| Nama Pasien |
: DEDI SYAPUTRA |
No.RM |
: 044908 |
| NIK |
: 1219061507000002 |
Pekerjaan |
: Belum Bekerja |
| Tgl.Lahir |
: 1997-07-15 Usia : 27 tahun 4 bulan 3 hari |
Warga Negara |
: WNI |
| Jenis Kelamin |
: Laki Laki |
Agama |
: Islam |
| No.Handphone |
: 082161849210 |
Status Pernikahan |
: Belum Kawin |
| No.Telepon |
: |
Nama Dokter |
: dr .DEDE GUNAWAN M.Ked(Paru), Sp.P, FISR |
| Jaminan |
: BPJS Kesehatan |
Tanggal Kunjungan |
: 2024-11-11 10:30 |
| TD |
: 100/70 mmhg mmHg |
| Nadi |
: 100 x/menit |
RR |
: 28 x/menit |
| Suhu |
: 37,5 c 0C |
Spo |
: 91 % |
| TB |
: 175 cm |
BB |
: 80 Kg |
| Rujukan Dari |
: |
| Anamnesa |
: sesak nafas
anamnesis: sesak nafas (+) batuk (+) dahak (+) riwayat asma (-) riwayat merokok (+) riwayat OAT (-) |
| Pemeriksaan Fisik |
: |
| Laboratorium |
:
(1) PEWARNAANGRAM (2) TCM |
| Radiologi |
: |
| USG |
: |
| EKG |
: - |
| Diagnosa |
:
bronchopneumonia - bronkhitis - terduga tb paru -
ICD 10 :
J42 | Unspecified chronic bronchitis |
| Tindakan Medis |
:
ICD 09 :
|
| Therapy / Resep |
:
Cetirizine 10mg (1 x 1 1 tablet)
,
Cetirizine 10mg (- 1 tablet)
,
Levofloxacin Hemihydrate 500 mg (1x500mg 1 tablet)
,
Metylprednisolo 4 mg (2x1 14 Pcs)
,
Salbutamol 4 mg (3 x 1 2 tablet)
,
Salbutamol 4 mg (3x4mg 2 tablet)
,
Aqua pro injection (- 4 Vial)
,
Aqua pro injection (/12jam 1 Vial)
,
Ceftiaxiason inj (1 grm /12jam 1 Vial)
,
Ceftiaxiason inj (per 12 jam 2 Vial)
,
Ceftiaxiason inj (1gr/12jam 3 Vial)
,
Ceftiaxiason inj (1gr / 12 jam 1 Vial)
,
Ceftiaxiason inj (per12 bjam 1 Vial)
,
Dexamethason inj (1amp/12jam 4 Ampul)
,
Dexamethason inj (per 12 jam 1 Ampul)
,
Dexamethason inj (Per 8 Jam 2 Ampul)
,
Dexamethason inj (5mg/12jam 1 Ampul)
,
Dexamethason inj (per12 bjam 1 Ampul)
,
Ranitidin inj (50 mg/12jam 2 Ampul)
,
Ranitidin inj (per 12 jam 2 Ampul)
,
Ranitidin inj (50 mg/12 jam 1 Ampul)
,
Ranitidin inj (per12 bjam 1 Ampul)
,
NAC/ N-Acetylcystyne/ Acetylcysteine (3x 200mg 3 Tablet)
,
NAC/ N-Acetylcystyne/ Acetylcysteine (3 x 1 4 Tablet)
,
NAC/ N-Acetylcystyne/ Acetylcysteine (3x200mg 2 Tablet)
,
NAC/ N-Acetylcystyne/ Acetylcysteine (3x200 mg 2 Tablet)
,
Fentolin Nebul (Per 8 Jam 4 Ampul)
,
Azitromycin Tab (1 x 1 2 tablet)
,
Bfluid / Aminofluid (fls 2 fls)
,
Bfluid / Aminofluid (1 fls /hari 1 fls)
,
Cairan KN-3B/ kaen 3b/ ka-en 3b (fls 4 fls)
,
Cairan KN-3B/ kaen 3b/ ka-en 3b (Per 8 Jam 5 fls)
,
Cairan KN-3B/ kaen 3b/ ka-en 3b (20 ggt/i 2 fls)
,
Ceterizin 10mg (2x1 1 tablet)
,
Ventolin nebul (Per 8 Jam 4 ampul)
,
Ventolin nebul (/8jam 2 ampul)
,
Ventolin nebul (per 8jam 2 ampul)
,
Pulmicort 0,25 mg/ml (Budesma) (Per 8 Jam 8 Ampul)
,
Pulmicort 0,25 mg/ml (Budesma) (/8jam 2 Ampul)
,
Cefixime 200 mg (2x1 14 tablet)
|
| Instruksi |
: |
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