MAPING AQSA 3 SELASA PAGI 30 MEI 2023
K1B1 K1B2
DPJP : dr. Azzaki Abubakar,
SpPD-KGEH
COW : dr. Ahmad Hibban
Awriya
Ruangan : dr. Nori
Nama :Erna Yuliani
CM : 0-85-47-60
TL : 03/09/1986
TM : 27/05/2023
Ass/
1. Abdominal discomfort ec dd
1. Ulcus gaster
2. Ulcus duodenum
3. Cholelithiasis
2. Peningkatan enzim
transaminase ec dd
1. ALI
2. Drugs induced
3. Viral inf
Th :
Bedrest
Diet MB 1700 kkal/hari
IV. Omeprazole 40 mg/12 jam
IV. Ondansetron 4 mg/8 jam
NAC 3x200 mg
Curcuma 3x1 tab
Planing :
USG Abdomen besok (Divisi)
EGD rencanakan Selasa
Lab : 27/5/23
Hb/l/t : 15,5/8, 8/220
Mcv/mch/mchc : 30/35/35
Diftel : 0/0/0/85/14/1
Sgot/sgpt : 307/304
Hbsag : negatif (1bln lalu)
Ur/cr : 17/0, 6
Na/k/cl : 137/4/117
K1B3 K1B4
DPJP : dr Fauzi Yusuf SpPD Bedah digestive
KGEH
COW : dr. Rianda
Ruangan : dr Mirza
Nama : Syarifah Nur
CM: 1-33-41-61
TL: 10/6/1965
TM: 26/5/23
Ass/
1. Hepatomegali ec dd:
- HCC
- metastase proses
2. Pneumonia
3. Anemia sedang NN ec dd
- peny. Kronik
- perdarahan
4. Elevated enzime transaminase
5. Hipoalbuminemia sedang ec dd
- hiperkatabolisme
- Low intake
Th/
Bedrest
Diet Hati 1700 kkal / hari
Ivfd Aminofusin Hepar 1 fls/24 jam
Drip Levofloxacin 750mg/24jam
IV Lansoprazole 30mg/24jam
Po Viestral 1x1
Po Sinkronik 2x1
Lactulac syr 3xCII
Duragesix patch
Domperidon 3x10mg
Fossen Enema 1 sup (K/P)
Planing:
CT Scan Abdomen 3 Fase (16/06/23)
26/05/2023
AFP:3.39
ALP:245
Urinalisa: normal
Lab 25/5/23
Hb/l/t : 8,0/16,85/458
Mcv/mch/mchc : 83/27/32
Diftel : 1/0/0/74/18/7
Albumin :: 2,50
HbsAg/Anti HCV: Non reaktif/neg
Bil Tot/Dir/Ind: 0,86/0,51/0,35
SGOT/SGPT: 278/40
GDS: 82
Ur/cr : 46/1,3
Na/k/cl : 129/5,5/110
===============
================
 MAPING AQSA 3 SELASA PAGI 30 MEI 2023
K2B1 K2B2 K2B3 K2B4 K2B5
DPJP: dr. Mahriani Sylvawani DPJP: dr. Hendra Zufry DPJP : dr. M. Riswan, DPJP: dr. M Fuad, DPJP : dr. M Fuad, Sp.PD
Sp.PD-KR Sp Pd SpPD KHOM SpPD-KHOM KHOM
COW : dr taufiq COW: dr. Akmal COW : dr. Akmal COW: dr. Hibban COW : dr. dr. Ahmad
Ruangan: dr.anisa Ruang: dr. Kurniawan Ruangan : dr. Jose Asmara Ruangan: dr. Sergio Hibban Awriya
Ruangan : dr. Gio
Nama: Suwarni Nama : Saidah Binti Ali Nama : Nur Asiah Nama: Martini Nama : Ruhmini binti
CM : 1-33-91-93 CM : 1-03-97-50 CM : 1-31-12-77 CM: 0-79-32-11 Razali
TL : 01/07/1968 TL : 15/02/1966 TL : 01-03-1972 (51 tahun) TL: 10-07-1967 CM: 1-33-98-08
TM : 22/05/2023 TM : 29/05/23 TM: 24-05-2023 TL :01/07/1983 (39thn)
TM: 01/05/2023
TM : 29/05/2023
Diagnosis : Ass/ Ass/ Diagnosa: Diagnosa:
