Koyan
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Ruan g / Bed Identitas Pasien Keluhan Diagnosis Hasil Pemeriksaan Terapi II-1 Bed 2 Husna Laila (37 tahun) Perempuan Masuk : 09 November 2015 DPJP : Prof. dr. Lukman Hakim Zein, Sp.PD Nyeri perut (+), mual (+), lemas (+) KU: Sens: CM TD: 110/70 x/i HR: 88 x/i RR: 20 x/i T: 36,3 C PD: Mata: anemis (+/+), ikterik (-/-) T/H/M: dbn/dbn/dbn Leher: TVJ: R-2 Thoraks: SP: vesikuler melemah pada lapangan bawah paru kiri, ST: (-) Abdomen: soepel, teraba Kolelithiasis Anemia ec. Penyakit kronis Suspek limfoma malignan Gastritis Trombositosis reaktif dd esensial Hasil Lab (16/11/15): DR : Hb / L / Tr = 8,9 / 7,77 / 327 MCV / MCH / MCHC = 78,4 / 25,3 / 32,2 Kimia Klinik : hati : bil.total/direk = 0,66 / 0,3 ALP = 58 SGOT / SGPT = 14 / 12 Albumin = 3,5 Ginjal Ur / Cr = 14 / 0,54 As. Urat = 4,9 Elektrolit Na / K / Cl = 147 / 3,5 / 110 Imunoserologi HbsAg (-) ; AFP = 3,35 ; CA 19-9 = 4,8; anti HCV (-) Hasil lab (13/11/15): KGD Tirah baring Diet MB IVFD NaCl 0,9% 20 gtt/i Inj. Ceftriaxon 1 gr/12 jam/ IV Inj. Ketorolac 30 mg/ 8 jam/ IV Paracetamol 3 x 500 mg tab KSR tab 1 x 600 mg Omeprazole 2 x 20 mg tab Loperamide tab 1 tab/ mencret Metoclopramide tab 3 x 1 Codein 10 mg tab 2 x1 R/ choleslystomy + laparotomi biopsi dari bedah digestif BMP
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Koyan
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Ruang / Bed
Identitas Pasien Keluhan Diagnosis Hasil Pemeriksaan Terapi
II-1Bed 2
Husna Laila (37 tahun)
Perempuan
Masuk : 09 November 2015
DPJP : Prof. dr. Lukman Hakim Zein, Sp.PD
Nyeri perut (+), mual (+), lemas (+)
KU:Sens: CMTD: 110/70 x/iHR: 88 x/iRR: 20 x/iT: 36,3 C
PD:Mata: anemis (+/+), ikterik (-/-)T/H/M: dbn/dbn/dbnLeher: TVJ: R-2Thoraks: SP: vesikuler melemah pada lapangan bawah paru kiri, ST: (-)Abdomen: soepel, teraba massa di epigastrium, murphy sign (+), H/L/R ttb, peristaltik (+) normalEkstremitas: edema (-/-), CRT <2”, akral hangat
Kolelithiasis
Anemia ec. Penyakit kronis
Suspek limfoma malignan
Gastritis
Trombositosis reaktif dd esensial
Hasil Lab (16/11/15):DR : Hb / L / Tr = 8,9 / 7,77 / 327MCV / MCH / MCHC = 78,4 / 25,3 / 32,2Kimia Klinik : hati : bil.total/direk = 0,66 / 0,3ALP = 58SGOT / SGPT = 14 / 12Albumin = 3,5Ginjal Ur / Cr = 14 / 0,54 As. Urat = 4,9Elektrolit Na / K / Cl = 147 / 3,5 / 110ImunoserologiHbsAg (-) ; AFP = 3,35 ; CA 19-9 = 4,8; anti HCV (-)
