MAPPING AQSA 2 Rabu PAGI (14 JUNI 2023)

K1B1 K1B2 K1B3 K1B4 K1B5

DPJP: Divisi KKV dr. DPJP PULMO DPJP: dr. Masralena DPJP: dr. Masra
Azhari Gani, Sp.PD Siregar, Sp.PD-KPTI Lena SpPD KPTI
COW: dr. Dwi Teguh Cow: dr. Teguh
Irawan Ruangan: dr. Ilham
Ruangan: dr. Ilham
Abdi
Nama: Mauliddin Bin Nama: Kasmadi Bin Nama: Abdullah
Jakfar Hasbi Hukum, 61 Tahun
CM: 1340602 CM: 1335404 CM: 1172000
TL: 25/07/1983 TL: 02/01/1993 TL: 08/08/1961
TM: 7/06/2023 TM: 11/06/2023 TM: 09/06/2023
Ass/ Ass/ Ass/
1. AF NVR 1. Ascites gr III ec 1. Hemetemesis dan
2. HF Stage C Fc dd related to SH melena ec
NYHA III-IV ec dd 2. SH stad. DC CP - Varises esofagus
- HHD B related to bleeding
- IHD Hep.B - Varises fundus
3. Asites grade II ec dd 3. Anemia berat HM gaster
related HF EC related to SH 2. Sirosis hepatis
4. Trombositopenia decompersata CTP
Th/ ec dd related to B
Bedrest SH 3. Anemia berat NN
O2 4L NK 5. Status ec dd
IVFD Comafusin Hepar 1 Hipokoagulasi - Penyakit kronik
fl/12 jam 6. Hipoalbuminemia - perdarahan
Diet hati II 1700 kkl/hari sedang 4. Hipertensi stage I
+ 5,4 gr garam/hari 7. AKI stage I terkontrol
Iv omeprazole 40 g/12 prerenal ec dd/ 5. Hipoablbuminemi
jam - Infeksi a Berat ec dd
PO spironolactone 2x100 - Dehidrasi - Liver disease
mg - Low intake
PO UDCA 2x250 mg Th/ 6. Hiperglikemia ec
PO curcuma 3x1 Bedrest dd:
PO propranolol 1x10 mg Diet hati II - Dm tipe 2
PO lactulac sus 3xC II 1700kkal/hari - Reactive
Drip furosemide IVFD Aminofusin hyperglikemia
Hepar 1 fls/24 jam
P/ IV Lansoprazole Th/
Ekokardiografi 30g/24 jam Bedrest
Lab IV Ceftriaxone 1gr/12 O2 2-4 lpm
Urinalisis jam Dite hati II 1700 kkal
Makroskopik: Drip Ocrootide 2 amp IVFD Nacl 0,9% 20
Kuning /Keruh (dlm 50 cc NaCl drip tpm
Berat jenis:1.026 kec. 6,25 cc/) IVFD Aminofusin
pH 5 IV Vit K 1 amp/12 Hepar 1 tpm/24 jam
Leukocyte: positive jam IVFD NaCl 0,9% 20
protein: positive (+1) IV As.Tranexamat 500 tpm
Ketone: positive mg/8 jam Drip ocreotride 2 ap +
Urobilinigen: positive PO Curcuma tab 8 jam 50 cc Nacl 0,9% kec
Darah: positive PO CPZ ¼ tablet 6,25 cc/jam selama 72
Granular Cast:positive IV Albumin 25 mg 1 jam
Hyalin Cast: positive fls/24 jam IV lansoprazole
Sedimen urine: 30g/24j
Leukocytes: 10-25 P/ IV Vit K 10g/8j
Eritrosit: 25-50 EKG IV Kalnex 500g/8 jam
Epitel: 0-1 Urinalisa IV ondancetron
Lab (9/6/10) Rontgen Thorax PA 4mg/12j
Urinalisa: USG Abdomen Amlodipin 1x10g
Warna: Kuning Konsul GEH Transfusi PRC s/d Hb
Kejernihan: Keruh (terpasang drain 9
Berat Jenis: 1,026 asistes) Drip Albumin
pH: 5,0 25%/hari
L/P/Keton/Darah: + Lab 11/06/2023
Leu/eri/epitel: 10-25/25- Hb/L/T: 5,6/5,27/45 P/
50/0-1 Mcv/Mch/Mchc: Konsul GEH
Glanular cast: + 65/21/32 Urinalisa
Epitel: + Diftel: 3/0/-1/74/14/10
PT/APTT: 21,10/34,40 Lab 12/6
Imunoserologi: HbsAg: reaktif Urobilinogen +
AFP: 2,10 Bilirubin direct: 0,88 Lab 10/6/23
Bilirubin indirect: 0,72 Hb/L/T: 3,4/9,59/99
Protein total: 4,90 HT/E: 11/1,7
 MAPPING AQSA 2 Rabu PAGI (14 JUNI 2023)
Lab tgl 11/06 Albumin: 2.40 MCV/MCH/MCHC:
H/L/T:7.5/3.77/49 Ur/Cr: 103/1,50 64/20/31
Mcv/mch/mchc: 71/23/33 Na/K/Cl: 135/4,50/120 Diftel: 0/0/1/69/19/11
Birulium total : 3,55 Lab 9/6/23
Direct/indirect : 2,1/1,45 Hb/L/T: 3,9/7,94/72
SGOT/SGOT : 29/13 HT/E: 13/1,9
Alb : 3,40 MCV/MCH/MCHC:
Ca : 8,8 67/21/31
Ur/Cr : 53/0,8 Diftel: 0/0/0/77/20/3
Na/K/Cl : 131/4,00/104 Bill Tot/D/I:
0,88/0,34/0,54
Urine rutin (tanggal) PT/APTT: 1,71/1,27
Darah + Anti HCV / HBsAg: -
Granular/Hyalin +/+ SGOT/SGPT: 94/82
Keton + Albumin: 2,40
Leukosit + GDS: 229
Protein +1 Ur/Cr: 88/0,90
Na/K/Cl: 135/4/116

