MAPPING AQSA 2 SENIN SORE (12 JUNI 2023)

K1B1 K1B2 K1B3 K1B4 K1B5

DPJP: Divisi KKV dr. DPJP: dr. M. Riswan, DPJP: dr. Masralena DPJP: Dr. dr. Fauzi DPJP: dr. Masra
Azhari Gani, Sp.PD Sp.PD-KHOM Siregar, Sp.PD-KPTI Yusuf SpPD KGEH Lena SpPD KPTI
Cow: dr. Rianda Akmal COW: dr. Dwi Teguh Cow: dr. Rianda Akmal Cow: dr. Teguh
Ruangan: dr. Yose Irawan Ruangan: dr. Mirza Ruangan: dr. Ilham
Ruangan: dr. Ilham
Abdi
Nama: Mauliddin Bin Nama: Tarmizi Hanafiah Nama: Kasmadi Bin Nama: Abdullah
CM: 1340373 Hasbi Nama Tn. M. Hanafiah
Jakfar Hukum, 61 Tahun
TL: 12/08/1958 CM: 1335404 CM: 1339423
CM: 1340602 CM: 1172000
TM: 4/06/2023 TL: 02/01/1993 TL: 24/10/1991 (31 th)
TL: 25/07/1983 TL: 08/08/1961
TM: 11/06/2023 TM: 24/5/23
TM: 7/06/2023 TM: 09/06/2023
Ass/ Ass/ Ass/ Ass/ Ass/
1. AF NVR 1. Tumor Paru ec dd 1. Ascites gr III ec 1. Obs Jaundice ec multiple 1. Hemetemesis dan
2. HF Stage C Fc tumoe mediastinum dd related to SH cholecystolithiasis melena ec
NYHA III-IV ec dd 2. Cancer pain 2. SH stad. DC CP - Varises esofagus
- HHD B related to Th/ bleeding
- IHD Th/ Hep.B Bedrest - Varises fundus
3. Asites grade II ec dd Bedrest 3. Anemia berat HM Diet Hati II 1700kkal/hari gaster
related HF Diet MB 1700 kkal/hari EC related to SH Ivfd Nacl 0.9% 20 tpm 2. Sirosis hepatis
IVFD NaCL 0,9% 4. Trombositopenia iv omeprazole 40mg/24 j decompersata CTP
Th/ Tramadol tab 50mg ec dd related to Iv cefoferazon 1gr/12jam B
Bedrest IV lansoprazole SH Pct 3x500mg 3. Anemia berat NN
O2 4L NK 30mg/24jam 5. Status Curcuma tab 3x1 ec dd
IVFD Comafusin Hepar 1 Hipokoagulasi Po UDCA 2x250mg - Penyakit kronik
fl/12 jam 6. Hipoalbuminemia - perdarahan
P/ sedang 4. Hipertensi stage I
Diet hati II 1700 kkl/hari Susul hasil biopsi Planing:
+ 5,4 gr garam/hari 7. AKI stage I terkontrol
prerenal ec dd/ Hari ini Tindakan 5. Hipoablbuminemi
Iv omeprazole 40 g/12 Alih rawat
jam Radiologi (4/6/2023) - Infeksi a Berat ec dd
PO spironolactone 2x100 Thoraks AP/lateral - Dehidrasi - Liver disease
mg Kesimpulan: 31/05/23 - Low intake
PO UDCA 2x250 mg - Susp. Pancoast tumor Th/ MRCP: 6. Hiperglikemia ec
PO curcuma 3x1 - Aortosclerosis Bedrest Multiple cholecytoslithiasis dd:
PO propranolol 1x10 mg Diet hati II - Dm tipe 2
PO lactulac sus 3xC II 1700kkal/hari - Reactive
Bronchoscopy (9/6/23) Lab:02/06/2023
Drip furosemide IVFD Aminofusin hyperglikemia
Normal H/L/T:11.7/7.30/262
Lab (11/6/2023) Hepar 1 fls/24 jam Mcv/mch/mchc:77/26/34
P/ Aptt:30,20 IV Lansoprazole Diftell:4/1/0/54/33/8 Th/
Ekokardiografi Pt:17,20 30g/24 jam PT/APTT:1.00/1.01 Bedrest
Lab IV Ceftriaxone 1gr/12 Bil T/D/I:7.92/5.69/2.23 O2 2-4 lpm
Urinalisis jam SGOT/SGPT:35/50 Dite hati II 1700 kkal
Lab: (04/06/2023)
Makroskopik: Drip Ocrootide 2 amp Albumin:3.20 IVFD Nacl 0,9% 20
Hb/L/T: 10,1/21,62/402
