| Nama Pasien |
: NURHADISYA PUTRA |
No.RM |
: 045389 |
| NIK |
: 1219065708950017 |
Pekerjaan |
: Belum Bekerja |
| Tgl.Lahir |
: 1995-08-17 Usia : 29 tahun 3 bulan 9 hari |
Warga Negara |
: WNI |
| Jenis Kelamin |
: Laki Laki |
Agama |
: Islam |
| No.Handphone |
: 083827414128 |
Status Pernikahan |
: Belum Kawin |
| No.Telepon |
: |
Nama Dokter |
: dr .DEDE GUNAWAN M.Ked(Paru), Sp.P, FISR |
| Jaminan |
: Umum |
Tanggal Kunjungan |
: 2024-11-26 10:40 |
| TD |
: 140/90mmhg mmHg |
| Nadi |
: 90x/i x/menit |
RR |
: 28 x/menit |
| Suhu |
: 36,5 c 0C |
Spo |
: 98% % |
| TB |
: 158 cm |
BB |
: 45 Kg |
| Rujukan Dari |
: |
| Anamnesa |
: sesak nafas |
| Pemeriksaan Fisik |
: |
| Laboratorium |
:
|
| Radiologi |
: |
| USG |
: |
| EKG |
: |
| Diagnosa |
:
--- -
ICD 10 :
A15.3 | Tuberculosis of lung, confirmed by unspecified means, J18.9 | Pneumonia, unspecified |
| Tindakan Medis |
:
ICD 09 :
|
| Therapy / Resep |
:
Paracetamol 500 mg (3x500mg 3 tablet)
,
Salbutamol 4 mg (2x4mg 3 tablet)
,
Salbutamol 4 mg (2x1 2 tablet)
,
Aqua pro injection (per 12 jam 1 Vial)
,
Aqua pro injection (- 1 Vial)
,
Aqua pro injection (pcs 1 Vial)
,
Ceftiaxiason inj (per 12 jam 3 Vial)
,
Ceftiaxiason inj (1gr/12jam 1 Vial)
,
Ceftiaxiason inj (per12jam 1 Vial)
,
Ranitidin inj (per 12 jam 4 Ampul)
,
Ranitidin inj (per12jam 1 Ampul)
,
NAC/ N-Acetylcystyne/ Acetylcysteine (3x200mg 3 Tablet)
,
NAC/ N-Acetylcystyne/ Acetylcysteine (3 x 1 1 Tablet)
,
NAC/ N-Acetylcystyne/ Acetylcysteine (3x 200mg 2 Tablet)
,
NAC/ N-Acetylcystyne/ Acetylcysteine (3x200 mg 1 Tablet)
,
Asering (per 8 jam 3 fls)
,
Asering (10 tts/i 1 fls)
,
Asering (20gtt/i 1 fls)
,
Levofloxacin Infus 500mg (per 24 jam 1 botol)
,
Metamizol Injeksi (Novalgin/norages) (k/p 1 ampul)
,
Methylprednisolone 125 mg injeksi (62,5mg / 12 jam 2 ampul)
,
Methylprednisolone 125 mg injeksi (per 12 jam,62,5 mg 1 ampul)
,
Ringer Lactat / RL (per 8 jam 1 fls)
,
Ventolin nebul (per 8 jam 6 ampul)
,
Pulmicort 0,25 mg/ml (Budesma) (per 8 jam 5 Ampul)
,
vitamin b6 10mg (2x10mg 2 tablet)
,
Levofloxacin Infus 750mg (- 1 botol)
,
Levofloxacin Infus 750mg (per hari 1 botol)
|
| Instruksi |
: |
|
