Denah Ruang Rawat

AQSHA 2 (Penyakit Dalam Pria)

Hari/Tanggal : senin, 17 Desember 2018

Dokter Jaga : dr.firdaus/dr.henna
Dokter Muda jaga : sandi/nola/randy/naya

K1B1 K1B2 K1B3 K1B4

DPJP : dr. Krishna, Sp. PD DPJP : dr. Krishna, Sp. PD DPJP : dr. Krishna, Sp. PD DPJP : dr. Krishna, Sp. PD
COW : dr. Kudrah COW : dr. Kudrah COW : dr. Kudrah COW : dr. Kudrah
PPDS : dr. Muhsin PPDS : dr. Muhsin PPDS : dr. Muhsin PPDS : dr. Muhsin
DM : Alvin DM : Alvin DM : Alvin DM : Alvin
Nama : Rahmad Syafii Ahmad Nama : Cut Ali Nama : Sulaiman Ibrahim Nama : Zulfiat sri
TTL : 22 th TTL : 01/07/1940 (78 thn ) TTL : 31/12/1940 ( 77 Tahun) TTL 15/01/1957(61 thn )
Alamat : Pidie Alamat : Dusun pemuda, Aceh Jaya Alamat : Pidei Alamat : kota banda aceh
Pekerjaan : mahasiswa Pekerjaan : Petani/pekebun Pekerjaan : Pensiunan Pekerjaan : Wiraswasta
CM :1186453 CM :1-19-39-99 CM :1193411 CM : 1-16-41-93
Hari rawatan : 5 Hari rawatan : 4 Hari rawatan : 5 Hari rawatan : 2

A/ A/ A/
1. Colitis ulseratif drajat 1, CHF nyha lll-lv ec dmc 1. 1. Massa A/r Epigastrium ec dd/ : A/
berat 2 CPC 2. –limpoma maligna 1.CKD stg V ec HN dg edema paru
3. TB paru dd pneumonia 3. –ca caput pakreas akut
Th/ 4.Destroyed long ec dd TB Paru 4. 2. Dyspepsia tipe dismotility dd type 2. pneumonia
- Tirah Baring 5. Hernia inguinalis dextra mixed 3.hipertensi on terapi
- Diet MII 1700 kkal/hari 6. Tricuspit regirgutation 5. 3. Hidrop gall bladder
- Salofalk 4x 500 mg 6. 4. Hepatitis C kronik
- IV Metil prednesolon 125 mg/12 Th/ 7. 5. Hipertensi On Terapi Th/
jam (H3) 1.Bedrest 8. 6. BPH -tirah baring semi folwer
- IV Omeprazole 40 mg/12 jam 2. O2 2 liter/ menit -o2 3-4 liter/i
- Lenal Ace 2x169 mg 3. Diet MII 1700kkal/hari Th/ -drip furosemide 20 mg
- Calsitriol 2x1 tab 4.IV FD Frutrolit 10 gtt/menit -Bedrest -iv. Ceftriaxone 2gr/24j
- IVFD Futrolit 20 gtt/i 5.IV Cefoperazone 1 gr/ 8 jam(H4) - Diet M II 1700 kkal/hari ( Rendah -treway
6.IV Furosemide 1 amp/ 8 jam Garam) -lenal ace 2x169 mg
Lab 13/12/2018 7.Paracetamol 500 mg (k/p) - Amlodipin 1x10 mg -asam folat 2x400 mcg
Hb/Ht/E/L/Tr 8.Nebule Ventolin 1 mg/8 jam - Sucralfat Syr 3x150 cc -valsartan 1x 80 mg
9,4/30/3,9/14,6/405 9. Nebul Combivent 1resp/8 jam - Curcuma 2x1 tab Flumucil 3x200 mg
MCV/MCH/MCHC - Omeprazole 2x20mg -erdostain 3x300 mg
76/24/32 Lab 13/12/2018
Diftel : 4/0/0/65/25/6 LED ; 107 Lab 08/12/2018 Lab 16/12/2018
SGOT/SGPT : 20/14 Hb/Ht/E/L/T Hb/Ht/E/L/T
Lab 11/12/2018 12,9/38/4,8/7,6/185 10,1/31/3,5/9,2/282
Hb/Ht/E/L/Tr Lab 12/12/2018 MCV/MCH/MCHC MCV/MCH/MCHC
9,7/31/4,0/14,7/451 Hb/Ht/E/L/Tr 80/27/34 90/29/33
MCV/MCH/MCHC 13,7/42/5,4/12,4/315 Diftel: 33/0/0/24/33/10 Diftel; 5/1/0/68/19/7
76/24/32 MCV/MCH/MCHC Ur/cr: 20/1,21 HBsAg : -
Diftel : 5/1/0/66/23/5 78/26/33 Ur/Cr: 86/8,62
Ur/Cr : 12/0,99 Diftel : 1/1/0/72/13/13 Lab 07/12/2018 Na/K/Cl: 141/5,1/106
SGOT/SGPT : 12/8 Ur/Cr : 38/1,09 Anti HCV /HBsAg : +/ -
Na/K/Cl :140/4,7/104
Lab 06/12/2018
Lab 08/12/2018 Hb/Ht/E/L/T
Hb/Ht/E/L/T 11.8/ 32/4.2/ 6.3/ 168
9,7/31/4,0/14,7/451 MCV/MCH/MCHC
MCV/MCH/MCHC 76/28/37
76/24/32 Diftel: 21/1/0/23/39/13
Diftel: 5/1/0/66/23/5 GDS : 116
Ur/cr: 12/0,99 Ur/Cr: 515/0.96
SGOT?SGPT:12/8 Na/K/Cl: 133/4.3/96
Gds: 108
 K2B1 K2B2
DPJP : dr. Krishna, DPJP : dr. Krishna, Sp.