Kuning /Keruh (dlm 50 cc NaCl drip Ca:10.2 tpm
mcv/mch/mchc: 83/28/33
Berat jenis:1.026 kec. 6,25 cc/) Ur/Cr:15/0.2 IVFD Aminofusin
Diftel: 40/0/0/39/14/7
pH 5 IV Vit K 1 amp/12 Na/K/Cl:142/4/111 Hepar 1 tpm/24 jam
KGD: 94
Leukocyte: positive jam IVFD NaCl 0,9% 20
Ur/cr: 36/0,80
protein: positive (+1) IV As.Tranexamat 500 tpm
Na/K/Cl: 137/4,50/106 Lab:28/05/23
Ketone: positive mg/8 jam Drip ocreotride 2 ap +
H/L/T:11.8/5.96/384
Urobilinigen: positive PO Curcuma tab 8 jam 50 cc Nacl 0,9% kec
Mcv/mch/mchc:77/25/34
Darah: positive PO CPZ ¼ tablet 6,25 cc/jam selama 72
Diftell:2/1/0/46/38/13
Granular Cast:positive IV Albumin 25 mg 1 jam
SGOT/SGPT:39/55
Hyalin Cast: positive fls/24 jam IV lansoprazole
Bil T/D/I:8.82/6.24/2.58
Sedimen urine: 30g/24j
Leukocytes: 10-25 P/ IV Vit K 10g/8j
25/05/2023 IV Kalnex 500g/8 jam
Eritrosit: 25-50 EKG
USG Abdomen: IV ondancetron
Epitel: 0-1 Urinalisa
Cholelitiasis dg cholesititis 4mg/12j
Lab (9/6/10) Rontgen Thorax PA
Urinalisa: USG Abdomen Amlodipin 1x10g
Warna: Kuning Konsul GEH 25/05/23 Transfusi PRC s/d Hb
Kejernihan: Keruh (terpasang drain Amilase:55 9
Berat Jenis: 1,026 asistes) Lipase:70 Drip Albumin
pH: 5,0 CEA:1.03 25%/hari
L/P/Keton/Darah: + Lab 11/06/2023
Leu/eri/epitel: 10-25/25- Hb/L/T: 5,6/5,27/45 Lab:24/05/2023 P/
50/0-1 Mcv/Mch/Mchc: Urinalisa : Normal Konsul GEH
Glanular cast: + 65/21/32 ALP:160 Urinalisa
Epitel: + Diftel: 3/0/-1/74/14/10 Ca.19.9:7.63
PT/APTT: 21,10/34,40 LDH:111 Lab 10/6/23
Imunoserologi: HbsAg: reaktif LED:99 Hb/L/T: 3,4/9,59/99
AFP: 2,10 Bilirubin direct: 0,88 HT/E: 11/1,7
Bilirubin indirect: 0,72 Lab 23/5/23 MCV/MCH/MCHC:
Protein total: 4,90 H/l/t: 12,6/ 6/366 64/20/31
 MAPPING AQSA 2 SENIN SORE (12 JUNI 2023)
Lab (7/6203) Albumin: 2.40 Mcv/Mch: 77/26 Diftel: 0/0/1/69/19/11
Ca/Na/K/Cl: Ur/Cr: 103/1,50 Dif: 3/1/0/41/47/8 Lab 9/6/23
7,5/144/6,30/115 Na/K/Cl: 135/4,50/120 PT/APTT: 1,0/1, 01 Hb/L/T: 3,9/7,94/72
Ur/Cr: 138/5,60 Hcv/Hbsag: Neg/Neg HT/E: 13/1,9
Bil T/D/I: 8,65/5, 99/2, 66 MCV/MCH/MCHC:
Lab (6/6/2023) SGOT/SGPT: 58/72 67/21/31
H/L/T:10,8/8,37/221 Alb/glob: 3,2/4, 5 Diftel: 0/0/0/77/20/3
Mcv/mch/mchc: 90/31/34 Gds 95 Bill Tot/D/I:
Diftell: 1/1/0/81/7/10 Ur/Cr: 24/0, 4 0,88/0,34/0,54
Birulium total : 3,55 Na/K/Cl: 142/1/5/105 PT/APTT: 1,71/1,27
Direct/indirect : 2,1/1,45 Ca 9,8 Anti HCV / HBsAg: -
SGOT/SGOT : 29/13 SGOT/SGPT: 94/82
Alb : 3,40 Albumin: 2,40
Ca : 8,8 GDS: 229
Ur/Cr : 53/0,8 Ur/Cr: 88/0,90
Na/K/Cl : 131/4,00/104 Na/K/Cl: 135/4/116
 MAPPING AQSA 2 SENIN SORE (12 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 Planing: Nebule Ventolin 2 (ext)
Lactulac susp 3x1 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 Transfusi PRC s/d Hb 10 Iv. Insulin 10 unitdlaam
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
mg PO Lactulax syr C H/L/T:9/7.58/358 PO Lenal Ace