1. Cancer pain 1. Stroke Iskemik Ca tiroid post kemoterapi 1. Trombositopenia ec dd 1.Bisitopenia dengan
2. Hepatomegali ec dd/ 2. DM tipe 2 siklus ke-3 dengan regimen ITP leukositosis ec dd
1. Hepatoma doxorubicin dan cisplatin 2. DM tipe 2 a. AML
2. Metastase proses Th/ Th/
Bedrest Hipoalbumin berat ec dd b. ALL
3. Pneumonia (CAP) Low Intake Bedrest 2. Hipertensi stage I
Diet DM 1700kkl/hari
4. Hipertensi terkontrol Hiponatermia Hipoosmolar Diet MB 1700 kkal/hari 3. Hipoalbuminemia ringan
IVFD RL 20 GTT/mnt
Threeway
Sc Lantus 0-0-0-18 Hipervolemik ec dd
Th/ (pukul 22.00) IV Omeprazole 40mg/12
a. Hiperkatabolisme
Bedrest Valsartan 1x80 mg jam
Th/ b. Low intake
Diet hati 1.700kkal/hari Fenofibrat 1x100mg
Threeway Bedrest Metilprednisolone
Planning
IV omeprazole 40mg/24jam Konsul neurologi
Diet MB 1700 kkal/hari 2x4mgs Th/
IV Ketorolac 1amp/8jam Cek lipid profile IVFD NaCl 0,9% 20 tpm Mecobalamin 2x500mg Bed rest
IV ceftriaxone 2g/24jam (22/5- Foto thorax IV Ceftriaxone 2g/24j Diet MB 1700kkl/hari
5hari) CT Kepala Non-kontras IV Furosemide 20 mg/8 Lab 26/5/23 IVFD NaCl 0,9% 20TPM
PO Valsartan 160mg/24jam jam Hb/l/t : 14,7/8,87/84 Amlodipin 1x10 Mg
PO Curcuma 3x1 Lab IV Ondansetron 8 mg/12 Mcv/mch/mchc : Natrium Bikarbonat 3x500
Hb/l/t : 12,8/9,96/336 jam 84/30/36 Mg
Urine rutin 26/5/2023 Mcv/mch/mchc : 83/29/35 Diftel : 2/0/0/66/25/7
IV Omeprazole
Diftel : 4/1/0/47/39/9
pH : 6,0 40mg/24jam Lab 28/5/23
BJ : 1,020 Fluimucyl 3x200mg Lab 25/5/23 Hb/l/t : 10,2/56,13/117
Glukosa : negatif Nebul Ventolin /8jam Hb/l/t : 14,9/8,02/88 Mcv/mch/mchc : 98/34/34
Darah negatif Drip Albumin 1 fls/24 jam Mcv/mch/mchc : Diftel : 0/0/1/0/49/50
Leukosit : negatif 83/30/36 Albumin : 3,4
Diftel : 1/0/0/68/25/6 Ca : 8,7
P/Cek ulang DR, UrCr,
USG Abdomen (24/05/2023) Retikulosit : 2,1 Ur/cr : 28/0,7
Elektrolit, ALbumin
Multiple nodul di hepar dd/ HCC, As urat : 4,0 Na/k/cl : 144/4,4/124
proses metastase hepar 28/5/23
Organ-organ intraabdomen Lab 24-05-2023
lainnyavtak tampak kelainan Lab 23/5/2023 Hb/L/T: 14,4/9,18/104
Hb/L/T : 9,6/1,53/140 MCV/MCH/
Lab 22/05/2023 MCV/MCH/MCHC : MCHC:83/30/36
Fe : 19 81/28/35 Diftel: 5/0/0/44/42/9
Ferittin 533,25 Diftel : 2/1/0/80/15/2 Pt/apt : 1,05/0,88
Calcium: 7,1 Albumin: 3,7
Lab 22/05/2023 Albumin : 2,46 GDS: 167
Hb/L/T : 11,8/12,1/160 Na/K/Cl : 124/3,80/94 Ur/Cr: 29/0,70
Mcv/mch/mchc : 74/25/34 Na/K/Cl: 143/4,0/112
Diftel : 11/0/0/71/13/5 Lab 17/5/23
SGOT/SGPT : 28/13 FT4: 9,42
GDS : 107 TSHs: 0,375
Ur/Cr : 24/0,6
Na/K/Cl : 142/3,2/105
Lab 12/05/2023
Hb/L/T : 13,6/9,55/214
MCV/MCH/MCHC :
83/28/34
Diftel : 0/0/1/85/6/8

