| Nama Pasien |
: SUPARMAN |
No.RM |
: 045175 |
| NIK |
: 6107011510730001 |
Pekerjaan |
: Wiraswasta |
| Tgl.Lahir |
: 1973-10-15 Usia : 51 tahun 1 bulan 22 hari |
Warga Negara |
: WNI |
| Jenis Kelamin |
: Laki Laki |
Agama |
: Islam |
| No.Handphone |
: 082276213477 |
Status Pernikahan |
: Kawin |
| No.Telepon |
: |
Nama Dokter |
: dr .DEDE GUNAWAN M.Ked(Paru), Sp.P, FISR |
| Jaminan |
: BPJS Kesehatan |
Tanggal Kunjungan |
: 2024-11-13 09:00 |
| TD |
: 138/80 mmHg |
| Nadi |
: 122 x/menit |
RR |
: 33 x/menit |
| Suhu |
: 36 0C |
Spo |
: 98 % |
| TB |
: 160 cm |
BB |
: 65 Kg |
| Rujukan Dari |
: |
| Anamnesa |
: sesak nafas (+)
anamnesis : sesaknafas (+) batuk (+) dahak ?(+) demam(-) riwayat demam (+) riwayat merokok (+) riwayat OAT 6 tahun yang lalu |
| Pemeriksaan Fisik |
: |
| Laboratorium |
:
(1) TCM (2) PEWARNAAN GRAM (3) DARAH LENGKAP (4) ureum creatinin (5) FAAL HATI |
| Radiologi |
: |
| USG |
: |
| EKG |
: sinus tachycardia
possible right atriall abnormality
rightward axis
RVH |
| Diagnosa |
:
bilateral pneumonia + ppok -terduga tb paru
oedem paru -
ICD 10 :
|
| Tindakan Medis |
:
ICD 09 :
00.13 | Injection or infusion of nesiritide, 00.13 | Injection or infusion of nesiritide, 00.13 | Injection or infusion of nesiritide, 00.13 | Injection or infusion of nesiritide, 00.13 | Injection or infusion of nesiritide, 00.13 | Injection or infusion of nesiritide, 93.94 | Respiratory medication administered by nebulizer |
| Therapy / Resep |
:
Ambroxol HCl (3x1 C1 1 tablet)
,
Ambroxol HCl (3x1 9 tablet)
,
Levofloxacin Hemihydrate 500 mg (1x750 mg 6 tablet)
,
Methylergometrine Maleat / metergin/ metil ergometrin (/12jam 2 tablet)
,
Metylprednisolo 4 mg (/12jam 2 Pcs)
,
Paracetamol 500 mg (1x500mg 3 tablet)
,
Paracetamol 500 mg (3x500mg 1 tablet)
,
Aqua pro injection (pcs 1 Vial)
,
Aqua pro injection (- 8 Vial)
,
Ceftiaxiason inj (1gr/12jam 1 Vial)
,
Ceftiaxiason inj (per 12 jam 1 Vial)
,
Ceftiaxiason inj (/12jam 15 Vial)
,
Furosemide inj (per 12 jam 1 Ampul)
,
Furosemide inj (/8jam 9 Ampul)
,
Furosemide inj (/12jam 9 Ampul)
,
Omeprazole inj (/12jam 3 Ampul)
,
Ranitidin inj (50 mg/12jam 1 Ampul)
,
Ranitidin inj (per 12 jam 1 Ampul)
,
Ranitidin inj (/12jam 14 Ampul)
,
NAC/ N-Acetylcystyne/ Acetylcysteine (3x 200mg 1 Tablet)
,
NAC/ N-Acetylcystyne/ Acetylcysteine (3x200 mg 2 Tablet)
,
NAC/ N-Acetylcystyne/ Acetylcysteine (/8jam 5 Tablet)
,
NAC/ N-Acetylcystyne/ Acetylcysteine (3x200mg 16 Tablet)
,
NAC/ N-Acetylcystyne/ Acetylcysteine (3x1 2 Tablet)
,
NAC/ N-Acetylcystyne/ Acetylcysteine (- 1 Tablet)
,
Fentolin Nebul (/8jam 3 Ampul)
,
Asering (fls 1 fls)
,
Asering (10 tts/i 2 fls)
,
Asering (- 9 fls)
,
Asering (/12jam 1 fls)
,
Levofloxacin Infus 500mg (/24 jam 6 botol)
,
Mecobalamin 500 µg (1x1 1 tablet)
,
Meptin Nebule (Procaterol) (/8jam 2 ampul)
,
Methylprednisolone 125 mg injeksi (/12 jam 1 ampul)
,
Methylprednisolone 125 mg injeksi (per12 bjam62,5 mg 1 ampul)
,
Methylprednisolone 125 mg injeksi (/12jam 10 ampul)
,
Ventolin nebul (Per 8 Jam 3 ampul)
,
Ventolin nebul (/8jam 15 ampul)
,
Aspilet/ Miniaspi (1x80 mg 1 tablet)
,
Aspilet/ Miniaspi (1x80mg 3 tablet)
,
Clopidogrel 75 mg/ CPG (1x75mg 3 tablet)
,
Pulmicort 0,25 mg/ml (Budesma) (Per 8 Jam 3 Ampul)
,
Pulmicort 0,25 mg/ml (Budesma) (/8jam 15 Ampul)
,
Levofloxacin Infus 750mg (/24 jam 1 botol)
,
Levofloxacin 750mg tab (1x750 mg 1 tablet)
|
| Instruksi |
: |
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