Lab (7/6203)
Ca/Na/K/Cl:
7,5/144/6,30/115
Ur/Cr: 138/5,60

Lab (6/6/2023)
H/L/T:10,8/8,37/221
Mcv/mch/mchc: 90/31/34
Diftell: 1/1/0/81/7/10
Birulium total : 3,55
Direct/indirect : 2,1/1,45
SGOT/SGOT : 29/13
Alb : 3,40
Ca : 8,8
Ur/Cr : 53/0,8
Na/K/Cl : 131/4,00/104
 MAPPING AQSA 2 Rabu PAGI (14 JUNI 2023)

K2B1 K2B2 K2B3 K2B4 K2B5

DPJP: dr. M. Riswan, Dpjp: dr. M. Riswan, DPJP: dr. Masra Lena DPJP: Dr. dr. Fauzi DPJP: dr. Islamuddin,
SpPD-KHOM SpPD-KHOM Siregar, SpPD KPTI Yusuf SpPD KGEH Sp.PD
COW: dr. Rianda Cow: dr. Akmal COW: dr. Dwi Teguh Cow: dr. Rianda Cow: dr. Rianda Akmal
Ruangan: dr. jose Ruangan: dr. Jose Irawan Akmal Ruangan dr. Triwahyudi
Ruangan: dr. Ilham Ruangan dr. Mirza
Abdi
Nama: Zainuddin bin M Nama : Marwan Ben Nama : Iskandar Bin M Nama : M. Din Nama : Ibrahim Bin Sabi
Yaqub CM : 1-33-80-81 Amin CM : 1338677 CM : 1-34-05-87
CM: 1-31-06-78 TL : 30-12-1993 (29 Th) CM : 1-34-09-13 TL : 04/07/1962 TL : 07/06/1972
TL: 18-04-70 (53 Th) TM : 05/06/23 TL : 01-07-1958 TM : 07/06/2023 TM : 07/06/2023
TM: 6-6-23 TM : 10/06/23
Ass/ Ass/ Ass/ Ass/ Ass/
1. Asites grade III ec dd 1. Pansitopenia ec dd 1.Sirosis hepatis stadium 1. Massa Rectosigmoid 1. CKD Stage IV dengan
Related sirosis hepatis (1) Anemia aplastik dekompensata ctp b ec dd edema paru akut
2. Sirosis hepatis sta dc (2) CML 2. Post melena ec varises 1. Ca Rectosigmoid (perbaikan)
related hep b (3) MDS esofagus grade lll-lV 2. Metastase proses 2. Pneumonia CAP psi
3. Hep b kronik 2. Hiponatremia 3. Gastritis antral 2. PSMBB ec Related to skor III
Hipoosmolar 4. Gastopati Malignant 3. Hipoalbuminemia
Th/ hipovolemik 5. Hipoalbumin berat ec 4. Tb Paru Lama
Bedrest 3. Hipoalbuminemia dd Th/
Diet MB 1700 kkal /hari sedang ec dd/ 1. Liver disease Bedrest Th/
IV furosemid 20 mg /8 (1) low intake 2 low intake Diet M II 1700 kkal/ h Bedrest
jam (2) hiperkatabolisme 6. DM tipe 2 IV lansoprazole 3g/ 12 Diet Ginjal 1700 kkal/hari
IV lansoprazol 30mg 4. Neutropenia ec 7. Hipoalbumin jam + 0,6 gr protein/KGBB
/24 jam malignancy hematologi Salofalk 3x500g O2 4 lpm
IVFD Aminofusil hepar Th/ Domperidone 3x10 g Three way
1 fl (20l) s Th/ IV Lansoprazole 3o Iv furosemid 40g (ext)
Spironolacton 2x100 mg Bedrest mg/24 jam Nebule Ventolin 2 (ext)
Lactulac susp 3x1 Planing:
Diet MD 1700kkal/hari IV Aminofusin Hepar 1 Evaluasi KU Iv. Ca gluconate (ext)
Curcuma 3x1 IVFD NaCl 0,9% 20 tpm fls/24 jam Iv. Insulin 10 unitdlaam
Transfusi PRC s/d Hb 10
IV Omeprazole 40 PO Spironolactone 100 Susul biopsi PO N-Acetilsistein
P/ mg/12 j mg/24 jam 3x200g
EGD Senin PO Curcuma 3x1 IV Furosemide 20 mg/12 IV omeprazole
PO Paracetamol 3 x 500 jam Lab:11/06/2023 IV kalitake
Lab 07/06/2023 mg PO Lactulax syr C H/L/T:9/7.58/358 PO Lenal Ace
Analisa cairan asites PO As.Folat 2x0,4 mg II/8jam Mcv/mch/mchc:8/27/34 PO Bic nat 5000 mg/8
Bekuan: negatif Ciprofloxacin 2x500mg IV Albumin 25% fls/24 Diftell:11/1/0/60/19/9 jam
Glukosa: 114 Drip Novalgin 1 amp/8 jam Ca:8.4 PO As. Folat