Lab 09/05/2023
Hb/L/T : 12,3/7,35/197
MCV/MCH/MCHC :
83/28/34
Diftel : 0/1/0/67/18/14
Albumin : 2,80
Na/K/Cl : 128/3,30/110
 MAPING AQSA 3 SELASA PAGI 30 MEI 2023
K3B1 K3B2 K3B3 K3B4 K3B5
Dpjp: dr. Islamuddin, SpPD DPJP: Dr. dr. M Diah, SpPD DPJP: Dr. dr. M Diah, Dpjp: dr. M Fuad, SpPD- DPJP dr. Abdullah, SpPD, KGH
Cow: dr. Rianda Akmal KKV SpPD KKV KHOM COW dr. Taufiqurrachman
Ruangan: dr. Tri Wahyudi COW: dr. Taufiqurrachman Divisi KKV Cow: dr. Ahmad Hibban Ruangan dr. Asri Mukti Nanta
Ruangan: dr. Dhena Awriya
Ruangan: dr. Sergio
Pratama
Nama: Aminah Binti Nama: Nuraini Binti Husen Nama: Hj Syukriah Nama : Aminah binti M ali Nama: Husniar
Usman CM: 1258764 CM: 09908796 CM : 1206740 CM: 0-10-39-44
CM: 1-33-90-84 TL: 01/12/1973(49th) TL: 01/07/1955 TL : 05/07/1950(72th) TL: 18-06-1969
TL: 16/06/1971 TM: 26/5/23 TM : 26/5/23 TM: 27-05-2023
TM: 19/05/2023
Ass/ Ass/ Ass/ Ass/ diagnosis:
1. Efusi Pleura dextra ec dd 1. Epigastric Pain ec dd 1. Penurunan kesadaran 1. Pansitopenia ec Anemia 1. Hipertensi emergency
1. Psoses malignancy - gastropati diabetic (perbaikan) ec dd Aplastik 2. CKD stg V dg edema paru akut
2. Pleuropneumonia - ulkus gaster - uremic ensefalopati ec dd:
3. Ca Paru 2. Diabetic neuropati - syok sepsis Th/ 1. DN
2. Anemia Sedang HM ecdd 3. DM tipe II NW 2. CKD stg V ec dd 2. HN
Bedrest
1. Penyakit Kronis 4. Hiponatremia hipoosmolar 3. PGOI
- DN Diet mII 1700kkal/hari
2. Def. Fe euvolemi 3. CAP PSI score 123
- HN Ivfd nacl 0,9% 20gtt/i
3. Phylloides Mammae 5. Hipoalbuminemia ringan 4. Efusi pleura bilateral
- PNC Iv lansoprazole 5. CHF fc NYHA IV
dextra ec dd Ca Mammae 6. Anemia sedang NN 3. DM tipe II 30mg/24jam 6. Edema anasarka ec dd:
4. Cancer Pain
4. HF stg C Fc NYHA III Iv methylprednisolone 1. Hipoalbuminemia
5. Leukositosis ec dd Th/
1. Pneumonia Bedrest 62,5mg/12jam(26/5) 2. Related to CKD
2. Reaktif Ca Diet DM 1700kkal/hari Th/ 7. Susp efusi pericard
Ivfd nacl 0,9% 20gtt/i Bedrest Planning : 8. Hipoalbuminemia berat
Th/ Iv omeprazole 40mg/12jam Diet ginjal 1700kkal/hari Transfuse tc 9. Anemia berat NN ec dd:
Bedrest Iv metoclopramide IV Ceftriaxone 1g/12jam Transfuse prc 1. CKD
Novorapid 8-8-8IU 2. Occult bleeding
Diet TKTP 1700 kkal/hari 1amp/8jam
Iv lansoprazole 40mg/12jam 10. Nefrolithiasis desktra
Codein 2x1 tab Paracetamol 2x100mg Lab 26/5/23
Clindamycin 3x300mg Gabapentin 1x100mg Sc heparin 5000unit/12jam Hb/l/t : 6,2/1,02/9
P/
Vip Albumin 1x1 Iv furosemide 20mg/12jam Mcv/mch/mchc : 87/30/34 Urinalisa
Sucralfat Syr 3xCII Urinalisa : glukosa +2, lekosit Synbio 2x1tab Diftel : 0/0/0/58/36/6 Kultur urin+STAB
Tramadol 2x25mg 25-50 Bisoprolol 1x5mg Pt/apt : 1,03/0,81 Procalcitonin
Furosemide 20mg/12 jam Na/k/cl : 134/3,4/103 Anti hcv : - Minta Jadwal HD ke DPJP
LDL : 121 Lab 22/5/23 Hbsag : -
P/ Tg: 98 Hb/l/t : 9,0/10,88/93 Bil T/D/I : 0,74/0,22/0,52 Lab 27-05-2023
CT scan Thorak k/NK rabu Hdl :51 Mcv/mch/mchc : 84/28/34 Hb/L/T: 7,4/14,07/199
Sgot/sgpt : 16/8
31/5 Kolesterol total 190 Diftel : 0/0/0/85/5/10 MCV/MCH/MCHC: 85/27/32
Ur/cr : 29/0,90
Analisa sitologi cairan efusi: Hba1c 7.1 Ca : 10,1 Diftel: 4/0/1/78/10/7
susul hasil Kalsium : 8.9 Na/k/cl : 141/3,6/114
Mg : 2,9 PT/APTT: 0,95/1,03
Kultur cairan efusi D-Dimer: 2920
Ur/cr : 76/3,7
FNAB --> sudah tapi gagal Lab 26/5/23 HIV: Nonreaktif
Na/k/cl : 140/4,1/108
Hb/l/t : 9,9/8,43/351 Anti HCV: Negatif
Lab 22/05/2023 mcv.mch/mchc : 77/27/36 Hbsag: Nonreaktif
Hb/L/T: 9,5/16,10/479 diftel : 2/0/0/51/40/7 Lab 25/5/23
SGOT/SGPT: 10/10
MCV/MCH/MCHC: albumin : 3,2 Ca : 8,5
Protein total: 6,10
78/25/32 gds : 126 Mg : 2,4 Albumin: 2,20
Diftel: 0/0/0/73/20/7 ur/cr : 11/0,40 Ur/cr : 145/5,3 Globulin: 3,90
Fe: 28 na/k/cl : 127/3,9/97 Na/k/cl : 138/3,9/101 Ca/Mg: 7,8/2,1
GDS: 280
Lab 19/05/2023 Ur/Cr: 170/6,70
Hb/L/T: 8,6/23,02/555 Na/K/Cl: 143/4,6/119
MCV/MCH/MCHC: 76/24/32
Diftel: 0/0/1/81/12/6
Albumin: 2,50
GDS: 98
Ur/Cr: 13/0,50
Na/K/Cl: 132/3,80/108