Sp.PD PD
COW : dr. Kudrah COW : dr. Kudrah
PPDS : dr. Muna PPDS : dr. Muna
DM : isna dan entan DM : isna dan entan
Nama : sahudin Nama : ABD. Rasyid
TTL : 01/07/1944 (74 th) TTL : 10-07-1966 (52th)
Alamat : gayo lues Alamat : aceh besar
Pekerjaan : Petani Pekerjaan : pekebun
CM : 1-19-06-95 CM : 1-15-83-16
Hari rawatan : 5 Hari rawatan : 12
A/
1. Hepatocelluler Ca A/
related Hep. B 1.Penurunan kesaradan dd/
2. Jaundice ec dd -Metabolik ensefalopati
- HCC -stroke (VTE)
- cholangio ca -metastase proses
- ca ampula vateri 2.Ca esophagus post
- ca caput pankreas kemotrapi siklus IV
3.High risk trombosis
Th/
- Bed rest
- Diet hati II 1700kkal/hari Th/
- IVFD aminofusin hepar 1 - Bedrest
fls/hari - Diet MII gastro
- IV omeprazole 40 mg /12 duodenum tube 6x200 cc
jam - Diet Lunak 1700
- Curcuma 3x1 kkal/hari per oral bila
- Graphalac Syr 3xCI kooperatif
- IVFD futrolit 20gtt/i
Lab 10/12/2018 - IVFD clinimix + clinoleic
Hb/Ht/E/L/T 1 fls /hari 20gtt/i
10,0/25/3,7/10,6/260 - Paracetamol 3x500mg
MCV/MCH/MCHC - Laxadin syr 3x CI
67/27/40 - KSR 2x600mg
Diftel: 3/0/0/88/5/4 - Tracetat 2x1
Ur/cr: 44/0,95 - Pradaxa 1x75mg
Na/K/Cl: 124/4,0/86
Lab 13/12/2018
Urinalisa
Kuning, jernih
pH 6,5
lekosit /protein: -/-
glukosa /keton: -/-
nitrit-
urobilinogen +
bilirubin /darah: -/-
leukosit 2-3
eritrosit 1-2
epitel 8-10
Lab 10/12/2018
Hb/Ht/E/Tr/L
12,5/34/41/298/9,6
MCV/MCH/MCHC
83/30/37
Diftel : 0/0/0/56/36/8
Ca/Ur/Cr : 7,7/8/0,38
Na/K/Cl :136/3,2/98
K2B3 K2B4 K2B5
DPJP : dr. Krishna, DPJP : dr. Krishna, Sp.PD DPJP : dr. Krishna, Sp. PD
Sp.PD COW : dr. Kudrah COW : dr. Kudrah
COW : dr. Kudrah PPDS : dr. Muna PPDS : dr. Muna
PPDS : dr. Muna DM : isna dan entan DM : isna dan entan
DM : isna dan entan
Nama : Bakhtiar M.Nur Nama: Yuswandi Nama: usman syakubat
TTL : 01-07-1975 Umur: 01-01-1990 (28th) Umur: 31/12/1959 (58 thn)
( 43thn ) Alamat: Aceh jaya Alamat: pidie jaya
Alamat :aceh jaya Pekerjaan: Wiraswasta Pekerjaan: petani
Pekerjaan : wiraswasta CM: 1-19-21-41 CM: 1-19-36-09
CM : 1-19-41-93 Hari rawatan: 17 Hari rawatan: 9
Hari rawatan : 4
A/ A/
1.NSTEMI 1. obs. Jaundice ec dd
A/ 2.CHF NYHA III-IV ec - ca caput pancreas
1. hipoglikemia ec low myxoma atrium dextra - ca ampula vateri
intake 3.Myxoma at right atrium - cholangio ca
2. Post Drainase abses a.r 4.Pulmonal hipertensi 2. post PSMBA
Thorax Posterior severe
3.DM tipe 2 Normoweight 5.Tricuspid regurgitasi Th/
4. Anemia HM ec dd moderate - Bedrest
- penyakit kronis 6. Efusi pericard mild - Diet Hati II 1700 kkal/hari
- Def.Fe - IVFD Nacl 0,9 % 20 gtt/i
-occult bleeding Th/ - IV ceftriaxone 2 gr/24 jam (H6)
5. TB Paru dd Pneumonia - Bedrest, semi fowler - IV omeprazole 40 mg/ 12 jm
6. Hipoalbumin berat - Threeway - Sucralfat syr 3xcI
7. Hipokalemia - Drip furosemide 10 mg/j - Cetrizine 2x10 mg
- Drip Dobutamin mulai 5 - Curcuma 3x1
Th/ meq titrasi dosishinga - IV vit K 1 amp/8j
-Bedrest target MAP≥ 6 mmHg
-Diet M II 1700 kkal/hari- - Cilostazol 1x100mg
Diet Sonde 6x200 cc - Sc arixtra 2.5mg/24j Lab 14/12/2018
-NGT dan kateter - Clopidogrel 1x75mg AFP 1,38