Lab 07/06/2023 PO As.Folat 2x0,4 mg II/8jam Mcv/mch/mchc:8/27/34 PO Bic nat 5000 mg/8
Analisa cairan asites Ciprofloxacin 2x500mg IV Albumin 25% fls/24 Diftell:11/1/0/60/19/9 jam
Bekuan: negatif Drip Novalgin 1 amp/8 jam Ca:8.4 PO As. Folat
Glukosa: 114 jam Ur/Cr:14/0.70 Drip albumin 25%
Kejernihan: keruh Na/K/Cl:142/3.30/111 IV Ciprofloksasin 20g/1h
MN: 85 Lab 10/06/2023
PMN: 15 P/ Hb/L/T: 12/14,03/172
Transfusi PRC target Hb Mcv/mch/mchc: Lab:09/06/2023 P/
Protein total: 6,20 gr/dL H/L/T:7.6/12.33/368
Warna: kuning >7 90/32/35 Urinalisis
Pemeriksaan MDT dan Diftel: 3/0/0/74/14/9 Mcv/mch/mchc:83/27/33 Cek DR, Ur/Cr, elektrolit
BMP PT/APTT; 1,24/1,02 Diftell:5/0/0/7313/9 HD
06/06/2023 SGOT/SGPT: 46/26 Gen Xpert
Urine rutin Albumin: 2,30 08/06/2023 Ro thorak (susul hasil)
Berat jenis: 1,020 Lab (11/6/2023)
Hb/L/T:6,4/1,25/9 Ur/Cr: 79/1 Colonoskopi: Kultur Sputum
Bilirubin: negatif Na/K/Cl: 138/3,5/106 Masa di rectum Hemodialisis selasa -
Darah: negatif Mcv/mch/mchc:82/28/35
Diftel:0/0/0/18/56/26 jumat
Epitel: 0-1
Eritrosit: 0-2 Lab:07/06/2023
Glukosa: negatif Lab 09/06/2023 H/L/T:8.3/7.28/504 Radiologi
Kejernihan: jernih Hb/L/T: 8,9/3,81/78 Mcv/mch/mchc:83/27/33 Tb Paru
Keton: positif Mcv/mch/mchc: Diftell:9/1/0/30/50/10 Cor tak tampak kelainan
Leukosit: negatif 83/28/34 PT/APTT:0.97/1.01
Nitrit: negatif Diftel: 0/0/0/49/28/23 Lab 09/06/23
pH: 5 Lab 22/05/2023 Urinalisis:
Protein: negatif 07/06/2023 Hb/L/T: 10,5/6,70/417 Warna: Kuning
Urobilinogen: positif Urine rutin Mcv/Mch/mchc: kemerahan
Warna: kuning Berat jenis: 1,013 89/29/32 Kejernihan: Keruh
Bilirubin: negatif Dif: 11/1/0/36/46/6 Berat Jenis: 1,018
Lab 05/06/2023 Darah: negatif Albumin : 3.60 pH: 5,0
Hb/L/T: 10,6/7,04/297 Epitel: 0-1 Ur/cr: 0,70/12 Leukosit/Darah: +
MCV/MCH/MCHC: Eritrosit: 0-2 N/K/Cl : 145/3,70/109 Leu/eri/epitel: 25-50/450-
88/29/33 Glukosa: negatif 500/0-1
Diftel: 4/1/0/59/28/8 Kejernihan: jernih Sel ragi: +
Lab 15/05/2023
HbsAg: Non reaktif Keton: negatif bakteri: +
N/K/Cl : 144/3,70/111
Albumin: 3,30 Leukosit: negatif
Bil tot/d/i : 0,65/0,3/0,35 Nitrit: negatif Lab 08/06/2023
 MAPPING AQSA 2 SENIN SORE (12 JUNI 2023)
Sgot/sgpt : 23/10 pH: 5 Hb/L/T: 8,8,/17,92/ 105
GDS : 98 Protein: negatif MCV/MCH/MCHC:
Ur/Cr : 27/1,10 Urobilinogen: positif 79/27/34
Na/K/Cl : 144/5,20/113 Warna: kuning Diftel: 0/0/0/92/3/5
kecoklatan PROCALSITONIN :6,35
K:5,8
Lab 07/06/2023 Albumin: 1,71
Anti HCV: negatif Ur/Cr: 288/16,42
Bilirubin direct: 1,23 Na/K/Cl: 130/5,8 /117
Bilirubin indirect: 0,73
Bilirubin total: 1,96 Lab 6/6/2023
SGOT/SGPT: 36/15 Hb/L/T: 10,5/25,14/152
MCV/MCH/MCHC:
06/06/2023 83/28/33
Foto thoraks AP Diftel: 0/0/0/96/2/2
Kesan: tidak tampak Albumin: 2,10
kelainan pada cor dan Ur/Cr: 318/19,70
pulmo saat ini Na/K/Cl: 132/7,30/110