Kejernihan: keruh jam Ur/Cr:14/0.70 Drip albumin 25%
MN: 85 Na/K/Cl:142/3.30/111 IV Ciprofloksasin 20g/1h
PMN: 15 Lab 10/06/2023
Protein total: 6,20 gr/dL P/ Hb/L/T: 12/14,03/172
Transfusi PRC target Hb Mcv/mch/mchc: Lab:09/06/2023 P/
Warna: kuning
>7 90/32/35 H/L/T:7.6/12.33/368 Urinalisis
Pemeriksaan MDT dan Diftel: 3/0/0/74/14/9 Mcv/mch/mchc:83/27/33 Cek DR, Ur/Cr, elektrolit
06/06/2023
BMP PT/APTT; 1,24/1,02 Diftell:5/0/0/7313/9 HD
Urine rutin
Berat jenis: 1,020 SGOT/SGPT: 46/26 Gen Xpert
Bilirubin: negatif Lab (11/6/2023) Albumin: 2,30 08/06/2023 Ro thorak (susul hasil)
Darah: negatif Hb/L/T:6,4/1,25/9 Ur/Cr: 79/1 Colonoskopi: Kultur Sputum
Epitel: 0-1 Mcv/mch/mchc:82/28/35 Na/K/Cl: 138/3,5/106 Masa di rectum Hemodialisis selasa -
Eritrosit: 0-2 Diftel:0/0/0/18/56/26 jumat
Glukosa: negatif Lab:07/06/2023
Kejernihan: jernih H/L/T:8.3/7.28/504 Radiologi
Lab 09/06/2023
Keton: positif Mcv/mch/mchc:83/27/33 Tb Paru
Hb/L/T: 8,9/3,81/78
Leukosit: negatif Diftell:9/1/0/30/50/10 Cor tak tampak kelainan
Mcv/mch/mchc:
Nitrit: negatif PT/APTT:0.97/1.01
83/28/34
pH: 5
Diftel: 0/0/0/49/28/23 Lab (12/6)
Protein: negatif
Lab 22/05/2023 Cl 111
Urobilinogen: positif
07/06/2023 Hb/L/T: 10,5/6,70/417 Cr 13.32
Warna: kuning
Urine rutin Mcv/Mch/mchc: LED 79
Berat jenis: 1,013 89/29/32 Hb/L/T: 6,1/8,15/417
Lab 05/06/2023
Bilirubin: negatif Dif: 11/1/0/36/46/6 Mcv/Mch/mchc: 80/27/34
Hb/L/T: 10,6/7,04/297
Darah: negatif Albumin : 3.60 Dif: 8/0/0/68/18/6
MCV/MCH/MCHC:
Epitel: 0-1 Ur/cr: 0,70/12 Ur/cr: 196/13,22
88/29/33
Eritrosit: 0-2 N/K/Cl : 145/3,70/109 N/K/Cl : 139/4,2/111
Diftel: 4/1/0/59/28/8
HbsAg: Non reaktif Glukosa: negatif
Albumin: 3,30 Kejernihan: jernih Lab 15/05/2023
Bil tot/d/i : 0,65/0,3/0,35 Keton: negatif N/K/Cl : 144/3,70/111 Lab 09/06/23
Sgot/sgpt : 23/10 Leukosit: negatif Urinalisis:
GDS : 98 Nitrit: negatif Warna: Kuning
 MAPPING AQSA 2 Rabu PAGI (14 JUNI 2023)
Ur/Cr : 27/1,10 pH: 5 kemerahan
Na/K/Cl : 144/5,20/113 Protein: negatif Kejernihan: Keruh
Urobilinogen: positif Berat Jenis: 1,018
Warna: kuning pH: 5,0
kecoklatan Leukosit/Darah: +
Leu/eri/epitel: 25-50/450-
Lab 07/06/2023 500/0-1
Anti HCV: negatif Sel ragi: +
Bilirubin direct: 1,23 bakteri: +
Bilirubin indirect: 0,73
Bilirubin total: 1,96 Lab 08/06/2023
SGOT/SGPT: 36/15 Hb/L/T: 8,8,/17,92/ 105
MCV/MCH/MCHC:
06/06/2023 79/27/34
Foto thoraks AP Diftel: 0/0/0/92/3/5
Kesan: tidak tampak PROCALSITONIN :6,35
kelainan pada cor dan K:5,8
pulmo saat ini Albumin: 1,71
Ur/Cr: 288/16,42
Na/K/Cl: 130/5,8 /117
Lab 05/06/2023
Hb/L/T : 7,2/2033/20
MCV/MCH/MCHC : Lab 6/6/2023
80/27/34 Hb/L/T: 10,5/25,14/152
Diftel : 0/0/1/40/47/12 MCV/MCH/MCHC:
PT/APTT : 1,18/0,99 83/28/33
HbsAg : Non reaktif Diftel: 0/0/0/96/2/2
Albumin : 2,80 Albumin: 2,10
Ca : 8,9 Ur/Cr: 318/19,70
GDS : 111 Na/K/Cl: 132/7,30/110
Ur/Cr : 35/0,50
Na/K/Cl : 125/4,60/94
 MAPPING AQSA 2 Rabu PAGI (14 JUNI 2023)
K3B1 K3B2 K3B3 K3B4 K3B5

