| Nama Pasien |
: M EFENDI |
No.RM |
: 009702 |
| NIK |
: 1219061001820001 |
Pekerjaan |
: Nelayan |
| Tgl.Lahir |
: 1982-01-10 Usia : 42 tahun 8 bulan 30 hari |
Warga Negara |
: WNI |
| Jenis Kelamin |
: Laki Laki |
Agama |
: Islam |
| No.Handphone |
: 0852755133455 |
Status Pernikahan |
: Kawin |
| No.Telepon |
: |
Nama Dokter |
: dr .DEDE GUNAWAN M.Ked(Paru), Sp.P, FISR |
| Jaminan |
: BPJS Kesehatan |
Tanggal Kunjungan |
: 2024-10-09 12:32:21 |
| TD |
: mmHg |
| Nadi |
: x/menit |
RR |
: x/menit |
| Suhu |
: 0C |
Spo |
: % |
| TB |
: cm |
BB |
: 46kg Kg |
| Rujukan Dari |
: |
| Anamnesa |
: sesak nafas- |
| Pemeriksaan Fisik |
: |
| Laboratorium |
:
|
| Radiologi |
: |
| USG |
: |
| EKG |
: |
| Diagnosa |
:
ICD 10 :
J18.9 | Pneumonia, unspecified |
| Tindakan Medis |
:
ICD 09 :
A15.0 | Tuberculosis of lung, confirmed by sputum microscopy with or without culture |
| Therapy / Resep |
:
Ambroxol HCl (3x30mg 8 tablet)
,
Omeprazole 20 mg (2x20mg 14 tablet)
,
Ondansentron 4 mg (per 8 jam 3 tablet)
,
Aqua pro injection (per 12 jam 6 Vial)
,
Ceftiaxiason inj (per 12 jam 6 Vial)
,
Ondansentron inj (per 8 jam 8 Ampul)
,
Ranitidin inj (per 12 jam 8 Ampul)
,
NAC/ N-Acetylcystyne/ Acetylcysteine (3x200mg 9 Tablet)
,
Bfluid / Aminofluid (per 24 jam 3 fls)
,
Codein 10 mg (3x10mg 18 tablet)
,
NaCl 0.9% (per 8 jam 1 fls)
,
Ringer Lactat / RL (per 8 jam 7 fls)
,
Salbutamol 2 mg (2x2mg 9 tablet)
|
| Instruksi |
: |
|