Mammografi 23/05/2023
Kesan:
- Benigna Calcification
mamma kanan dan kiri
(Bi-Rads C2)
- Penebalan kulit pada
mamma kanan
- Tak tampak lymph node di
axilla kanan dan kiri

Ro thorax 19/05/2023
Kesan:
- Suspek Cardiomegaly
- Pneumonia
- Efusi Pleura Kanan
kemungkinan adanya
massa belum dapat
disingkirkan
 MAPING AQSA 3 SELASA PAGI 30 MEI 2023
K4B1 K4B2 K4B3 K4B4 K4B5
DPJP: dr. Siti Adewiah, Dpjp: dr. Siti Adewiyah, DPJP: dr. Fuad, Sp.PD DPJP : dr Riswan SpPD DPJP : dr Fauzi Yusuf SpPD
SpPD KKV Sp.PD KKV COW: dr. Hiban KHOM KGEH
COW: dr. Taufiq Ruangan: dr. Sergio COW : dr Akmal COW : dr. Rianda
Cow: dr. Taufiq
Ruang: dr Dhena Ruangan : dr Jose Ruangan : dr Mirza
Ruangan: dr. Dhena
RABER GH dan PULMO
Nama: Nurdiana Nama: Nurmi binti M Nama: Nurlina Binti Nama : Maulida Binti Banta Nama:Nurhayani
CM: 1040950 Saleh/45 th Khairuddin Husen CM : 0.84.53.93
TL: 01/07/1965 ( 57 thn) CM: 1339800 CM: 1-33-59-03 CM : 1332204 TL : 14.09.1970
TL: 14/7/1977 TM : 25/05/23
TL: 5-11-1982 TL : 10/07/1998 (24 thn)
TM: 27/5/23
TM: 4/05/2023 TM : 06/05/2023

