Identitas pasien Keluhan Diagnose Pemeriksaan Therapy

Nama : Nur Intan - Sesak Napas (+) - CHF Fc III-IV Tanggal 26/01/2016 - Tirah baring
RM : 97.98.39 e.c HHD - Darah rutin - O2 2-4 l/I nasal
Bed : 6 - DM tipe 2 WBC/RBC/HGB/HCT/MCV/MCH kanul
Umur : 49 tahun Terkontrol 32.40/2.16/6.0/17.2/79.6/27.8 - IVFD NaCl 3%
DPJP : dr. T. Abraham - Hipertensi MCHC/PLT/RDW-CV/RDW-SD 10gtt/I Mikro
Sp.PD - CKD Stg IV e.c 34.9/393/16.0/47.0 - Diet DM 1100
Dokter ruangan : DIV dd/ HIV PDW/MPV/P-LCR/PCT Kal dengan 45 gr
dr.Wanda - Susp. DVT dd/ 9.1/9.5/19.1/0.37 protein
selulity Neut/Lymph/Mono/Eo/Baso - Inj. Cefoperazon
- ISK 29.61/1.17/1.48/0.08/0.06 1gr/12 jam/IV
- Fusy TB Paru dg - Inj. Gentamisin
Sekunder Infeksi tgl 26-01-2016 140 mg/3hari/IV
- Hipo SGOT : 21,00U/L - Inj.
Albuminemia SGPT : 12,00 U/L Metoclopramide
- Efusi Pleura Alkaline phostase: 639,00 10mg/8jam/IV
U/L - Inj. Ketorolac 1
Total bilirubin : 2,60 mg/dl amp/ 8jam/IV
Direct bilirubin : 1,79 mg/dl - Furosemide
Ureum : 189,00 mg/dl 1x40mg tab
Creatinin : 3,14 mg/dl - Warfarin 1x2 mg
Uric Acid : 12,30 mg/dl tab
- Sinvastatin
tgl 26-01-2016 1x10mg tab (malam)
Fibrinogen : 195mg/dl - Captopril 3x6,25
mg tab
- Paracetamol
3x500mg tab k/p
- Ambroxol Syr
3xCI
- Laxadine Syr
1xCI
Identitas pasien Keluhan Diagnose Pemeriksaan Therapy
Nama : Suharti - Demam (+) - TB putus obat Tanggal 27 01/2016 - Tirah baring
RM : 98.63.57 - Darah rutin
Bed : 23 - Luka borok - Ulkus kronik dd/ TB WBC/RBC/HGB/HCT/MCV/MCH - Diet MB TKTP
Umur : 53 tahun pada paha dan cutis dd/ ulkus tropikum 6,56/2,70/7,0/20,8/77,0/25,9
DPJP : dr. Asnawi lipatan paha kanan o/t femoralis (R) + o/t MCHC/PLT/RDW-CV/RDW-SD - IVFD NaCl 0,9%
Sp.PD (+) inguinal (R) 33,7/385/15,5/42.0 30gtt/I (makro)
Dokter ruangan : PDW/MPV/P-LCR/PCT Inj. Meropenem
dr.Dedi - Nyeri (+) - Kahexia 9,0/9.1/116,4/0.35
-
1gr/8jam dalam 100 cc
Anemia e.c penyakit Neut/Lymph/Mono/Eo/Baso NaCl 0,9% habis dalam
-
kronik dd/ Def. Fe 5,78/0,46/0,32/0.00/0.00 3 jam
(tgl 29-01-2016)
- Sindroma - Inj. Metronidazole
Immunidefisiensi SGOT : 34,00U/L 500mg/8jam/IV
SGPT : 22,00U/L
- Hipoalbuminemia Alkaline phostase: 53,00U/L - Inj. Ondansetron
Total bilirubin : 0,30mg/dl 4mg/8jam/Iv
Direct bilirubin : 0,12mg/dl
Albumin: 2,10 gr/dl - Nystatin drip
Ureum : 72,00mg/dl 4x2cc
Creatinin : 1,61mg/dl
- Paracetamol
Uric Acid : 8,10mg/dl
3x500mg tab
KGD Adrandom: 99,00mg/dl
- Inj. Novalgin 1
Natrium,Kalium,Chlorida amp/8jam (kalau temp
Natrium : 132,00 mmol/L > 38,5oC
Kalium : 4,50 mmol/L
Chlorida : 117,00 mmol/L - Fuson cream 2x
sehari
- HIV Kualitatif (tgl 29-01-2016)
(positif)
- TES HIV (tgl29-01-2016)
(REAKTIF)