DPJP: dr sarah DPJP : dr. Cut Mela DPJP: Dr.dr Fauzi DPJP: dr. Eva DPJP: dr. Sarah
firdausa SP PD Yunita Sari, SpPD., Yusuf, SP PD KGEH Musdalita, Sp.PD.KR Firdausa,Sp.PD
COW dr rianda akmal KGH COW: dr. Rianda Cow: dr. Rianda COW: dr. Rianda
Ruangan : dr aufa COW: dr. Akmal Akmal Ruangan: dr. Tri Akmal
Ruangan: dr. Ruangan: dr. Mirza Wahyudi Ruangan: dr.Aufa
Kurniawan
Nama: Nurdin Yusuf Nama: Ichwan Jailani Nama: M. Rijal Nama: Junaidi Binti Nama: Rahmad Maulidin
CM: 1341124 CM: 1-34-08-79 CM :1.34.06.40 Jainor CM: 1305295
TL: 01/08/1962 TL: 11-02-1968 TL : 30.05.1981 CM: 1133784 TL: 20/08/1994
TM: 13/06/24 TM: 10/6/2023 TM :13/06/2023 TL: 26-10-1977 TM:14/06/23
TM: 08/6/2023
Ass/ Ass/ Ass/ Ass/ Ass/
1.Arthritis sepsis dgn 1. Ulkus diabeticum 1. Sindrom dyspepsia dg 1. CKD Stage V dengan 1. CKD stage V dgn
efusi genu ec OA genu wagner IV ar pedis hiccup persisten ec dd uremic syndrome ec udem paru on HD reguler
grade IV Sinistra 1.1 GERD dd 2. Anemia sedang NN ec
2. PPOK eksaserbasi 2. Sepsis ec dd 1.2 Gastritis Erosif - PNC dd
akut - Ulkus diabeticum 1.3 Ulcu Gaste 2. Anemia sedang - PGK
- Pneumonia related CKD - Perdarahan
P/ 3. Anemia Berat NM Th 3. Hipoalbumin sedang 3. HHD
Diet MB 1700kkal ec dd Bedrest ec dd
IVFD Nacl 0,9% - penyakit kroniS Diet Lunak 1700 - Renal Loss Th/
IV Ceftriaxone - Defisiensi besi kkal/hari - Low Intake 1. Bedrest
IV lansoprazole 4. AKI stage III on Ivfd Rl 20tpm 4. Hiperkalemia related 2. O2 nk 2-4 nrm
PO paracetamol CKD Iv lansiprazole 30mg/24 CKD diet ginjal 1700 kkal
jam 5. Gout Atritis 3. Iv ceftriaxone
Th/ bedrest P/ Iv metoclorpramid iv lansoprazole
Nebul O2 2lpm 10mg/8jam valsartan
Urinalisa Bedrest CPZ 1x24 mg Th/
Susul hasil radiologi Diet DM 1700 kkal/h + 1. Bedrest P/
0,9 g kkal/kgbb/l Planing 2. Diet ginjal 1700 HD
IVFD NaCl 0,9% 20tpm EGD kkal/ hari + protein
Lab:13/06/2023 IV Omeprazol 40g/24j 1,2 gr/kgbb/hari
H/L/T:11,6/9,86/208 IV Ampicilin sulbactam 3. Threeway Lab 9/06/23
Mcv/mch/mchc: 1,5g/6j Lab:13/06/2023 4. IV ceftriaxone H/L/T:10/4.4/144
80/26/33 Drip Insulin 50cc Nacl H/L/T:15.1/12.26/241 2g/24j Mcv/mch/mchc:
Diftel:0/0/0/89/7/4 0,9% Mcv/mch/mchc:84/30/36 5. IV lansoprazole 87/30/35
GDS 67 Po Clindamisin 3x300 gr Diftel:4/0/0/63/26/7 30mg/12j Diftel:7/0/0/51/33/9
Albumin 2,6 Po Gabapentin 1x100g PT/APTT:0.96/0.87 6. Herbeser 1 x 100 Albumin 3,4
Ur/cr : 38/0,4 Po Atorvastatin 1x20g Anti HCV(-) mg Ca2+ 8,2
Na/K/CL Po Lactulac syr 3xcII HBsAg:Non reaktif 7. Allopurinol 1 x 100 Ur/cr : 134/11,3
140/3,3/107 Parasetamol 1000g/8jam GDS:95 mg Na/K/CL
Valsatran 80g/24jam Ur/Cr:18/1.00 8. Kalitake 1 sachet/8j 137/3,8/107
Na/KCl:135/3.60/106 9. IV Ca Gluconose 1
Lab 12/6 amp (extra)
LED 130 10. Ventolin 1 respul
HT/E : 30/ 4,1 (extra)
HB/L : 9,3 /20,18 11. IV Novorapid
MCV/MCH/MCHC: dalam 10 unit dex
23/31/72 40% 50cc (Extra)
diftel: 12. PO Domperidone
0/0/0/94/4/2 10g/8 jam