-IVFD dex 10% 20 - Aspilet 1x80 mg Bill.total/direct/indirect
gtt/menit - Cefazolin 1gr/24 jam 33,16/21,67/11,49
-IV ceftriaxone 2 gr/24 SGOT/SGPT
jam Lab 12/12/2018 151/77
-Clyndamisin 3x300 Hb/Ht/E/Tr/L
-Paracetamol 3x500 11,2/34/4,8/277/12,1 Lab 11/12/2018
-KSR 2x600 MCV/MCH/MCHC PT/APTT: 12,8/51,4
-Transfuse PRC s/d 83/30/37 Bilirubin direct 19,87
Hb≥10 gr/dl Diftel : 0/0/0/56/36/8 ALP : 252
-Drip albuminar 25% Ca/Ur/Cr : 7,7/8/0,38
100cc/ hari (H1) Na/K/Cl :136/3,2/98 Lab 11/12/2018
-IVFD Nacl 0,9% Urinalisa
Lab 05/12/2018 Kuning, pekat
Lab 14/12/2018 Hb/Ht/E/L/Tr pH 7,0
Hb/Ht/E//L/Tr 10,7/32/4,6/478/16,4 lekosit /protein: +/+1
3,6/12/1,8/8,3/278 MCV/MCH/MCHC glukosa /keton: -/+
MCV/MCH/MCHC 70/23/33 nitrit /urobilinogen: -/-
65/20/31 Diftel: 0/0/0/84/10/6 bilirubin /darah: +/+
Diftel : 9/0/0/64/22/5 Ca: 8.7 leukosit 10-15
Ur/cr:12/0,40 Ur/cr: 114/1,36 eritrosit 8-10
Na/K/Cl: 143/2,7/113 Na/K/Cl: 127/5,5/88 epitel 6-8
Urinalisis
Protein (+1) Lab 09/12/2018
Darah (+) Hb/Ht/E/Tr/L
13,8/35/4,7/391/9,0
Lab 04/12/2018 MCV/MCH/MCHC
Ca ; 8,6 76/30/39
Na/K/Cl Diftel : 2/1/0/60/21/16
130/4,9/91 Ur/Cr :28/1,26
Na/K/Cl : 142/3,1/100
SGOT/SGPT ; 137/73
Albumin 2,74
Globulin 4,00
Gds 111
Anti HCV –
HBsAg –
 K3B1
DPJP : dr. Fauzi yusuf,
Sp.PD
COW : dr. Karolina
DR : dr. Andri
DM : syahput dan abdi
Nama: T. Sukardit Ali
Umur ; 14-11-1953 (65 th)
Alamat ; Aceh Besar
CM: 0-96-77-16
Hari rawatan: 2
A/
1. Penurunan kesadaran ec
dd/
-HE grade III-IV
-stroke
-metastase proses
-sepsis
-imbalance elektrolit
-Metastase proses
2. sirosis hepatis std
decompensate dgn hepatoma
3. PSMBA ec dd/
-varises esophagus bleeding
-varises fundus bleeding
-Gastropati hipertensi portal
4. Pneumonia dd/ TB Paru
dengan infeksi sekunder
5. hipoalbuminemia
6. High risk trombosis
Th/
- Bedrest Head up 30
- O2 2-4 L/i nasal kanul
- NGT/ kateter
- Diet sonde hati 6x200cc
- IVFD comafusin hepar 1
fls/ hari
- Threeway
- IV cefoperazone sulbactam
1gr /8j
- IV vit k 10 gr/8j
- Drip omeprazole dlm 50cc
Nacl 0,9% via shrimp
pump 5cc/j
- Lactulac syr 3xCII
- Fosen enema (k/p)
- Albumin 25% 100cc/hari
(H2)
Lab 14/12/2018
Hb/Ht/E/Tr/L
11,7/34/3,5/135/8,5
MCV/MCH/MCHC
97/33/34
Diftel : 3/1/1/55/26/14
PT/APTT: 13,8/48,0
HbsAg: -
Bilirubin direct: 1,11
SGOT/SGPT: 79/24
Albumin: 2,10
GDS: 78
Ur/Cr :100/1,35
Na/K/Cl : 132/4,9/106
K3B2
DPJP : dr. Fauzi yusuf,
Sp.PD
COW : dr. Karolina
DR : dr. Andri
DM : syahput dan abdi
Nama: Adnan ali
Umur ; 01-07-1956 (62 thn)
Alamat ; tibang, Banda aceh
CM: 1-18-90-16
Hari rawatan: 9
A/
1. Pneumonia (HCAP)
(perbaikan)
2. Hipotensi ec. Syok
Kardiogenik (Disfungsi
Diastolik)
3. CKD stage V ec PNC on
HD reguler
4. Post pemasangan DJ Stent
a/r Nefrolitiasis dextra
5. OA genu dextra
6.Hiperuresemia
Th/
-Bedrest
-Diet ginjal 1700kkal/hari +
protein 70 gr/hari
-IV cefepime 1gr /24jam
(H4)
-Lenal ace 2x 169 mg
-As. Folat 2x400 mg
-Paracetemol 3x500 mg
-HD (Senin-kamis)
-Balance cairan seimbang
-Azitromisin 1x500gr (H4)
-Drip Dobutamin 5mcg
/kgBB/jam
- Balance Cairan seimbang
Lab 11/12/2018
Hb/Ht/E/L/T
8,5/26/2,9/22,0/413
MCV/MCH/MCHC