Lab 05/06/2023
Hb/L/T : 7,2/2033/20
MCV/MCH/MCHC :
80/27/34
Diftel : 0/0/1/40/47/12
PT/APTT : 1,18/0,99
HbsAg : Non reaktif
Albumin : 2,80
Ca : 8,9
GDS : 111
Ur/Cr : 35/0,50
Na/K/Cl : 125/4,60/94
 MAPPING AQSA 2 SENIN SORE (12 JUNI 2023)
K3B1 K3B2 K3B3 K3B4 K3B5

DPJP : Dr. dr. Fauzi DPJP : dr. Cut Mela DPJP: Dr. Desi Salwani DPJP: dr. Eva DPJP: dr. M. Riswan
Yusuf, Sp.PD KGEH Yunita Sari, SpPD., Sp.PD KGH Musdalita, Sp.PD.KR Sp.PD
COW : dr. Rianda KGH COW: dr. teguh Cow: dr. Rianda Cow: dr. Rianda
Akmal COW: dr. Akmal Ruangan: dr. Arfah Ruangan: dr. Tri Ruangan: dr. Jose
Ruangan: dr. Mirza Ruangan: dr. Wahyudi
Kurniawan
Nama : Muhammad Nama: Ichwan Jailani Nama: Usman Harun Nama: Junaidi Binti Nama: Suwardi bin
Taib CM: 1-34-08-79 CM: 1340433 Jainor Sulaiman
CM : 1334074 TL: 11-02-1968 TL: 10/3/1969 CM: 1133784 CM: 1246600
TL : 1/7/1959 TM: 10/6/2023 TM: 6/6/2023 TL: 26-10-1977 TL: 04-05-1967
TM :8/6/2023 TM: 08/6/2023 TM: 11/6/2023
Ass/ Ass/ Ass/ Ass/ Ass/
1. Gastritis antral 1. Ulkus diabeticum 1. Nefrolitiasis dext 1. CKD Stage V dengan Pseudomyxome
2. Anemia Berat wagner IV ar pedis dengan nefritis dex uremic syndrome ec peritoneal post
3. Polip recti Sinistra 2. Nefrolitiasis kiri dgn dd kemoterapi
4. Hipoalbumin Berat 2. Sepsis ec dd hidronefrosis grade 4 - PNC
- Ulkus diabeticum 3. BPH 2. Anemia sedang Th/
Th/ - Pneumonia related CKD IVFD NaCl 0,9% 20tpm
Bedrest 3. Anemia Berat NM Th/ 3. Hipoalbumin sedang IV furosemid
Diet M II 1500 kkal/hari ec dd Bedrest ec dd 20mg/12jam
IVFD RL 20 tpm SS - penyakit kroniS Diet mb 1700 kkl/hari - Renal Loss IV ondansetron 4mg/8jam
Tutosol 1 fls/hari - Defisiensi besi IVFD NaCL 0,9% 20 - Low Intake Terapi lain sesuai FDO
Drip lansoprazole 60 cc 4. AKI stage III on tpm/menit 4. Hiperkalemia related
dengan kec 5cc/jam CKD Herbeser 1x100 mg CKD
5. Gout Atritis P/
IV ondonsetron 4 mg/ 8 IV Ceftriaxone 2gr/24 Pro kemoterapi
jam P/ jam
Drip Albumin 1flsh/24 O2 2lpm IV lansoprazol 30
jam (+3) Bedrest mg/24jam Th/ Lab/10/06/2023
Diet DM 1700 kkal/h + Bicnat 3x200 gr 1. Bedrest Hb/L/T : 11,4/8,36/442
0,9 g kkal/kgbb/l Alopurinol 1 x 500 mg 2. Diet ginjal 1700 NMCV/MCH/MCHC :
P/ 86/28/33
Persiapan EGD IVFD NaCl 0,9% 20tpm kkal/ hari + protein
IV Omeprazol 40g/24j 1,2 gr/kgbb/hari Diftell : 0/0/1/89/9/1
EKG P/
Cek Albumin ulang IV Ampicilin sulbactam Evaluasi DR Ur/Cr 3. Threeway
1,5g/6j 4. IV ceftriaxone Lab/08/06/2023
Drip Insulin 50cc Nacl 2g/24j Hb/L/T : 10,5/7,04/392
Lab:12/06/2023 0,9% Radiologi 5. IV lansoprazole NMCV/MCH/MCHC :
H/L/T:9.9/18.20/380 Po Clindamisin 3x300 gr CT Scan Abdomen tanpa 30mg/12j 84/29/34
Mcv/mch/ Po Gabapentin 1x100g kontras 6. Herbeser 1 x 100 Diftell : 6/0/0/60/27/7
mchc:84/28/34 Po Atorvastatin 1x20g Nefrolitiasis dekstra + mg SGOT/SGPT : 32/4
Diftell:1/0/0/91/7/1 Po Lactulac syr 3xcII Nefritis dextra 7. Allopurinol 1 x 100 Ur/Cr : 22/0,77
Albumin:2.52 Parasetamol 1000g/8jam Nefrocalsinosis sinistra mg Na/K/Cl : 139/2,50/107
Ca:8.2 Valsatran 80g/24jam + Hidronefrosis Grade 8. Kalitake 1 sachet/8j
Ur/Cr:18/0.9 IV 9. IV Ca Gluconose 1
Na/K/Cl:139/3.4/109 amp (extra)
Lab 12/6
LED 130 Lab 10/06/2023 10. Ventolin 1 respul
Lab:08/06/2023 HT/E : 30/ 4,1 UR/CR : 133/6,10 (extra) `
H/L/T:3.8/13.06/435 HB/L : 9,3 /20,18 11. IV Novorapid
Mcv/mch/ MCV/MCH/MCHC: dalam 10 unit dex
Lab 08/06/2023
mchc:87/28/33 23/31/72 40% 50cc (Extra)
HBsAg: non rekatif
Diftell:1/0/0/83/11/5 diftel: 12. PO Domperidone
HIV : Non rekatif
PT/APTT:1.29/1.15 0/0/0/94/4/2 10g/8 jam
Anti HVC : negative
Anti HCV:(-) Procalsitonin : 0,61
HBsAg: Non Reaktif PSA total:2,68 P/
GDS:94 Lab 10/6/23
Hb/L/T: 7,4/15,11/503 Na/K/Cl: 147/3,50 /118 1. Cek asam urat
Albumin:2.00 Ca: 8,6 2. Urinalisa
Ur/Cr:25/0.80 HT/E: 7,4/3,4
MCV/MCH/MCHC: PT/APTT: 0,1/0,94 3. Cek elektrolit
Na/K/Cl:137/3.40/109 ulang
4. EKG
67/22/33 Lab 05/06/2023
Diftel: 1/0/0/87/6/6 Hb/L: 10,4/6,56
PT/APTT: 1,20/1,05 MCV/MCH/MCHC: Lab 08/06/23
Anti HCV/ HBsAg: - 05/30/33 Hb/L/T: 7,0/15,66/291
Albumin: 2,50 Diftel: 0/101/74/18/7 MCV/MCH/MCHC:
SGOT/SGPT: 57/19 Ur/Cr: 146/6,82 70/23/32
Ca/Na/K/Cl: Diftell: 1/0/1/85/9/4
8,3/125/5,50/94 PT/APPT: 1,65/1,15
Lab 05/06/2023
GDS: 700 Ddimer: >20000
Urin rutin
Ur/Cr: 82/2,20 HIV R1: Non reaktif
Bj :1,012
Anti HVC: -
Bil : negative
HbsAg: Non reaktif
Darah : positif
Albumin: 2,8
Eoitel :0-1
Ur/Cr: 199/10,40
Eritrosit:10-25
Ca/Na/K/Cl:
MAPPING AQSA 2 SENIN SORE (12 JUNI 2023)
Glukosa : negative 9,2/145/6,20/121
Kejernihan: keruh
Keton : positif AGD:
Leukosit : positif Po2: 126
Nitrit : positif Hco3: 8,6
PH : 5,0 Total CO2: 9,1
Protein: +1
Urobilinogen : negative
Warna : kuning muda

