
• Darah : tidak ada pertumbuhan bakteri
• Urin : tidak ada pertumbuhan bakteri
• Sputum:
– Dijumpai batang gram (-)
– Bakteri aerob: Acinetobacter baumanii
• Sensitive: Amikasin, Tigecyline
• Resisten: Ampicillin Sulbactam, ceftazidime, ceftriaxon, cefepime,
ciprofloxacin, gentamycin, meropenem, trimetropim/sulfametoxazole

NB: KULTUR SPUTUM DIAMBIL SETELAH PEMBERIAN ANTIBIOTIK

EVALUASI
 Hematologi Rutin
Jenis Pemeriksaan Satuan Hasil Nilai Rujukan

Hb g/dl 7,7 12-16

Leukosit /μl 13.550 4,000-11,000
Ht % 24 39-54
PERBAIKAN
Trombosit /μl 416.000 150,000-450,000
MCV fL 87 81-99
MCH pg 27,8 27-31
MCHC g/dL 31,8 21-37
Neutrofil % 75,2 50-70
Limfosit % 22,0 20-40
Monosit % 3,6 2-8
Eosinofil % 0,3 1-3
Basofil % 0,3 0-1
Kesan : leukositosis
 Hasil

Bil. Total 2,4 PERBAIKAN!

Anjuran: USG ABDOMEN  data tidak
ada
Bil Direk 1,9

SGOT 105

MENINGKAT
SGPT 131 Hasil Foto Thorax pasien menunjukkan
adanya TB paru dan diberikan OAT,
sehingga OAT mungkin penyebab
peningkatan SGOT dan SGPT