89/30/33
Diftel: 1/1/0/72/19/7
Asam urat : 9,3
Lab 06/12/2018
Hb/Ht/E/Tr/L
9,3/27/3,1/343/19,2
MCV/MCH/MCHC
86/30/35
Diftel : 1/1/0/71/20/7
Ur/Cr :109/7,31
Na/K/Cl : 137/3,6/98
K3B3 K3B4 K3B5
DPJP : dr. Fauzi yusuf, DPJP : dr. Fauzi yusuf, DPJP : dr. Fauzi yusuf, Sp.PD
Sp.PD Sp.PD COW : dr. Karolina
COW : dr. Karolina COW : dr. Karolina DR : dr. Andri
DR : dr. Andri DR : dr. Andri DM : syahput dan abdi
DM : syahput dan abdi DM : syahput dan abdi
Nama : Panedi Muslige Nama : Ridwan Nama : Abdullah Ismail
TTL : 23-12-1984 ( 33 thn) TTL :181-05-1953 (65 thn) TTL : 01/07/1948 (70 thn)
Alamat : Aceh Tengah Alamat : aceh besar Alamat : Aceh Besar
Pekerjaan : Wiraswasta Pekerjaan: petani Pekerjaan : Petani
CM :1-19-37-97 CM : 0-91-27-44 CM : 1-19-23-57
Hari rawatan : 10 Hari rawatan :2 Hari Rawatan : 16
A/ A/ A/
1. Prolong fever ec dd/ 1. retensi urine ec ca. prostat 1. CKD stg V ec PNC
-Typhoid toxic 2.AKI stg III post renal 2. sepsis ec dd
-Malaria 3. Hipertensi stg II -selulitis
-Perikarditis -pneumonia
-Pneumonia (HAP) Th/ 3. Pnemonia
2. Elevated liver enzymes ec. -tirah baring 4.DVT upper ekstremitas
dd/ -diet ginjal 1700kkal/hari superior dd/
-Hepatitis Tifosa -kateter urine -sellulitis post AV shunt
-Hepatitis Viral -Iv ceftriaksone 2gr/24j -kompartemen syndrome
-Hepatitis Autoimun -Bicnat 3x1 5. HHD
3. Hipoalbumin ec. dd/ -amlodipin 1x10 mg
-Distributel loss -Ivfd f utrolit 20 gtt/i Th/
-Protein loss - Bedrest
- O2 8 l/menit simple mask
Th/ Lab 16/12/2018 - Lenal ace 2x169mg
-Bedrest Hb/Ht/E/L/T - Asam folat 2x400 mcg
-Diet MII 1700 kkal/hari 10,4/30/3,7/6,6/217 - HD rabu-sabtu (saran free
-IV FD NaCl 0,9 % 30 tpm MCV/MCH/MCHC heparin)
-IV Cefriaxone 2 gr/24 jam 83/28/34 - drip moxifloxacin 400mg
-curcuma 3x1 Diftel: 1/0/0/78/14 /24jam H2
-drip metamizole 1 amp Ur/Cr: 110/3,76 - lansoprazole 30mg/12 jam
/8jam (H1) Na/K/Cl: 137/4,1/106
Urinalisa 14/12/2018
Kuning, Keruh Lab 14/12/2018
pH 8,0 Analisa gas darah
lekosit /protein: +/+1 pH: 7,524
glukosa /keton: -/+ pCO2: 24,90
nitrit /urobilinogen: -/- pO2:65
bilirubin /darah: -/+ HCO3: 20,7
leukosit 6-8 Total CO2: 21,5
eritrosit 4-6 Kelebihan basa (BE): -0,8
epitel 2-3 Saturasi O2: 94,2
Lab 12/12/2018 Lab 13/12/2018
Hb/Ht/E/Tr/L Hb/Ht/E/Tr/L
10,5/30/3,6/124/6,3 6,1/18/2,5/71/15,4
MCV/MCH/MCHC MCV/MCH/MCHC
82/29/35 72/25/35
Diftel : 0/1/0/48/45/6 Diftell: 0/1/0/94/2/3
Ur/Cr :39/0,58
Na/K/Cl : 140/4,3/111 Lab 12/12/2018
SGOT/SGPT : 168/140 Hb/Ht/E/Tr/L
PT/APTT :13,5/21,8 6,4/19/2,6/155/4,6
MCV/MCH/MCHC
74/25/33
Diftell: 5/1/0/70/18/6
Na/K/Cl: 138/4,2/115
 K4B1
DPJP : dr.Fauzi yusuf,
Sp.PD
COW : dr. Karolina
DR : dr. Andri
DM : najib
Nama : Hasan Basri AR
TTL : 01/07/1977 (41 thn )
Alamat : Bireuen
Pekerjaan : Petani Pekebun
CM : 1-19-40-07
Hari rawatan : 5
K4B2
DPJP : dr.Fauzi yusuf,
Sp.PD
COW : dr. Karolina
DR : dr. Andri
DM : najib
Nama : Joni Bahriansyah
TTL : 12/09/1971 (47 thn)
Alamat : Banda Aceh
Pekerjaan : Wiraswasta
CM : 1-18-64-47
Hari rawatan : 9
K4B3 K4B4 K4B5
DPJP : dr.Fauzi yusuf, DPJP : dr.Fauzi yusuf, DPJP : dr.Fauzi yusuf,
Sp.PD Sp.PD Sp.PD