Lab (2/6/2)
H/L/T: 10,4/6,56/206
MCV/MCH/MCHC:
90/30/33
Diftel: 1/0/0/74/18/7
Ur/Cr: 146/6,82

Urinalisis:
Protein +1
 MAPPING AQSA 2 SENIN SORE (12 JUNI 2023)
K4B1 K4B2 K4B3 K4B4 K4B5

DPJP: Prof. Dr. dr. DPJP: dr. Masralena DPJP: dr. Eva Musdalita, DPJP dr Desi Salwani, DPJP: dr. Alfi
Maimun Syukri, Sp.Pd Siregar, Sp.PD-KPTI Sp.PD.KR SpPD KGH Syahrin, Sp.PD
KGH COW: dr. Dwi Teguh Cow: dr. Rianda Cow: dr teguh COW: dr. Hibban
COW: dr. Akmal Irawan Ruangan: dr. Tri Ruangan dr arfah Ruangan: dr.
Ruangan: dr. Ruangan: dr. Ilham Abdi Wahyudi Annisa
Gamalinino
Nama: Abdul Murad Nama: Ibrahim Nama : Ilyas AR Nama : Anwar Yusuf Nama: Sulaiman
CM: 1-28-87-27 CM: CM : 1-34-08-93 Cm : 1340018 Hasyem, 60 Tahun
TL: 01/07/1976 TL: TL : 31/12/1944 TL 25/05/1955 CM: 1340430
TM: 29/05/2023 TM: TM : 10/06/23 TM 6/6/23 TL: 15/02/1963
TM:09/06/2023
Ass/ Ass/ Ass/ Ass/ Ass/
1. CKD Stage IV on HD 1. Bisitopenia ec dd 1) Hematochezia dengan 1. Brust Fr. Vertebre T4 + 1. Bisitopenia ec
reguler - CML melena ec dd : spine stenosis - Anemia
2. Pneumonia CAP - AML 1. Varices esofagus 2. Paraparese inferior aplastic
3. HT stage II 2. AKI Stage 1 ec dd bleeding 3. Anemia sedang HM ec - Leukopenia
- Dehidrasi 2. Varices fundus dd - MDS
Th/ - Infeksi bleeding 1 Peny kronik
Bedrest Th/ 2) Sirosis Hepatis Std DC 2 Def Fe Th/
Diet Ginjal Bedrest related Hep B 3 AKI stage III Bedrest
1700kkal/hari+ protein IV Cefipime 1gr/8j 3). Anemia berat NN ec 4 Hiponatremi Diet MB 1700
1,29g/KgBB/hr + RG+ IV Lansoprazole 3g/1h perdarahan Hipoosmolar kkal/hari
bebas kalium IV Paracetamol Drip 1gr/8 4). Geriatri Problem Nonketotik IVFD Nacl 0,9%
IV Levoper 2x1 j 5 Hyperuricemia 20tpm
PO Bisoprolol 1x5 mg PO Curcuma tab/8jam Th/ 6 ISK IV omeprazole
PO Adalatforos 1x30mg Bedrest 20g/24jam
PO Valsartan1x160 mg P/ Diet Lunak 1700 Kkal/hari Th/ Metilprednisolon
PO PCT 3x500mg Susul hasil MDT IVFD Nacl 0,9% 20 tpm Bedrest 62,5g/12 jam
PO Laxadin syr 3xIIc BMP IV Omeprazole 40 gr/24 Diet ginjal 1700 kkal + Fosen Enema 1 fls
PO Hytroz 1x2mg Konsul divisi HOM jam 0,6 g/kgBB extra susp
IV Vitamin K 1 amp/12 1vfd nacl 0,9 20 tpm PO Lactulax syr CI /8
P/ Lab 11/06/2023 jam Iv lansoprazole 3g/24 jam
Echocardiogram Hb/L/T : 4,4/38,71/75 IV Ceftriaxone 2 gr/24 jam jam Transfuse PRC
(tunggu jadwal) Mcv/mch/mchc: 86/30/35 IV Albumin fls/24 jam Iv ceftriaxone 2 g/24 jam sampai HB 10G/DL
Take down AV Shunt Difftel: 1/1/0/40/18/40 Drip ocreotide 1 amp 6,25 Domperidone 10g/8jam
(menunggu stabil Ur/cr : 72/1,30 cc/jam Alopurinol 1 x 100 mg
P/
leukosit) Na/K/Cl : 132/4,30/105 Komafusin hepar 1 Lactulac 3 x 30 cc
Crossmatch
Cek ulang lab cito tgl fls/24jam PCT 1000 mg/12 jam
BMP
10/06/2023 (susul hasil) Fosen Enema 1 fls extra
Cek DR
Lab 11/6 susp

Radiologi 6/6/23 HCO3 : 21,5 Urin rutin 12/6

Kesan: Tak tampak pCO2 : 27 P/ Glukosa +2,
gambaran infark di pH : 7,5 Cek serum TIBC, Jernih, kuning
parenkim otak pO2 94 Ferritin, DR Ur/Cr, Keton +
total CO2 : 22,3 elektrolit