Hasil lab (13/11/15):KGD = 69Kolestrol total = 145TG / HDL / LDL = 104 / 20 / 87
Hasil lab (11/11/15):DR : Hb / L / Tr = 8,5 / 12,6 / 432MCV / MCH = 78,7 / 24,9Ferritin = 371,2Besi (Fe) = 27TIBC = 136Agregasi trombositADP 1 μM = 68,4ADP 2 μM = 35,8ADP 5 μM = 79,8ADP 10 μM = 51,7USGKesimpulan = hepatomegali, non fokal lesi
Tirah baring Diet MB
IVFD NaCl 0,9% 20 gtt/i Inj. Ceftriaxon 1 gr/12 jam/ IV Inj. Ketorolac 30 mg/ 8 jam/ IV Paracetamol 3 x 500 mg tab KSR tab 1 x 600 mg Omeprazole 2 x 20 mg tab Loperamide tab 1 tab/
mencret Metoclopramide tab 3 x 1 Codein 10 mg tab 2 x1
R/ choleslystomy + laparotomi
biopsi dari bedah digestif BMP
+ cholesistitis + cholelitiasisFoto ThoraxKesimpulan = efusi pleura kiri
Hasil Lab (09/11/15):KGD = 104DR : Hb / L / Tr = 9,2 / 20,16 / 502MCV / MCH = 80,7 / 24,6Kimia Klinik : Albumin = 3,4Ginjal Ur / Cr = 12 / 0,55 Elektrolit Na / K / Cl = 135 / 2,9 / 98
II-1 Bed 3
Netty Vera Br Tarigan
Perempuan
28 tahun
Masuk: 17 November 2015
DPJP: dr. Syafrizal Nasution, Sp.PD, KGH
Penurunan kesadaran (+), gelisah (+), meracau (+)
KU:Sens: CM,TD: 90/70 mmhgHR: 72 x/iRR: 26 x/iT: 36 C
PD:Mata: konj. Palpebra inferior pucat (+/+), sklera ikterik (-/-)T/H/M: tidak ada kelainanLeher: TVJ R-2 cmH20, pemb. KGB (-), trakea medialThoraks: SP: vesikuler
AKI Stadium Failure
Ileus Obstruktif dd Ileus Paralitik
Anemia e.c Penyakit Kronis
Post PSMBA e.c Stress Ulcer dd Gastritis Erosiva
Post SC
Hipoalbuminemia
Hasil Lab (21/11/15)Darah RutinHb/WBC/HT/PLT/MCV/MCH6,3/19,81/18,1/164/82,3/28,6Metabolisme KHKGDS : 57,8Faal GinjalUreum/Kreatinin : 97,1/5,34ElektrolitNa/K/Cl : 131/3,8/99AGDApH/pCO2/pO2/HCO3/TCO2/BE/SaO27,44/29/184/19,7/20,6/-3,4/100
Hasil Lab (19/11/15)Darah RutinHb/WBC/HT/PLT/MCV/MCH6,7/18,5/19,3/81/82,5/28,6Metabolisme KHKGDS : 46,1Faal Ginjal
Tirah baring NGT tidak terpasang(Penolakan) Diet Ginjal Inj Ceftriaxone 1 gr/12 jam Drip Metronidazole 500 mg/8
jam Provenid Supp {K/P} Koreksi Albumin 20% kebutuhan
2 fls
(+/+), ST: -Abdomen: soepel, H/L/R ttb, peristaltik (+) normalEkst: pitting edema (-/-)
Ureum/Kreatinin : 136/6,44ElektrolitNa/K/Cl : 131/3,8/103AGDApH/pCO2/pO2/HCO3/TCO2/BE/SaO27,457/24,5/147,1/16,9/17,7/-6,2/99,2
Hasil Lab (17/11/15)Darah RutinHb/WBC/HT/PLT/MCV/MCH8,4/39,86/23,6/53/81,4/29Metabolisme KHKGDS : 47Faal GinjalUreum/Kreatinin : 108,2/5,35ElektrolitNa/K/Cl : 130/4,1/104Faal HatiAlbumin : 1,8Faal HemostasisPT/APTT/TT/INR : 1,05/1,22/0,65/1.06