COW : dr. Karolina COW : dr. Karolina COW : dr. Karolina
DR : dr. Andri DR : dr. Andri DR : dr. Andri
DM : najib DM : najib DM : najib
Nama : M Nasir Nama : syukran ussri Nama :Herman Syah
TTL : 11-06-1990 (28 thn) TTL : 18/10/1991 (27) TTL : 28-04-1976 (42 thn)
Alamat : Nagan raya Alamat : Gayo lues Alamat : Aceh Selatan
Pekerjaan :petani/pekebun Pekerjaan : petani Pekerjaan : Petani/pekebun
CM : 1-19-31-65 CM : 1193581 CM : 1-19-39-15
Hari rawatan : 12 Hari rawatan : 7 Hari rawatan : 5

A/ A/ A/ A/
1.penurunan kesadaran ec dd/ 1. Multipel Ulkus Gaster 1.Colitis infeksi non spesifik 1.Bisitopenia ec dd/ A/
-syok sepsis 2. cushing syndrome 2.Candidiasis oral ec -leukemia akut 1. PSMBA ec. dd/
-HE latrogenik dd/ insufisiensi immunocom-promise state -anemia aplastic -varises esophagus
-imbalance elektrolit adrenal kronis 3.Peumonia dd TB Paru -hemolitik anemia bleeding
2. syok sepsis ec dd/ 3. Hepatitis C kronis insfeksi sekunder -varises fundus bleeding
- pneumonia 4. polineuropati 4..DM tipe 1 Th/ -ulkus gaster
-malignancy 5.anemia sedang NN ec dd/ 5. Asites ec dd/ -Bedrest 2.Hepatomegali ec dd/
3. HE Grade III-IV dg -perdarahan - TB Peritoneal -Diet MB 1700kkal/hari -HCC
pencetus infeksi dan -peny.kronis - Hipoalbuminemia -IV FD NaCl 0,9 % 20 gtt/i -Metastase proses
konstipasi 6. Gangguan Penyesuaian - Malignancy - transfusi prc s/d hb > 3.Cancer pain
4. PSMBA ec dd/ 10gr/dl 4.Hepatitis B kronik
-varises esophagus bleding Th/ 5. Status Hipokoagulasi
-varises fundus bleding Th/ -Bedrest Lab 15/12/2018
-gastropati hipertensi porta - Bedrest -Diet DM 1700kkal/hari Hb/Ht/E/Tr/L Th/
5.anemia berat dd/ - Diet MII 1700 kkal/hari -IV FD NaCl 0,9 % 20 gtt/i 8,1/26/2,7/88/3,8 -Bedrest
-perdarahan - Threeway -SC Apidra 16-16-16 unit MCV/MCH/MCHC -Diet hati I 6x200 cc/hari
-peny.kronis - IV Lansoprazole -SC Lantus 0-0-0-0-32 unit 95/30/32 -NGT
6.HCC dg Hep B Kronik 30mg/12jm -Flumucy tab 3x200 mg Diftel: 4/1/0/53/30/12 -IV FD Comafusin hepar 1
7. hipoglikemia ec low intake - IV Ondansetron 4mg/ 8 jam -itrakonazole 2x100mg fls/hari
8. high risk thrombosis - IV mecobalamin 500mg -synbio 3x1 Lab 13/12/2018 -Curcuma 3x1
9.status hipokoagulasi /12jam -Ketoconazole cream 2xUE Hb/Ht/E/L/Tr -Lactulac syr 3x30cc
10. hypokalemia sedang -Tramal supp (k/p) -KSR 1x600mg 8,3/26/2,8/4,7/92 -cefoperazon sulbactam
- IV buscopan 1 amp/8jm MCV/MCH/MCHC 1gr/8jam
Th/ -clobazam 1x10mg (21.00) Lab 12/12/2018 94/30/32 -IV Omeprazole 40mg/12
-Bedrest -amitriptilin 2x12,5mg Na/K/Cl : 136/3,3/98 Diftel:4/0/0/61/26/9 jam
- NGT Bil total:1,19 -IV Octreotide 100 mcg
-Diet Hati II 1700kkal/Hari + Lab 07/12/2018 Lab 11/12/2018 Bil direct: 0,24 inisial
Rendah lemak 6x200 kkal SGOT/SGPT: 19/14 Ca: 8,6 SGOT/SGPT:113/21 -Drip Octreotide200mcg
-Threeway Albumin 3,30 LDH: 1803 dlm 50 cc NaCl 0,9% 
-IV Omeprazole 40mg/12jam Globulin: 2,00 Lab 10/12/2018 6,25 cc/jam via syring
-IV Cefoperazon Sulbactam 1 Hb/Ht/E/L/Tr Lab 12/12/2018 pump
gr/8 j (H3) Lab 06/12/2018 11,6/34/4,0/8,6/229 HEMOSTASIS - IV. Vit. K 10 mg/ 8jam