LAB 12/6/23 Lab 10/6/23 Lab 12/6

Ferritin: 5203,00 Hasil USG Urologi:
Hb/l/t: 7,2/18,35/134 Bilirubin direct 0,26
Besi(fe) 48 Sludge didalam gall
Mcv/mch/mchc: 76/26/34 Cl 11.1
bladder
PT/APTT: 1,29/1,2 Cr 0,88
Nephritis bilateral
Lab 4/06/23 Diftel: 0/0/0/79/16/5 Diftel : 0/0/0/82
Nephrolithiasis bilateral
Hb/L/T :10,4/19,89/213 Ur/cr: 190/3,80 MCV/MCHC
Kista ren dextra poe atas
MCVMCH/MCHC: Ca: 7,9 81/35
cystitis
74/27/336 Na/k/cl :151/4,9/128
Diftel: 1/0/0/90/4/5 GDS :116 Lab 11/6
Cl: 104 SGOT/SGPT: 46/33 Limfosit : 7 Lab (9/6/23)
Ur/Na/K/Cr: HbsAg: Reaktif Mcv/mch/mchc : Hb/L/T: 4,9/2,71/393
267/132/4,90/11,90 Anti-HCV: Negatif 27/78/35 HT/E: 14/1,8
Diftel : MCV/MCH/MCHC:
Lab 31/05/2023 0/0/0/72/7/20 79/28/35
H/L/T: 9,9/20,73/116 Trombosit :97 Diftel: 3/0/0/31/41/25
Na/K/Cl: 136/4,30/104 Ur : 99
Na 132
Lab 30/05/23
As. Urat: 6,1 Lab tgl 7/6/23
Hb/l/t : 9,8/3,57/122
Mcv/mch/mchc :
Lab:29/05/23
77/27/35
H/L/T:7,2/17,87/81
Diftel : 0/0/0/50/13/50
Mcv/mch/
Ur/cr : 115/1,77
mchc:77/28/37
Na/k/cl : 128/4.0/102
Diftell:0/0/1/93/3/3
PSA : 0,30
HCV/HBsAg :(-)
 MAPPING AQSA 2 SENIN SORE (12 JUNI 2023)
Albumin:3.10 LED : 5
Ur/Cr:227/18,4
Na/K/Cl:128/4,2/108

Lab tgl 30/05/23

Hb/L/T : 11,0/3,17/177
Mcv/mch/mchc :
78/27/35
Diftel : 0/1/0/45/14/40
Ur/cr : 109/1,93
GDS 86
Na/K/Cl/ca :
128//3,4/93/8,9
A urat : 17,5

Ro LS ap/lat
Levoskoliosis lumbalis
Spondiloartrosis
troracolumbalis
Spondylosis
thoracolumbalis
Fraktur komplesi VL 1
Nephrolithiasis sinistra

Ro thorax
Cor dan pulmo dalam
batas normal.
 MAPPING AQSA 2 SENIN SORE (12 JUNI 2023)

