| Nama Pasien |
: HARUN |
No.RM |
: 052631 |
| NIK |
: 1219063112560009 |
Pekerjaan |
: Karyawan Swasta |
| Tgl.Lahir |
: 1956-12-31 Usia : 67 tahun 10 bulan 20 hari |
Warga Negara |
: WNI |
| Jenis Kelamin |
: Laki Laki |
Agama |
: Islam |
| No.Handphone |
: 08979952058 |
Status Pernikahan |
: Kawin |
| No.Telepon |
: |
Nama Dokter |
: dr .DEDE GUNAWAN M.Ked(Paru), Sp.P, FISR |
| Jaminan |
: BPJS Kesehatan |
Tanggal Kunjungan |
: 2024-11-11 09:30 |
| TD |
: 110/70mmhg mmHg |
| Nadi |
: 92 x/menit |
RR |
: 22x/ i x/menit |
| Suhu |
: 36,5 c 0C |
Spo |
: 99% % |
| TB |
: 162 cm |
BB |
: 60 Kg |
| Rujukan Dari |
: |
| Anamnesa |
: sesak nafas
Anamnesis : sesak nafas (+) batuk (+) dahak (+) riwayat OAT (+) lebih kurang 2 bulan ini dari dr umum lanjut puskesmas labuhan ruku
riwayat meroko (+) |
| Pemeriksaan Fisik |
: |
| Laboratorium |
:
|
| Radiologi |
: |
| USG |
: |
| EKG |
: - |
| Diagnosa |
:
Pneumonia + Ppok EA-- -
ICD 10 :
J18.9 | Pneumonia, unspecified, J44.0 | Chronic obstructive pulmonary disease with acute lower respiratory infection |
| Tindakan Medis |
:
ICD 09 :
|
| Therapy / Resep |
:
Ambroxol HCl (3 x 1 21 tablet)
,
Salbutamol 4 mg (2x1 15 tablet)
,
Salbutamol 4 mg (2x4mg 3 tablet)
,
Salbutamol 4 mg (- 1 tablet)
,
Salbutamol 4 mg (3x4mg 2 tablet)
,
Aqua pro injection (pcs 2 Vial)
,
Aqua pro injection (- 3 Vial)
,
Ceftiaxiason inj (per 12 jam 5 Vial)
,
Ceftiaxiason inj (1 grm /12jam 1 Vial)
,
Ceftiaxiason inj (1gr/12jam 3 Vial)
,
Ranitidin inj (per 12 jam 5 Ampul)
,
Ranitidin inj (50 mg/12jam 3 Ampul)
,
Ranitidin inj (50mg /12 jam 1 Ampul)
,
NAC/ N-Acetylcystyne/ Acetylcysteine (3x200 mg 3 Tablet)
,
NAC/ N-Acetylcystyne/ Acetylcysteine (3 x 1 6 Tablet)
,
NAC/ N-Acetylcystyne/ Acetylcysteine (3x 200mg 3 Tablet)
,
Fentolin Nebul (Per 8 Jam 6 Ampul)
,
Azitromycin Tab (1 x 1 7 tablet)
,
Bfluid / Aminofluid (fls 3 fls)
,
Bfluid / Aminofluid (1 fls /hari 1 fls)
,
Methylprednisolone 125 mg injeksi (per 12 jam 62,5mg 2 ampul)
,
Methylprednisolone 125 mg injeksi (per 12 jam 3 ampul)
,
Methylprednisolone 125 mg injeksi (/12 jam 1 ampul)
,
Methylprednisolone 125 mg injeksi (62,5 mg/12 jam 2 ampul)
,
Methylprednisolone 125 mg injeksi (62,5mg / 12 jam 1 ampul)
,
Methylprednisolone 4 mg (3 x 1 21 tablet)
,
Ringer Lactat / RL (20gtt/i 1 fls)
,
Ringer Lactat / RL (Per 8 Jam 7 fls)
,
Ringer Lactat / RL (fls 4 fls)
,
Ventolin nebul (per8jam 1 ampul)
,
Ventolin nebul (Per 8 Jam 4 ampul)
,
Pulmicort 0,25 mg/ml (Budesma) (Per 8 Jam 8 Ampul)
,
Levofloxacin Infus 750mg (per 24 jam 3 botol)
,
Levofloxacin Infus 750mg (per 12 jam 1 botol)
,
Levofloxacin Infus 750mg (per hari 1 botol)
,
Levofloxacin Infus 750mg (fls 1 botol)
,
Levofloxacin 750mg tab (1 x 1 7 tablet)
|
| Instruksi |
: |
|