Ass/ Ass/ Ass/ Ass/ Ass/

1. UAP dd/ NSTEMI
2.CKD stg V dengan uremik si
ndrom
3. Anemia berat NN ec dd
1. PGK
2. Perdarahan
4. HF Stage CHF NYHA III
5. Efusi Pleura bilateral
6. HHD
Diet ginjal protein 1,2 gr/kg
BB
Drip Heparin 10.000 unit/24
jam
Drip NTG (5mcg)  1.5
cc/jam
IV ceftriaxone 2 gr/24 jam
(20/05/23)
IV furosemide 20 mg/24 jam
IV omeprazole 40mg / 12 jam
Po valsartan 80 mg/24 jam
Po Lenal ace 2x169 mg
Asam folat 2x0,4 mg
Clopidogrel 75 mg/24 jam
Atorvastatin 1x20 mg
Herbesser 1x100 mg
Pt/aptt: 1.05/0.9
Aptt : 3640
Lab 26/05/23
Analisa cairan pleura
Warna kuning keruh
Bekuan negative
PMN 30
MN 70
Laeukosit 167
Total protein 1.1
Alb 0.7
Glukosa 217
1. Penurunan kesadaran
(perbaikan) ec. hipoglikemia
2. Ulcus diabetic wagner III
pedis sinistra
3. Hipoalbuminemia berat
4. DM tipe 2 overweight
5. Hipokalemia sedang ec dd:
1. Low intake
2. Renal loss
6. Anemia sedang HM ec dd:
1. Chronic disease
2. Defisiensi Fe
7. Ischemic lateral
8. Hipertensi stage II
9. AKI stage I pre renal
10. Scabies dd/ prurigo
Th:
Bedrest
IVFD Dex 10% 20 gtt
IV ampicillin sulbactam 1,5 gr/6
jam
IV lansoprazole 30 gr/24 jam
Gabapentin 1x100 mg
Cetirizine 2x10 mg
Clopidogrel 1x75 mg
Atorvastatin 1x20 mg
Albumin 25% 1x1 fls
KSR 3x600 mg
Lab 27/5/23
H/L/T: 8,4/22,65/266
MCV/MCH: 76/24
Dif: 0/0/0/95/3/2
GDS: 122
Albumin: 2,1
Calcium: 7,5
Ur/Cr: 48/1,4
Na/K/Cl: 134/2,9/118
1. Konstipasi ec dd 1. Anuria ec Nefrolitiasis Bilateral
1.Massa a/r Colli Dextra 2. Hidronefrosis Bilateral
- ca rekti
ec Limfadenitis TB 3. AKI Stage III Post Renal
- IBD 4. HT stage II
2.Hepatomegali ec dd
2.Susp Massa
5. DM tipe 2 obese grade I poorly
metastase proses mediastinum controlled
3. Cancer Pain NRS 6-7 6. Konstipasi ec dd:
-IBS tipe konstipasi
Th/ -gangguan saraf otonom
Bedrest Th/
Diet M III 1700 kkal/hari Bedrest Th/
IVFD Aminofluid 1 fls/hari Bedrest
Diet Sonde 6x200 cc Cateter
IV Tramadol 50mg/12 jam
IVFD NaCl 0,9% 20 tpm Diet DM 1700kkal/hari+rendah
IV Lansoprazole 30mg/24j Garam II
Lactulose syr 3xcll
IV ceftriaxon 2g/24j
IVFD Nacl 0.9% 20 tpm
IV Clinimix 1fl/24j Clinimix Fls/24j Iv Cefteiaxone 2gr/24 jam
Codein 3x10mg Iv cefoferazone 2gr/24jam
Iv omeprazole 40 mg/24 jam
Planning : Drip novalgin 1 amp
Iv ondansentron 4 mg/8jam
FNAB (22/5/23) dalam 500 ml RL/12 Po Metformin2x500mg
Pro colonoscopy jam Po Valsartan 1x160mg
Transfusi hingga Hb>10 Kalitake 3x1sch
Kaltropen supp /8jam Lactulac syr 3xCII
MST 2x1
Lab 20/5/23
Nebul Combivent /8 Planing:
Hb/l/t : 10,3/7,48/272 Urologii (URPS Elektif)
jam
Mcv/mch/mchc : 78/25/32
Diftel : 5/0/1/66/22/6 Nebul Fulmicort / Lab:28/05/2023
H/L/T:10.4/9.78/202
Na/k/cl : 142/4,1/102 12jam
Mcv/Mch/Mchc:79/25/31
Albumin 3,5 N Asetil Sistein Diftell:1/0/1/67/24/7
Pt/apt : 1,02/1,53 3x200mg Ca:8.9
Ur/Cr:86/14.40
Lab 16/5/23 Na/K/Cl:140/5.10/104
P/
Hb/l/t :8,7/7,02/390
Mcv/mch/mchc : 84/26/31 TTNA USG Guiding Lab:27/05/2023
H/L/T:10.7/9.73/195
Diftel : 5/0/0/68/20/7 Susul Hasil Mcv/mch/mchc:82/25/31
Pt/apt : 0,97/1,1 TTNA CT Scan Guiding Diftel:1/0/0/73/19/7
D dimmer : 4860 Selasa/22/5/23 Ur/Cr:109/14.9
Na/K/Cl:139/5.5/104
Ferritin : 479 Pantau nyeri Ca:8.7
Besi/fe : 59
25/05/2023
20/05/23
USG Urologi:
H/L/T:10,4/5.25/280 Nefrolitiasis Bilateral
Lab 12/5/23:
Hb/L/Ht/T: MCV/MCH/MCHC: Mild Hidronefrosis Bilateral