Lab 10/6/23 P/
Hb/L/T: 7,4/15,11/503 1. Cek asam urat
HT/E: 7,4/3,4 2. Urinalisa
MCV/MCH/MCHC: 3. Cek elektrolit
ulang
4. EKG
67/22/33
Diftel: 1/0/0/87/6/6
PT/APTT: 1,20/1,05 Lab 13/06
Anti HCV/ HBsAg: - Hb/L/T: 6,9/15,24/129
Albumin: 2,50 MCV/MCH/MCHC:
SGOT/SGPT: 57/19 66/22/34
Ca/Na/K/Cl: Diftell: 1/0/0/88/6/5
8,3/125/5,50/94 PT/APTT: 17,1 37,8
GDS: 700 Ht/E : 21/3,1
Ur/Cr: 82/2,20 Ferritin 739,3
BESI fe 20
Asam urat 11
MAPPING AQSA 2 Rabu PAGI (14 JUNI 2023)

Lab 08/06/23
Hb/L/T: 7,0/15,66/291
MCV/MCH/MCHC:
70/23/32
Diftell: 1/0/1/85/9/4
PT/APPT: 1,65/1,15
Ddimer: >20000
HIV R1: Non reaktif
Anti HVC: -
HbsAg: Non reaktif
Albumin: 2,8
Ur/Cr: 199/10,40
Ca/Na/K/Cl:
9,2/145/6,20/121

AGD:
Po2: 126
Hco3: 8,6
Total CO2: 9,1
 MAPPING AQSA 2 Rabu PAGI (14 JUNI 2023)
K4B1 K4B2 K4B3 K4B4 K4B5