K5B1 K5B2 K5B3 K5B4 K5B5

DPJP: dr. Eva Musdalita, DPJP: dr. Islamuddin, DPJP: dr. Masralena DPJP : dr. Islamuddin, DPJP : dr.
Sp.PD.KR Sp.pd Siregar, Sp.PD-KPTI SpPD Islamuddin, SpPD
Cow: dr. Rianda COW: dr. Rianda COW: dr. Dwi Teguh COW : dr. Rianda COW : dr. Rianda
Ruangan: dr. Tri Wahyudi Akmal Irawan Akmal Akmal
Ruangan: dr. Tri Ruangan: dr. Ilham Abdi Ruangan : dr. Tri Ruangan : dr. Tri
Wahyudi wahyudi wahyudi
Nama : Ruslan Bin Usman Nama: Muhazir bin M. Nama : Azhar Bin Ahmad Nama : Japrinan bin Cut Nama : Yosep
(66 th) Yacob Cut Agam, 59 th CM : 1-34-09-67
CM : 1161380 CM: 1-34-02-88 CM : 1-18-03-35 CM : 1-34-08-05 TL : 12-12-1974
TL : 01/07/1956 TL: 20/03/1986 Tl : 01/07/1960 TL : 1/7/1963 TM : 11/06/23
TM : 7/6/2023 TM: 02/06/2023 TM : 11/06/2023 TM : 9/6/2023
Ass/ Ass/ Ass/ Ass/ Ass/
1. RuQ Pain ec dd: 1. Krisis 1.Hematemesis melena ec dd 1. Hepatomegali ec dd 1.PSMBB ec dd
-colelitiasis dgn colecystitis Hiperglikemia 1). Ulkus gaster - Hepatoma 1).Hemoroid interna
-coledocolithiasis perbaikan ec dd 2). Ulkus duodenum - Liver abses 2).Polip Recti
2. Colic Renal ec dd: - KAD 3). Gastritis Akut 2. Dispepsia type like 2.Anemia Berat HM ec
-BSK 2. Sepsis ec dd 2. Anemia Berat NN ulcer dd :
-ISK - Pneumonia 3. Hipoglikemia 1).Def FE
3. Dispepsia tipe like-ulcer - Urosepsis 4. CAP Th/ 2). Penyakit Kronis
4. Anemia sedang HM ec dd: 3. Pneumonia CAP 5. HF stage CFC nyha II Bed Rest
-Def. Fe 6. CAD Diet MB 1700 kkal/hari
-Penyakit Kronis Th/ 7. Post stroke IVFD NaCl 0,9% 20 tpm
5. Gout Artritis Kronis 8.DM Tipe II NW Th/
Bedrest IV Cefoperazone 1gr/12j Bedrest
6. Hipertensi stg II Diet DM 1700kkal/hari IV Lansoprazole Diet MB 1700 kkal/hari
IVFD Nacl 0,9% 300 30mg/12j IVFD NaCl 0,9% 20
Th ml/24 jam Th/ Domperidone 3x10g tpm
Bedrest Drip cevofloxacin Bedrest Sc Heparin 3000 IU/12 IV Lansoprazole 30
Diet m II 1700 kkal/hari 75g/24 jam Diet DM 1700 kkal/hari jam mg/24 jam
IVFD RL 20 tpm IV Omeprazole 40 g/24 rendah garam Antihemorroid Supp
IV Cefoperazone 1g/12 j jam IVFD Nacl 0,9% 20 tpm P/ 2x1
IV Lansoprazole 30mg/12 j PO Amlodipin 10g/24 Drip levofloxacin 250 Konsul GEH pro USG Transfusi PRC s/d Hb
IV Buscopan 1 amp/8 j jam mg/jam Abdomen 10 gr/dl
Antasida 3x1 tab PO N-ACE 200g/8 jam IV Omeprazole 40 mg/24 Lipid profile
Domperidone 1x10mg PO Domperidone 10g/8 jam
Paracetamol 3x500mg jam IV Ondansentron 4 mg/8 jam
Amlodipine 1x10mg Lab 12/06/2023 Lab (11/6/23)
IV Vitamin K 1 amp/12 jam Kolesterol total 129
Valsartan 1x80mg Urin rutine (12/6/2023) PO N-asetylsistein 3x200 mg Hb/L/T: 6,5/5,33/224
Ketorolax DMP/8jam Hdl/ldl/trigli (24/93/75) HT/E: 25/3,7
Glukosa (+1)
Keton (+) MCV/MCH/MCHC:
Planning : Urin rutine (12/6/2023) 66/18/27
Planing/
Urinalisis Keton (+) Diftel: 13/1/0/51/23/12
Lab 10/06/2023 Urobilinogen (+) SGOT/SGPT: 18/17
Asam Urat Hb/L/T: 10,3/20,55/226
SI,TIBC, Ferritin Na/K/Cl: 144/4,30/115
Mcv/mch/mchc: Ur/Cr: 34/0,90
Foto Polos Abdomen 79/28/35 Lab (9/6/23)
Lab 11/06/23 GDS : 88
USG Abdomen Diftel: 0/0/0/95/2/3 Hb/L/T: 11,2/9,23/305
Hb/L/T: 4,5/10,15/384
EGD Albumin: 2,10 HT/E: 34/4,6
HT/E: 14/1,6
Ur/Cr: 27/0,70 MCV/MCH/MCHC: MCV/MCH/MCHC:
Radiologi 09/06/2023 Ca: 7,4 87/28/32 75/24/33
Thorax PA Na/K/Cl: 130/2,9/102 Diftel: 2/0/0/77/15/6 Diftel: 9/0/0/71/12/8
Kesan : HbA1c: 12,30 PT/APTT: 1,35/0,79 PT/APTT: 1,15/1,07
Cor tak membesar D-dimer: 440 D-dimer: 1960
Bronchopneumonia Anti HCV/ HBsAg: Anti HCV/ HBsAg: -
Lab 02/06/2023 Bilirubin total: 1,00
Efusi pleura kanan, suspek Hb/L/T: 12,9/8,96/396 Negatif/Non-reaktif
efusi pleura kiri SGOT/SGPT: 31/20 Bilirubin direct: 0,46
Mcv/mch/mchc: Bilirubin indirect: 0,54
Diafragma kanan letak tinggi 82/28/34 Bill T/D/I : 0,51/0,16/0,35
Na/K/Cl: 137/4,50,109 SGOT/SGPT: 57/19
Diftel: 0/0/0/87/5/8 Ca/Na/K/Cl:
Foto polos abdomen AGDA Ur/Cr: 24/1,50
Albumin : 2,70 9/140/3,60/112
Kesan : pH/PCO2/PO2/HCO3/ Ur/Cr: 29/0,60
Tak tampak gambaran ileus Total CO2/BE/SpO2: GDS : 83
maupun pneumoperitoneum 7,34/17,3/78/9,4/10/-
Tak tampak bayangan batu 13,8/94,6
radiopaque di sepanjang Albumin: 3,10
traktus urinarius GDP:375
Ur/Cr: 72/1
Lab 06/06/2023
Hb/L/T: 9,1/12,56/349
HT/E: 30/4,4
MCV/MCH/MCHC:
67/21/31
Diftel: 0/0/0/81/11/8
 MAPPING AQSA 2 SENIN SORE (12 JUNI 2023)
Bill Tot/D/I: 1,32/0,52/0,8
SGOT/SGPT: 36/16
Ur/Kr: 26/1,3
Na/K/Cl: 138/3,6/10
 MAPPING AQSA 2 SENIN SORE (12 JUNI 2023)

K6B1 K6B2 K6B3 K6B4 K6B5

DPJP SARAF DPJP: dr fauzi yusuf DPJP: dr. Sarah Firdausa, Dpjp : dr. Vera
sppd kgeh Sp.PD Abdullah SpPD KPsi
COW: dr rianda COW: dr. Rianda Akmal Cow : dr. Akmal
Ruangan: dr mirza Ruangan: dr. Aufa Ruangan : dr.
Gamalinino

Nama: Supriyadi Nama: Syahril Yusuf Nama: M.Yusuf A

CM: 1.33.76.40 CM: 1-34-00-99 CM: 1-01-77-41
TL: 03.05.1992 TL: 31/12/1993 (59 th) TL: 27/02/1962 (61 Th)
TM:07/06/2023 TM: 31/05/2023 TM: 05/06/2023