Lab 24/05/23 8,5/11,67/28/371 88/35/31 Ro Thorak:

D-dimer : 4990 Mcv/mch/mchc: 82/25/31 Diftel: 1/3/0/72/16/8 Cardiomegali
Difftel: 3/0/0/77/15/5 Na/K/Cl: 140/3.6/101
Lab 20/05/23 Na/K/Cl: 131/4,1/106 Genu Ap/Lateral:
APTT/PT: 0.89/0.97 OA Genu Bilateral
H/L/T: 8.6/10.11/189 CEA : 1,33 SGOT/SGPT : 22/25
MCV/MCH/MCHC : ALP : 308 Foto Polos Abdomen:
78/27/35 Ground Galss Aprance
Diftell : 3/0/1/78/9/9 Colonoscopy 11/5/23 menggambarkan asites
Suspek massa ekstra lumen Lab 15 /5/2023
H/L/T:9,5/7,41/232 Lab:25/05/23
Tidak dijumpai massa H/L/T:11.3/10.73/191
Lab 20/05/23 intralumen Mcv/mch/mchc:79/25/32
H/L/T: 7.5/9.14/230 Diftell:1/0/1/67/24/7
MCV/MCH/MCHC : HCV:(-)
Lab 08/05/2023 Lab cyto 11/5/2023
75/26/35 HBsAg: Non Reaktif
CEA : 1,17 H/L/T:10,7/9,25/221
Diftell : 0/0/0/87/5/8 HIV (-)
Na/k/cl :132/5/103 MCV/MCH/MCHC: Bil T/D/I:0.39/0.17/0.22
Kalsium :8.4 Lab 5/5/23 SGOT/SGPT:20/12
Hb/Ht/L/T:
86/30/35 Albumin:3.40
Ur/cr : 107/10.3 Diftel: 3/0/0/72/16/9
9,6/29/17,55/480 GDS:217
D-dimer: 5500 Ur/Cr:92/8.80
Lab 18/5/23 Mcv/mch/mchc: 78/26/33
Na/K/Cl:136/4.90/105
H/L/T: 6.6/9.07/232 Difftel: 1/0/0/85/8/6 Na/K/Cl: 140/3,30/108
MCV/MCH/MCHC : Ur/Cr: 16/0,38 APTT/PT: 0,71/0,98
 MAPING AQSA 3 SELASA PAGI 30 MEI 2023
75/26/35 Biltot/dir/indir: Eritrosit: 3,5
Diftell : 1/0/0/88/5/6 0,78/0,52/0,26
Na/k/cl : 123/5.4/98 HbsAg: non reaktif
HbsAg /Anti HIV/ Anti HCV
Lab 11/5/2023
Na/K/Ca/Cl:
: negative H/L/T: 11,1/9,22/196
132/4,1/8,2/102
Ur/Cr : 142/12.9 MCV/MCH/MCHC:
Anti HCV: negative
87/30/35
Albumin: 3,11
LED:61
SGOT/SGPT: 23/20
Rontgen Thorax Anti HCV: negatif
Anti HCV: negative
Efusi Pleura Sinistra FT4/TSH: 18,69/0,921
PT/APTT: 1,05/0,9
(konsul paru, sdh USG thorax : HBsAg: Non reaktif
e Diftel: 1/0/1/74/16/8