-curcuma 3x40mg PT/APTT: 11.2 / 26.9 MCV/MCH/MCHC D-dimer : 667,48
-Lactulac syr 3x30cc RF : Positif 85/29/34 Lab 16/12/2018
-Fentanyl patch 25 mcg (H3) Direct / Indirect : 0.16/0.26 Diftel:2/1/0/58/29/10 Lab 11/12/2018 Hb/Ht/E/Tr/L
-IVFD comafusin hepar 1 fls -SGOT/SGPT : 20/14 Ca : 8,6 Anti HCV : Negatif 7,5/21/2,2/389/13,4
/hari -Albumin : 3,31 HBsAg : Negatif MCV/MCH/MCHC
-kaltropen sup extra (k/p) Asam Urat : 7.0 Lab 07/12/2018 95/34/35
-ivfd nacl 0,9% guyur 1 liter Anti HCV (-) Lab 09/12/2018 Diftel: 1/1/0/77/11/10
-iv vit k 1 amp/8j Lab 05/12/2018 HbsAg (-) Hb/Ht/E/L/Tr PT/APTT
-transfusi prc 1kolf Hb/Ht/E/Tr/L 5,7/18/1,8/5,3/102 20,4/49,7
- drip kcl 25meg dalam nacl 9,9/20/2,4/496/6,1 Lab 05/12/2018 MCV/MCH/MCHC
0,9% 500 cc 20 gtt MCV/MCH/MCHC Hb/Ht/E/T/L 103/32/31 Lab 12/12/2018
83/42/51 11,5/31/3,9/7,2/271 Diftel:1/1/0/60/30/8 Hb/Ht/E/Tr/L
Diftel:4/1//0/66/18/11 MCV/MCH/MCHC SGOT/SGPT:82/20 10,8/29/3,2/277/11,5
Lab 14/12/2018 Ur/Cr : 9/0,88 80/29/37 MCV/MCH/MCHC
PT/APTT Na/K/Cl : 137/3,8/100 Diftel:1/1/0/72/19/7 91/34/38/21,7/11,2/14,5
13,3/42,9 Ur/Cr : 22/0,78 Diftel: 1/1/0/80/10/8
SGOT/SGPT Na/K/Cl : 132/4,1/86 Na/K/Cl : 137/4,9/112
861/396 Albumin : 3,30 SGOT/SGPT :1050/385
Urinalisa GDS : 800 Albumin : 3,39
AFP > 400,00 Ur/Cr : 39/1,03
Kuning pekat GDS : 79
Keruh HBsAg : Positif**
pH 6,5
Protein : +2
Bilirubin : +
Leukosit : 8-10
Eritrosit :1-2
Epitel : 3-5

Lab 12/12/2018
Hb/Ht/E/L/Tr
10,5/27/3,3/13,2/403
MCV/MCH/MCHC
82/31/39
Diftel:3/0/0/82/9/6
Ur/Cr : 102/1,63
Na/K/Cl ; 129/5,4/97
Albumin : 3,70
SGOT/SGPT : 695/362
GDS : 100
 K5B1 K5B2
DPJP : dr. Azhari Ghani, DPJP : dr. Azhari Ghani,
Sp.PD Sp.PD
COW: dr. Qausar COW: dr. Qausar
Dr : dr. Taufiq Dr : dr. Taufiq
DM : fauzan DM : fauzan
Nama: BUKHARI Nama: IDRIS RASYID
Umur: 53 th Umur: ; 03-02-1969 (49 thn)
Alamat : sabang Alamat : pidie jaya
CM: 1193768 CM: 1-17-58-38
Hari rawatan: 7 Hari rawatan: 12
A/ A/
1. UAP dd / NSTEMI 1. penurunan kesadarn ec
2. CKD stg 5 ec (perbaikan)
- PNC -uremic
- HN -stroke recurrent
3. CAD ec OMI Inf. 2. asites ec SBP
3.CKD st V on HD reguler
Th/ 4.Spendilitis lumbal
- bedrest 5. hepatitis c
- O2 NH 2-4L/m 6. hipertensi
- threeway Th/
- furosemid 20mg/8j -bedrest
- lenal ace 2x169mg -O2 Nh 2-4 l/m
- As.Folat 2x40mg - IVFD Nacl 0,9% 10tpm
- ISDN 3x10mg -Lenal Ace 2x1
- kalitake 3x1sach -Asam Folat 2x400mg
- atorfastatin 1x20mg -Amlodipin 1x10 mg
- bisoprolol 1x5mg -Bisoprolol 1x1
- sucralfat syr 3xCI -atorvastatin 1x2
- Clopidogrel 1x75mg -Citicolin 2x5
- amlodipine 1x10mg -IV. Meropenem 500mg/8j
- diovan 1x160mg
Lab 15/12/2018
Lab 15/12/2018 Hb/Ht/E/L/T
Troponin I 0,17 7,6/22/2,8/16/118
CK-MB 17 MCV/MCH/MCHC
Ur/cr 138/12,68 81/28/34
Na/K/Cl 140/ 5,1/105 Diftel: 0/0/0/88/4/6
Ur/Cr : 157/9,73
Lab 14/12/2018 Na/K/Cl : 137/4,2/99
Hb/Ht/E/L/T
8,3/25/2,9/9,2/211
MCV/MCH/MCHC Lab 13/12/2018
87/29/33 Hb/Ht/E/L/T
Diftel: 2/0/0/81/7/10 9,3/28/3,4/24,1/202
Albumin 2,97 MCV/MCH/MCHC
Ca 7,0 82/28/34
Asam urat 6,2 Diftel: 0/0/1/92/2/5
Na/K/Cl : 144/5,7/144 Albumin : 3,27*
Ur/Cr : 159/12,26
Na?K/Cl : 142/5,0/100
LED : 70
Lab 13/12/2018
