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Keluhan Utama

Riwayat Penyakit Sekarang

Pasien datang dengan keluhan….

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Riwayat Penyakit Dahulu :

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 Pemeriksaan Fisik
Objective Weak, Alert, GCS 456
BP 120/85 mmHg
HR 86 bpm
RR 20 x/m
Temp 36,3 º C
Head / Neck A- / I-/ C- / D-
Abdominal Bowel sound (+), soepel (+), Spleen and
liver was not palpable

Extremity Warm +/+, edema -/-

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Pemeriksaan Lab

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 Reference
Darah Value
…/8/23 …./8/23
Lengkap

WBC (x103/µL) 3,37 - 10

EO% 0.6-5.4
BASO% 0.3-1.4
NEUT% 39.8-70.5
LY% 23.1-49.9
MO% 4.3-10.10
RBC ( x106/µL) 3.69-5.46
HGB (g/dL) 11.0-14.7
HCT (%) 35.2-46.7
MCV (fL) 86.7 – 102.3
MCH (pg) 27.1 – 32.4
MCHC (g/dL) 29.7 – 33.1
RDW-CV (%) 12.2 – 14.8
PLT (x103/µL) 150-450
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 Reference
Faal Koagulasi (…./7) Range
PPT Sysmex
9 – 12s

APTT Sysmex
23 – 33s

INR

Ddimer 500 ng/mL

Fibrinogen 150-450 mg/dL

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 ER Ward Reference
Kimia Klinik
(…/7) (…/8) Value
K (mmol/L) 3.5 – 5.1

Na (mmol/L) 136 - 145

Cl (mmol/L) 98 - 107
BUN (mg/dL) 7-18
0,6-1,3
Serum Creatinin (mg/dL)

Albumin (g/dL) 3.4 – 5.0

M: 0 – 50
ALT (U/L) F: 0 – 35
M: 0 – 50
AST (U/L) F: 0 – 35

RBG (mg/dL) 100-126

Direct. Bil <0.2
Total Bil 0.2-1.0
Calcium 8.5-10.5

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IMUNOLOGY RESULT

Reference Range
…./…./….

HBsAg <1.0: Non Reactive

1.0: Reactive
Anti HCV <1.0: Non Reactive
1.0: Reactive
HBV DNA

Confirmatory