EKG awal : PVC CT Scan Thorax dengan

kontras: 11/5/2023
EKG 27/5 : T inverted anterior Massa mediastinum ant
uk. +/- 9x6x10,6cm dengan
Plan dd:
PT/APTT perhari 1.Malignant limfoma
Bila TDS <= 110 mmHg  2.Thymoma
NTG drip STOP Lesi blastik di corpus uk
+/- 9x6x10,6cm dengan
dd:
1.Bone island
2.Metastase

CT Scan Thorax tanpa

kontras:
Tampak lesi blastik di
corpus vertebrata VTh 2
Tampak pembesaran
hepar dengan uk +/-
16,5cm cranio-caudal
length

Radiologi 9/5/2023
USG Tiroid : USG tiroid
lobe kanan kiri tak tampak
kelainan

Urine 08/05/2023
Warna : kuning
Kejernihan : keruh
Protein : -
Glukosa : -
Darah : +
Leukosit : 10-25
Eritrosit : 2-5
Epitel : 0-1

Lab 5/5/2023
H/L/T : 12,6/12,72/289
MCV/MCH/MCHC:
84/30/36
Diftel : 2/0/0/71/17/10
GDS : 92
SGOT/SGPT: 34/54
Albumin : 4,3
PT/aPTT : 0,95/0,77
Ur/Cr : 22/0,5
Na/K/Cl : 135/2,9/106

USG soft tissue : multiple

lymphadenopati ukuran
±2,57 x 2,51 cm, 1,63 cm,
0,52 cm di jugular kanan,
diameter ±0,89 cm,1,32
cm, 1,58 cm, 1,38 cm, 0,64
cm, 0,6 cm di jugular kiri,
1,16 cm, 0,67 cm di
supraclavicula kanan, 1,42
cm di infraclavicula kanan,
0,62 cm di supraclavicula
kiri
MAPING AQSA 3 SELASA PAGI 30 MEI 2023
Thorax PA 6/5/2023
Massa mediastinum
superoanterior
dd/limfomaz thymoma