Hb/Ht/E/L/T
9,1/25/3,2/21,1/220
MCV/MCH/MCHC
77/28/37
Diftel: 1/0/0/89/3/7
Ca: 10,4
Ur/Cr : 216/16,20
Na/K/Cl : 136/4,9/101
Bil tot/direct/indir:
0,44/0,16/0,28
Albumin: 3,05
Lab 11/12/2018
Anti HCV: +
HBsAg: -
Ur/Cr : 159/12,26
Na?K/Cl : 142/5,0
K5B3 K5B4 K5B5
DPJP : dr. Azhari Ghani, DPJP : dr. Azhari Ghani, DPJP : dr. Azhari Ghani,
Sp.PD Sp.PD Sp.PD
COW: dr. Qausar COW: dr. Qausar COW: dr. Qausar
Dr : dr. Taufiq Dr : dr. Taufiq Dr : dr. Taufiq
DM : fauzan DM : fauzan DM : fauzan
Nama: irman hasyin Nama: Sukiman zakaria Nama : Husen
Umur: 02/10/1977 (41 th) Umur: 49 Tahun Umur: 37 tahun
Alamat : aceh besar Alamat: aceh besar Alamat : aceh besar
CM: 0-92-76-81 CM: 1193955 Pekerjaan : buruh tani
Hari rawatan: 2 Hari rawatan: 5 CM : 1-19-36-39
A/ Hari rawatan : 8
1.CKD stg V on HD regular A/
dg uremic sindrom ec HN 1.Ulkus gaster A/
2. PSMBA ec dd/ 2. Gout atritis 1. Dyspepsia tipe ulcer ec
-Gastritis erosive 3.cushing sindrom dd/
-Included heparin 4.omi inferior - ulcus peptikum
-ulkus gaster 5.hipoalbumin - ulcus duodenum
3.Anemia berat NN ec dd/ - gastritis erosiva
-perdarahan Th/ 2. Anemia ringan Mikrositik
-peny.kronis - Bedrest ec occult bleding
4.Gout Atritis fase kronis - Diet MII 1700 kkal/hr 3. retradisi mental derajat
5. HHD - IVFD Nacl 0,9% 20 gtt/i sedang
6.Hiperkalemia - IV Lansoprazol 30mg/12j
- sucralfat syr 3xcII Th/
Th/ - Allopurinol 1x100 mg -Bedrest
-tirah baring - Amoxicillin 2x1000 mg -Diet MII 1700 kkal/hr
-diet ginjal 1700 kkl1/hari+ - azitromicin 1x 500 mg -IVFD Nacl 0,9 % 20 tpm
60 gr protein - PCT 2x1000 mg - IV omeprazole 40mg/12j
- O2 2-3 l/i - simvastatin 1x20 mg - sukralfat syr 3xcI
-three way
-drip omeprazole 80 mg Lab 13/12/2018
dalam 50 cc nacl 0,9% Asam Urat : 8,6* Lab 16/12/2018
-iv. Ca glukonas 1 amp Urinalisis: PT/APTT: 10,6/26,0
(ekstra) Kuning
- nebul ventolin resp/8 j Jernih Lab 14/12/2018
-kalitake 3x1 sachet pH 6,5 Hb/Ht/E/T/L
-asam folat 2x400 mcg leukosi 2-3 10,1/34/5,9/343/4,7
-lenal ace 2x169 mg eritrosit 1-2 MCV/MCH/MCHC
-allopurinol 1x10mg epitel 3-5 59/17/29
-coditam 3x10 mg Diftel : 12/1/0/36/40/11
-transfusi prc sd hb > 11 gr/dl Ferritin 8,07
2 kolf hari ini dg premed Fe 13
furosemide PT/APTT 11,2/ 44,5
-hd pro heparin
-amlodipin Lab 10/12/2018
-jika hb > 6 gr/dl hd 1 kolf on Hb/Ht/E/T/L
hd 7,3/26/5,1/393/6,7
MCV/MCH/MCHC
Lab 16/12/2018 51/14/28
Hb/Ht/E/L/T Ur/Cr : 11/0,72
2,8/9/1,1/13,1/236 Na/K/Cl: 144/3,6/104
MCV/MCH/MCHC
82/27/33
Diftel: 1/0/0/69/24/8
Ur/Cr: 394/8,44
Na/K/Cl: 139/6,3/106
 K6B1 K6B2 K6B3 K6B4 K6B5
DPJP : dr. Azhari Ghani, DPJP : dr. Azhari Ghani, DPJP : dr. Azhari Ghani, DPJP : dr. Azhari Ghani, DPJP : dr. Azhari Ghani,
Sp.PD Sp.PD Sp.PD Sp.PD Sp.PD
COW: dr. Alkausar COW: dr. Alkausar COW: dr. Alkausar COW: dr. Alkausar COW: dr. Alkausar
Dr : dr. Taufiq Dr : dr. Taufiq Dr : dr. Taufiq Dr : dr. Taufiq Dr : dr. Taufiq
DM : Rini dan hafiz DM : Rini dan hafiz DM : Rini dan hafiz DM : Rini dan hafiz DM : Rini dan hafiz
Nama: Sofiyan Abdullah Nama:Mulyadi Legino R Nama: Katemen Paeran Nama: abd wahab Nama: abd Rahman