DPJP: Prof. Dr. dr. DPJP: dr. Masralena Dr. dr.Fauzi Yusuf DPJP: dr. Azzaki DPJP: dr. Alfi
Maimun Syukri, Sp.Pd Siregar, Sp.PD-KPTI SP.PD KGEH Abubakar, Sp.PD Syahrin, Sp.PD
KGH COW: dr. Dwi Teguh COW: dr. Rianda Akmal KGEH COW: dr. Hibban
COW: dr. Akmal Irawan Ruangan : Dr. Mirza COW: dr.Ahmad Ruangan: dr.
Ruangan: dr. Ruangan: dr. Ilham Abdi Hibban Annisa
Gamalinino Ruangan: dr. Nori
Nama: Abdul Murad Nama: Ibrahim bin ramli Nama: Edy Sapran Nama: Raden Bin M. Nama: Sulaiman
CM: 1-28-87-27 CM: 1340938 CM : 1.34.11.09 Yacob Hasyem, 60 Tahun
TL: 01/07/1976 TL: 21/07/1991 TL :30/1/1978 CM : 1.04.12.52 CM: 1340430
TM: 29/05/2023 TM: 11/6/23 TM :13/06/2023 TL : 07.06.1971 TL: 15/02/1963
TM : 11.06.2023 TM:09/06/2023
Ass/ Ass/ Ass/ Ass/ Ass/
1. CKD Stage IV on HD 1. Bisitopenia ec dd 1. Sups HCC ec Releated 1. Partial MBO ec dd 1. Bisitopenia ec
reguler - CML Hep B 1.1 ileus obstruksi - Anemia
2. Pneumonia CAP - AML 2. Sindrom dyspepsia tipe 1.2 enteritis aplastic
3. HT stage II 2. AKI Stage 1 ec dd dismolity 2. Anemia sedang NN ec - Leukopenia
- Dehidrasi 3. Hepatitis B dd - MDS
Th/ - Infeksi 2.1 perdarahan
Bedrest Th/ Th/ 2.2 penyakit kronik Th/
Diet Ginjal Bedrest Bedrest 3. Enteritik Bedrest
1700kkal/hari+ protein IV Cefipime 1gr/8j Diet hati 1700kkal/hari 4. Post covid 19 Diet MB 1700
1,29g/KgBB/hr + RG+ IV Lansoprazole 30g/1h Ivfd Aminofusin Hepar 1 5. Gout arthritis kronik kkal/hari
bebas kalium IV Paracetamol drip 1gr/8 j fls/24 jam 6. Hipoalbuminea berat IVFD Nacl 0,9%
IV Levoper 2x1 PO Curcuma tab/8jam Iv lansoprazole 30mg/24 7. AKI sedang stage III 20tpm
PO Bisoprolol 1x5 mg Diet MB 1700 kkal /hari jam ec dd hepatorenal IV omeprazole
PO Adalatforos 1x30mg Sicronic 2x1 syndrom 20g/24jam
PO Valsartan1x160 mg P/ Bisoprolol 1x5mg 8. Hiperkalemia Metilprednisolon
PO PCT 3x500mg Susul hasil MDT Lesichol 1x1 (perbaikan) 62,5g/12 jam
PO Laxadin syr 3xIIc BMP Praloxb3xCII Fosen Enema 1 fls
PO Hytroz 1x2mg Transfuse PRC sampai extra susp
HB>10 Planing Th PO Lactulax syr CI /8
P/ EGD Bedrest jam
Echocardiogram Lab 13/06/2023 Ct Scan Abdomen 3 fase PO Kalitake 2x1 sachet Transfuse PRC
(tunggu jadwal) Pt/aptt 20/36,3 Cek AFP per 12 jam sampai HB 10G/DL
Take down AV Shunt D-dimer 3750 Iv Viccilin 1.5 gr/12 jam
(menunggu stabil Albumin 2,53 Iv Omeprazol 40gr/12
13/06/23 P/
leukosit) LDH 961 jam
USG Abdomen: Crossmatch
Cek ulang lab cito tgl Ca 7,5 Drip albumin 1 flash/24
Hepatomegali BMP
10/06/2023 (susul hasil) Asam urat 8,6 jam
Splenomegali Cek DR
Ivfn chinimix 1 flash /24
Radiologi 6/6/23 Lab 11/06/2023 jam
Lab:13/06/2023 Urin rutin 12/6
Kesan: Tak tampak Hb/L/T : 4,4/38,71/75 Po bicnat 500g/8 jam
H/L/T:14.8/10.55/618 Glukosa +2,
gambaran infark di Mcv/mch/mchc: 86/30/35 Drip Metronidazole
Diftel:3/1/0/64/21/11 Jernih, kuning
parenkim otak Difftel: 1/1/0/40/18/40 500g/8 jam
Anti HCV:(-) Keton +
Ur/cr : 72/1,30
Na/K/Cl : 132/4,30/105 HBsAg: Non reaktif
LAB 12/6/23 Bil T/I/D:3.02/1.39/1.63 Planing
Lab (13/6/23)
Ferritin: 5203,00 SGOT/SGPT:526/95 Hb/L/T: 7,9/5,62/378
Besi(fe) 48 Albumin:3.40 Lab:13/06/2023 HT/E: 24/2.9
GDS:105 Na/K/Cl:139/5.10/119 MCV/MCH/MCHC:
Lab 4/06/23 Ur/Cr:31/0.90 ALP: 109 82/27/34
Hb/L/T :10,4/19,89/213 Na/K/Cl:137/4.50/106 Bilirubin direct: 5.80 Diftel: 0/0/0/85/7/8
MCVMCH/MCHC: Bilirubin indirect: 0.42
74/27/336 Bilirubin total: 6.22
Diftel: 1/0/0/90/4/5 SGOT/SGPT: 29/7
Ur/Cr: 181/5.17 Lab 12/6
Cl: 104
Albumin: 1.61 Bilirubin direct 0,26
Ur/Na/K/Cr:
Globulin: 3.88 Cl 11.1
267/132/4,90/11,90
Cr 0,88
Diftel : 0/0/0/82
Lab 31/05/2023 Lab: 12/06/2023
MCV/MCHC
H/L/T: 9,9/20,73/116 H/L/T:8.1/25.61/193
81/35
Na/K/Cl: 136/4,30/104 Mcv/mch/mchc:86/29/33
Diftel:1/0/0/86/7/6
GDS:77
Lab 30/05/23 Ur/Cr:143/4.19 Lab (9/6/23)
As. Urat: 6,1 Na/K/Cl:138/6.40/121 Hb/L/T: 4,9/2,71/393
Albumin: 1.56 HT/E: 14/1,8
Lab:29/05/23 MCV/MCH/MCHC:
H/L/T:7,2/17,87/81 79/28/35
Mcv/mch/ Diftel: 3/0/0/31/41/25
mchc:77/28/37
Diftell:0/0/1/93/3/3
HCV/HBsAg :(-)
 MAPPING AQSA 2 Rabu PAGI (14 JUNI 2023)
Albumin:3.10
Ur/Cr:227/18,4
Na/K/Cl:128/4,2/108
 MAPPING AQSA 2 Rabu PAGI (14 JUNI 2023)