Rontgen thorax RSPUR (5

mei 23)
Kesan : pelebaran
mediastinum superior
kanan suspect tumor
mediastinum
 MAPING AQSA 3 SELASA PAGI 30 MEI 2023
K5B1 K5B2 K5B3 K5B4 K5B5
Dpjp: dr. Eva Musdalita DPJP: dr. Alfi Syahrin, SpPD Dpjp: dr. M Fuad, SpPD-KHOM Bedah DPJP : dr Fauzi Yusuf SpPD
SpPD KR COW: dr. Ahmad Hibban Cow: dr. Ahmad Hibban Awriya KGEH
Cow: dr. Rianda Akmal Awriya Ruangan: dr. Sergio Pratama COW : dr. Rianda
Ruangan: dr. Yudi Ruangan: dr. Anisa Ruangan : dr Mirza
Aqsa 3 k5b1 Nama: Nurhasanah Nama: Eli Mardana Nama: Samsiah. MS
Nama: FiDiana bt CM: 1-01-26-08 CM: 1-33-94-39 CM: 0-73-99-67
mukhtar/32 th TL: 01-07-1971 TL: 03-01-2002 TL: 25-12-1960 (62th)
CM: 1339882 TM: 14-05-2023 TM: 24-05-2023 TM: 28-05-2023
TL: 1/9/1990
TM: 29/5/23
Ass/ Ass/ Ass/ AQSA 3 K5B5
1. Edema pretibia ec dd 1. Penurunan kesadaran ec dd 1. Thalassemia Nama: Samsiah. MS
1. Sindroma nefrotik CM: 0-73-99-67
1. Prolonged Hipoglikemia TL: 25-12-1960 (62th)
2. Related hipoalbumin 2. Uremic ensefalopati Th/ TM: 28-05-2023
2. Hipoalbuminemia berat Bedrest
3. Sepsis
ec dd Diet MB 1700 kkal/hari Ass/
4. Stroke iskemik
1. Related SN IVFD Nacl 0,9% 20 tpm 1.Carcinoma Recti
2. Low intake 2. CKD stage V on HD dg
IV lansoprazole 30mg/24 jam
uremic ensefalopati Th/
As folat 2x0,4mg
Th: iv ceftriaxone 1gr/12 3. Sepsis ec dd Bedrest
Mecobalamin 3x500mg Diet MB 1700 kkal/hari
jam 1. CAP Iv as traneksamat 250mg/8jam IVFD Nacl 0,9% 20 tpm
Iv furosemide 40mg/12 2. Urosepsis Exjade 1x500mg IV lansoprazole 30mg/24 jam
jam 4. CAP Santa E 400 1x1 Salofalk 3x500mg
Iv omeprazole 40mg/24 5. DM tipe 2 Cefixime 2x100mg(26/5)
jam Planing
6. HT stage II -
7. Anemia sedang NN ec P/
Lab 29/5/23
related CKD Transfusi PRC 1 kolf/hari sampai 29/05/2023
H/L/T: 12,2/7, 0/367 Colonoskopi:
8. Bradikardia asimptomatis HB>10gr/dl
MCV/MCH: 89/30/33 Colitis
Dif: 6/0/1/47/40/6
Th/ Lab 26/5/23
Pt/aptt: 0,82/ 0,87 Lab 16/5/23
Hb/l/t : 5,4/6,12/404 Hb/l/t : 11,1/9,32/309
Gds 80 Bedrest
Mcv/mch/mchc : 70/21/30 Mcv/mch/mchc : 88/29/33
Alb:1, 9 Diet Sonde 6x200cc/hari
Ur/Cr: 20/0, 6 Diftel : 1/1/0/59/28/11 Diftel : 4/0/1/47/41/7
IV. Levofloxacin 500mg/24 Ferritin : 448,80 PT/APTT: 0,87/0,86
Na/K/Cl: 144/3, 6/114 jam (16/5- 11h) HbsAg : Negatif
Hcv/hbsAg: neg/neg Fe : 134
IV. Omeprazole 40mg/24 jam GDS 97
Ot/pt 57/74 TIBC : 146 Ur/Cr : 53/1,74
IV citicolin 1000mg/12jam Na/K/Cl : 143/4,90/109
Drip Dopamin 1 ampul dalam Lab 24/05/2023
50 cc Nacl 0,9 % titrasi dosis Hb/L/T: 4,1/4,28/852
PO bicnat 500mg/8jam MCV/MCH/MCHC: 61/18/29
PO as. Folat 0,4mg/12jam Diftel: 0/1/0/52/36/11
Salbutamol 3x4 mg PT/APTT: 1,24/1,13
Bilirubin T/D/I: 11,26/1,41/9,85
P/ SGOT/SGPT: 43/29
Albumin: 3,30
Cek KGDP/Hari
GDS: 95
HD : senin - rabu - jumat
Ur/Cr: 21/0,40
Na/K/Cl: 141/4,20/111
Lab 25/5/2023
Hb/L/T : 10,1/7,69/220
Mcv/mch/mchc : 87/29/33
Alb ; 3,24
Na/K/Cl : 133/5,10/99
pT/aPTT : 0,9/0,8
D dimer : 970
Ur/Cr : 181/7,4
LED : 130

Lab 22/05/2023
Hb/L/T :10,8/10,34/245
Mcv/mch/mchc : 87/39/33
Diftel : 2/0/0/70/16/12
Ur/cr : 208/9,16
Na/K/Cl : 137/5,5/104
Alb : 3,47

Lab 19/05/2023
Hb/L/T : 9,2/6,33/240
Mcv/mch/mchc : 89/30/33
Diftel : 3/1/0/67/18/11
Ur/Cr : 112/5,76
Na/K/Cl : 141/3,9/111
MAPING AQSA 3 SELASA PAGI 30 MEI 2023
Albumin : 3,15
Procalsitonin : 0,99
LED : 98

CT Scan Kepala Tanpa

Kontras 19/09/2023
Tidak tampak kelainan oada
parenchymal serebri dan
serebellum
Sinusitis maksillaris kanan
dan sinusitis sphenoidalis

Lab 14-05-2023
Hb/L/T: 9,3/8,55/231
MCV/MCH/MCHC: 87/29/34
Diftel: 0/0/0/84/10/6
HIV: Non reaktif
Anti HCV: Negatif
Hbsag: Non reaktif
Albumin: 3,80
Ca: 9,1
Na/K/Cl: 146/4,30/115
Ur/Cr: 150/8,00
GDS: 19
PT/APTT: 1,10/0,9