Ass/ Ass/ Ass/

1. Massa rectum 1/3 distal 1.Penurunan kesadaran 1. Efusi genu bilateral dd
susp. Ca recti (perbaikan) ec dd Arthritis Septik Genu
2. Hemorroid interna Gr II - sepsis Dextra et Sinistra
3. Fisura Ani - Uremic Ensefalopati 2. CKD Stage V on HD
2. Sepsis ec dd: reguler
Th/ - Pneumonia 3. HF Stage C FC
Bedrest - Urosepsis NYHA III ec dd :
Diet Lunak 1700kkal/hari 3. Pneumonia CAP - HHD
IVFD RL 20 tpm 4. CKD Stage V ec dd - IHD
Iv Omeprazole 40mg/24 - PGOI 4. Iskemik Anteroseptal
jam - HN 5. Hipoalbuminemia
Iv Asam Tranexamat 6. Anemia berat (perbaikan) Sedang
500mg/12 jam ec dd:
Anti hemorroid 2x1 - Defisiensi besi Th/
- Penyakit Kronik Bedrest
7. Hipokalemia Diet Ginjal 1700
Planing
Tindakan Biopsi Hari ini kkal/hari + protein 1,2
Th/ g/kkBB/hari
Bedrest Threeway
08/06/2023 Diet ginjal 1700 kkal/hari + IV Ceftriaxone 2 g/24
Endoskopi: 1,2 protein/kgBB/hari jam
Hemorroid Interna Gr II Threeway IV Omeprazole 40
Fisura Ani IV Meropenem 1gr/8jam mg/24 jam
IV Omeprazole 40mg/12jam PO Paracetamol 2x1000
Lab:07/06/2023 P.O Acetylcystein mg
H/L/T: 16.3/7.27/219 200mg/8jam PO CPG 1x75 mg (stop
Mcv/mch/mchc:87/30/34 P.O Amlodipine 10mg/24jam sementara persiapan
Diftell:16/1/0/45/32/6 Attapulgit 1 Tab /Bab cair aspilet)
Anti HCV:(-) PO Valsatran 160 mg/24 jam PO Aspilet 1x80 mg
HBsAg: Non Reaktif Ventolin nebul (stop sementara
PT/APTT: 0.96/1.08 PO PCT 1 tab persiapan aspilet)
SGOT/SGPT:22/22 (K/P) PO Atorvastatin 1x20
Albumin:3.94/ mg
Ca:9.5 P/ PO Amlodipin 1x10 mg
Ur/Cr:14/1.02 Balance cairan PO Captopril 1x25 mg
Na/K/Cl:144/3.6/108 AV Shunt Lactulac syrp
CEA:33.02 Konsul BTKV Fosen enema susp

Lab 10/06/2023 P/
H/L/T: 8/6,95/132 HD reguler rabu-sabtu
Mcv/mch/mchc: 71/24/33 Echo menunggu
Diftell: 6/0/0/76/12/6 dipanggil
Ur/CR : 58/3,5 AV Shunt Rabu
Ca: 3,6 14/06/2023
Na/K/Cl : 140/3,60/111
Lab:10/06/2023
Lab 07/06/2023 H/L/T: 9,9/9,93/282
H/L/T: 8,0/5,55/171 Mcv/mch/mchc:
Mcv/mch/mchc: 69/24/35 82/28/34
Diftell: 11/0/1/65/14/9 Diftell: 0/0/0/88/8/4
Ur: 98 PT/APTT: 0,87/1,02
Asam Urat: 5,9 Albumin: 2,90
Kreatinin: 5,43 Ca:9.7
Si: 28/2455/6,09 Ur/Cr:81/6,20
Na/K/Cl:133/3,60/109
Ddimer : 19590
Urinalisa 05/06/23
Warna: kuning muda
MAPPING AQSA 2 SENIN SORE (12 JUNI 2023)
Kejernihan : keruh Lab 7/06/23
pH : 6,5 Kolesterol tot: 146
Berat jenis: 1,009 HDL/LDL:44/78
Leukosit : Positif Trigliserida:84
Protein : Positif (1+) LED :82
Glukosa : Negatif RF: negative
Keton : Positif CRP Kualitatif: positif
Nitrit : Negatif
Urobilinogen : Positife Lab 7/06/23
Bilirubin : Negatif Urin rutin
Darah : Positif Bj :1,008
Sedimen Bil : negative
Epitel : 25-50 Darah : negative
Eritrosit : 10-25 Eoitel :0-1
Leukosit : 0-1 Eritrosit:0-1
Glukosa : +1
Lab: 05/06/2023 Kejernihan: jernih
PT/APTT : 0,99/0,93 Keton : negatif
DDimer : 2740 Leukosit : negatif
Calcium : 7,8 Nitrit : negatif
Ur/Cr : 100/6,9 PH : 7,0
Na/K/Cl : 138/3, 4/106 Protein: +1
Sel ragi : positif
Lab: 03/06/2023 Urobilinogen : negatif
Hb/L/T: 8.0/14.04/197/ Warna : kuning muda
mcv/mch/mchc: 66/24/36
Diftel: 1/0/1/89/3/6 Lab: 05/06/2023
Ca/Mg: 10/3,2 Hb/L/T: 10/8,60/216
Ur/Cr: 53/4,60 mcv/mch/mchc:
Na/K/Cl: 138/3,20/108 84/28/33
Diftel: 0/0/1/82/12/5
Lab: 01/06/2023 PT/APTT: 1,97/0,95
Hb/L/T: 7.0/14.43/184/
mcv/mch/mchc: 65/24/37 HBsAg: non reaktif
Diftel: 0/0/1/94/1/4 HIV R2 : Non Reaktif
PT/APTT: 1,09/1,10 Anti HCV : Negatif
D-dimer: 2590 HbsAg : Non Reaktif
HBsAg: non reaktif Albumin: 2,60
Bilirubin total: 0,41 Ca: 7,7
Bil. direk: 0,15 Ur/Cr:81/7,20
Bil. Indirect: 0,26 Na/K/Cl : 137/3,90/109
SGOT/SGPT: 86/35
Albumin: 2,50
Ca/Mg: 8,0/2,0
Ur/Cr:143/10,80
Na/K/Cl:125/4,30/99