K5B1 K5B2 K5B3 K5B4 K5B5

DIVISI PULMONOLOGI DPJP: dr. Islamuddin, DPJP: dr. Masralena DPJP : dr. Islamuddin, DPJP : dr.
Sp.pd Siregar, Sp.PD-KPTI SpPD Islamuddin, SpPD
COW: dr. Rianda COW: dr. Dwi Teguh COW : dr. Rianda COW : dr. Rianda
Akmal Irawan Akmal Akmal
Ruangan: dr. Tri Ruangan: dr. Ilham Abdi Ruangan : dr. Tri Ruangan : dr. Tri
Wahyudi wahyudi wahyudi
Nama: Muhazir bin M. Nama : Azhar Bin Ahmad Nama : Japrinan bin Cut Nama : Yosep
Yacob Cut Agam, 59 th CM : 1-34-09-67
CM: 1-34-02-88 CM : 1-18-03-35 CM : 1-34-08-05 TL : 12-12-1974
TL: 20/03/1986 Tl : 01/07/1960 TL : 1/7/1963 TM : 11/06/23
TM: 02/06/2023 TM : 11/06/2023 TM : 9/6/2023
Ass/ Ass/ Ass/ Ass/
1. Krisis 1.Hematemesis melena ec dd 1. Hepatomegali ec dd 1.PSMBB ec dd
Hiperglikemia 1). Ulkus gaster - Hepatoma 1).Hemoroid interna
perbaikan ec dd 2). Ulkus duodenum - Liver abses 2).Polip Recti
- KAD 3). Gastritis Akut 2. Dispepsia type like 2.Anemia Berat HM ec
2. Sepsis ec dd 2. Anemia Berat NN ulcer dd :
- Pneumonia 3. Hipoglikemia 1).Def FE
- Urosepsis 4. CAP Th/ 2). Penyakit Kronis
3. Pneumonia CAP 5. HF stage CFC nyha II Bed Rest
6. CAD Diet MB 1700 kkal/hari
Th/ 7. Post stroke IVFD NaCl 0,9% 20 tpm
8.DM Tipe II NW Th/
Bedrest IV Cefoperazone 1gr/12j Bedrest
Diet DM 1700kkal/hari IV Lansoprazole Diet MB 1700 kkal/hari
IVFD Nacl 0,9% 300 30mg/12j IVFD NaCl 0,9% 20
ml/24 jam Th/ Domperidone 3x10g tpm
Drip cevofloxacin Bedrest Sc Heparin 3000 IU/12 IV Lansoprazole 30
75g/24 jam Diet DM 1700 kkal/hari jam mg/24 jam
IV Omeprazole 40 g/24 rendah garam Antihemorroid Supp
jam IVFD Nacl 0,9% 20 tpm P/ 2x1
PO Amlodipin 10g/24 Drip levofloxacin 250 Konsul GEH pro USG Transfusi PRC s/d Hb
jam mg/jam Abdomen 10 gr/dl
PO N-ACE 200g/8 jam IV Omeprazole 40 mg/24 Lipid profile
PO Domperidone 10g/8 jam
jam Lab (13/6/23)
IV Ondansentron 4 mg/8 jam Urin rutine (13/6/2023) Hb/L/T: 8,5/6,7/209
IV Vitamin K 1 amp/12 jam Keton (+) HT/E: 30/4,4
Urin rutine (12/6/2023) PO N-asetylsistein 3x200 mg Urobilinogen (+) MCV/MCH/MCHC:
Glukosa (+1) 69/19/28
Keton (+) Planning : Diftel: 11/1/0/53/26/9
Lab (13/6/23)
AFP : 1,56
Lab 10/06/2023 Lab 11/06/23 Urin rutine (13/6/2023)
Hb/L/T: 10,3/20,55/226 Hb/L/T: 4,5/10,15/384 Keton (-)
Mcv/mch/mchc: Lab 12/06/2023
HT/E: 14/1,6 Kolesterol total 129 Urobilinogen (-)
79/28/35 MCV/MCH/MCHC:
Diftel: 0/0/0/95/2/3 Hdl/ldl/trigli (24/93/75)
87/28/32 Lab (11/6/23)
Albumin: 2,10 Diftel: 2/0/0/77/15/6
Ur/Cr: 27/0,70 Urin rutine (12/6/2023) Hb/L/T: 6,5/5,33/224
PT/APTT: 1,35/0,79 HT/E: 25/3,7
Ca: 7,4 D-dimer: 440 Keton (+)
Na/K/Cl: 130/2,9/102 Urobilinogen (+) MCV/MCH/MCHC:
Anti HCV/ HBsAg: 66/18/27
HbA1c: 12,30 Negatif/Non-reaktif Diftel: 13/1/0/51/23/12
SGOT/SGPT: 31/20 Lab (9/6/23) SGOT/SGPT: 18/17
Lab 02/06/2023 Bill T/D/I : 0,51/0,16/0,35 Hb/L/T: 11,2/9,23/305 Na/K/Cl: 144/4,30/115
Hb/L/T: 12,9/8,96/396 Na/K/Cl: 137/4,50,109 HT/E: 34/4,6 Ur/Cr: 34/0,90
Mcv/mch/mchc: Ur/Cr: 24/1,50 MCV/MCH/MCHC: GDS : 88
82/28/34 Albumin : 2,70 75/24/33
Diftel: 0/0/0/87/5/8 GDS : 83 Diftel: 9/0/0/71/12/8
AGDA PT/APTT: 1,15/1,07
pH/PCO2/PO2/HCO3/ D-dimer: 1960
Total CO2/BE/SpO2: Anti HCV/ HBsAg: -
7,34/17,3/78/9,4/10/- Bilirubin total: 1,00
13,8/94,6 Bilirubin direct: 0,46
Albumin: 3,10 Bilirubin indirect: 0,54
GDP:375 SGOT/SGPT: 57/19
Ur/Cr: 72/1 Ca/Na/K/Cl:
9/140/3,60/112
Ur/Cr: 29/0,60
 MAPPING AQSA 2 Rabu PAGI (14 JUNI 2023)