TTL: 01/07/1964 ( 54 th) TTL: 28-08-1978(40 thn) TTL: 10-05-1953 (65th) TTL: 04-10-1949 (69 thn) TTL: 01-07-1947 (71 thn)
Alamat: aceh utara Alamat: banda aceh Alamat: Nagan Raya Alamat: pidie Alamat: aceh besar
Pekerjaan: petani Pekerjaan: wiraswasta Pekerjaan: Petani/pekebun Pekerjaan: pedagang Pekerjaan: petani
CM: 1-19-40-08 CM: 1-19-33-53 CM: 1193303 CM: 1-19-32-86 CM: 0-92-40-65
Hari rawatan: 2 Hari rawatan: 3 Hari rawatan: 13 Hari rawatan: 11 Hari rawatan: 19

A/ A/ A/ A/ A/
1.Chest pain ec prosesdd/ 1. CAD dd/ TB paru dengan 1.HCC related Hep. B 1. massa intra abdomen ec dd 1. penurunan kesadaran ec
-reverfet pain infeksi sekunder dd/susp 2. Cancer pain -ca colon transversum –sepsis
-pleuritik pain Lung cancer 3. Hepatitis B -ca gaster -imbalance elektrolit
2.Hepatomegali ec dd/ 2. Pain Regio thorax 4. Dispepsia Type Dismolity -ca mesenterium 2. sespis ec
-metastase proses - Pleurisy pain 6. HAP 2. cancer pain -pneumonia
-hepatoma - Cancer pain 3. Polip a/r rectosigmoid -urosepsis
-limfoma malignan 3. dyspepsia tipe like ulcer Th/ 4.ulkus gaster 3.AKI stage II prarenal
4. efusi pleura dextra ec dd - Bedrest 5.PPOK 4.HHD
Th/ -pleuritis TB - Diet hati II 1700 kkal /hari 5.PPOK eksaserbasi akut
-tirah baring -malignancy - Drip novalgin 1amp dlm Th/ 6. Ulkus Diabetik gr. II
-O2 2-4 l/i 5. kolik renal 250cc NaCl 0,9%/8j -Bedrest
-iv omeprazole 40 mg/12 j - IV Aminofusin 1 fls/hri -Diet DM 1500 kkal/hari Th/
- ivfd futrolit 20 gtt/i Th/ - IVFD NaCl 0,9% 20 gtt/i - IVFD - Bedrest
-curcuma 3x1 - Bedrest - Coditam 3x1 - IV ceftriaxone 2gr/24 jam - IVFD RL 20 gtt/i
-kaltrofen sup - O2 2-4 Lpm - Sinbio 1x2mg - IV Lansoprazole - Diet MII 1700 kkal/hari
-fosen enema/ hari - IVFD RL 20 gtt/i - Donperidon 3x10 mg - Nebul Combuven 2gr/24 - Levofloxacin 500mg
-fentanil paten 12 mcg - IV Cefazolin 1gr/8j - Sukralfat syr 3xc1 jam -Nebule Flexotide 1 resp/ 8
-Mst 3x10 mg - IV Ondacetron 4 mg/ 8 jam - Trancetat 1x1 - Azitomycin 500mg jam
-lactulac syr 3xcll - Tramadol 2x100mg - IV Ondansetron 4mg/8j -Sucrafat 3xCII - Nebule Ventolin 1 resp/8
-sucralfat syr 3xc11 - IV Buscopan - Tramadol 2x50mg jam
- Graphalac 2x100 mg Lab 12/12/2018 - kaltropen sup (extra) - IV Pantoprazole 40 mg/
Lab 15/12/2018 -gabapentin 2x1 Hb/Ht/E/L/Tr - duragesic patch 12,5 mcg 12 jam
Bil.tot/direc/indirect 14,3/38/4,6/9,6/148 - Clopidogrel 1x75 mg
0,61/0,26/0,35 Lab 15/12/2018 MCV/MCH/MCHC Lab 12/12/2018 - Atorvastatin 20 mg 1x1
Hb/Ht/E/L/Tr 84/31/37 Hb/Ht/E/L/Tr
13,9/39/4,6/20,7/347 Diftel: 0/1/0/85/10/4 11,8/34/4,3/21,2/324 Lab 15/12/2018
MCV/MCH/MCHC Ur/Cr: 60/1,26 MCV/MCH/MCHC Hb/Ht/E/L/Tr
86/31/36 Na/K/Cl: 144/4.1/103 80/28/35 11,6/38/6,1/6,8/91
Diftel: 0/1/0/78/12/9 PT/APTT : 14,7/50,2 Diftel: 11/1/1/66/13/8 MCV/MCH/MCHC
Ur/Cr: 55/1,40 PT/APTT : 15,1/48,6 62/19/31
Na/K/Cl: 132/4,3/97 Lab 06/12/2018 Diftel:2/1/0/73/16/8
Hb/Ht/E/L/Tr Ur/Cr: 118/2,06
10.1/29/3.6/9.0/283 Na/K/Cl: 146/5,0/108
MCV/MCH/MCHC
80/28/35 Lab 10/12/2018
Diftel:7/1/0/51/25/16 Ur/Cr: 162/2,61
Ur/Cr: 91/4.05
Na/K/Cl: 144/4.1/103 Lab 09/12/2018
Ur/Cr: 155/2,81
07/12/18
Albumin: 3,28