K6B1 K6B2 K6B3 K6B4 K6B5

DPJP SARAF DPJP: dr fauzi yusuf DPJP : DPJP: Prof. Dr. dr. Dpjp : dr. Vera
sppd kgeh Maimun Syukri, Sp.Pd Abdullah SpPD KPsi
COW: dr rianda KGH Cow : dr. Akmal
Ruangan: dr mirza COW: dr. Akmal Ruangan : dr.
Ruangan: dr. Gamalinino Gamalinino

Nama: Supriyadi Nama: Razali Bin Abu Bakar Nama: M.Yusuf A

CM: 1.33.76.40 CM : 1-34-12-23 CM: 1-01-77-41
TL: 03.05.1992 TL : 01/07/1959 TL: 27/02/1962 (61 Th)
TM:07/06/2023 TM : 14/06/2023 TM: 05/06/2023

Ass/ Ass/ Ass/

1. Massa rectum 1/3 distal 1.Anemia Berat NN ec dd 1. Efusi genu bilateral dd
susp. Ca recti penyakit kronik Arthritis Septik Genu
2. Hemorroid interna Gr II perdarahan Dextra et Sinistra
3. Fisura Ani 2. CKD Stage V ECDD 2. CKD Stage V on HD
a. DM reguler
Th/ b. PNC 3. HF Stage C FC
Bedrest DM Tipe II NW NYHA III ec dd :
Diet Lunak 1700kkal/hari - HHD
IVFD RL 20 tpm Th/ - IHD
Iv Omeprazole 40mg/24 Bedrest 4. Iskemik Anteroseptal
jam Diet ginjal 1700 kkal 5. Hipoalbuminemia
Iv Asam Tranexamat Threeway lansoprazole Sedang
500mg/12 jam Bicnat
Anti hemorroid 2x1 As folat Th/
Bedrest
Planing Planning Diet Ginjal 1700
Tindakan Biopsi Hari ini Urinalisa kkal/hari + protein 1,2
g/kkBB/hari
Threeway
08/06/2023 Lab 13/6 IV Ceftriaxone 2 g/24
Endoskopi: H/L/T: 6,8/7,6/228 jam
Hemorroid Interna Gr II Mcv/mch/mchc: 81/26/32 IV Omeprazole 40
Fisura Ani Diftell: 10/1/1/53/27/8 mg/24 jam
PT/APTT: 12,9/33,3 PO Paracetamol 2x1000
Lab:07/06/2023 Ur/Cr:117/11,6 mg
H/L/T: 16.3/7.27/219 Ht/Er : 21/2,6 PO CPG 1x75 mg (stop
Mcv/mch/mchc:87/30/34 sementara persiapan
Diftell:16/1/0/45/32/6 aspilet)
Anti HCV:(-) PO Aspilet 1x80 mg
HBsAg: Non Reaktif (stop sementara
PT/APTT: 0.96/1.08 persiapan aspilet)
SGOT/SGPT:22/22 PO Atorvastatin 1x20
Albumin:3.94/ mg
Ca:9.5 PO Amlodipin 1x10 mg
Ur/Cr:14/1.02 PO Captopril 1x25 mg
Na/K/Cl:144/3.6/108 Lactulac syrp
CEA:33.02 Fosen enema susp

P/
HD reguler rabu-sabtu
Echo menunggu
dipanggil
AV Shunt Rabu
14/06/2023

Lab:13/06/2023
H/L/T: 8,1/4,86/300
Mcv/mch/mchc:
MAPPING AQSA 2 Rabu PAGI (14 JUNI 2023)
84/28/33
Diftell: 1/0/0/67/24/8
PT/APTT: 12,9/33,3
Ur/Cr:117/9,3

Lab:10/06/2023
H/L/T: 9,9/9,93/282
Mcv/mch/mchc:
82/28/34
Diftell: 0/0/0/88/8/4
PT/APTT: 0,87/1,02
Albumin: 2,90
Ca:9.7
Ur/Cr:81/6,20
Na/K/Cl:133/3,60/109
Ddimer : 19590

Lab 7/06/23
Kolesterol tot: 146
HDL/LDL:44/78
Trigliserida:84
LED :82
RF: negative
CRP Kualitatif: positif

Lab 7/06/23
Urin rutin
Bj :1,008
Bil : negative
Darah : negative
Eoitel :0-1
Eritrosit:0-1
Glukosa : +1
Kejernihan: jernih
Keton : negatif
Leukosit : negatif
Nitrit : negatif
PH : 7,0
Protein: +1
Sel ragi : positif
Urobilinogen : negatif
Warna : kuning muda

Lab: 05/06/2023
Hb/L/T: 10/8,60/216
mcv/mch/mchc:
84/28/33
Diftel: 0/0/1/82/12/5
PT/APTT: 1,97/0,95

HBsAg: non reaktif

HIV R2 : Non Reaktif
Anti HCV : Negatif
HbsAg : Non Reaktif
Albumin: 2,60
Ca: 7,7
Ur/Cr:81/7,20
Na/K/Cl : 137/3,90/109