| Nama Pasien |
: ZULPAH |
No.RM |
: 054346 |
| NIK |
: 1219065309880005 |
Pekerjaan |
: IRT |
| Tgl.Lahir |
: 1988-09-13 Usia : 36 tahun 6 bulan 11 hari |
Warga Negara |
: WNI |
| Jenis Kelamin |
: Perempuan |
Agama |
: Islam |
| No.Handphone |
: 081260433350 |
Status Pernikahan |
: Kawin |
| No.Telepon |
: |
Nama Dokter |
: dr. Arief Kurniawan Siregar, Sp. PD |
| Jaminan |
: Umum |
Tanggal Kunjungan |
: 2025-03-20 02:22:22 |
| TD |
: 120/80 mmhg mmHg |
| Nadi |
: 80 x / i x/menit |
RR |
: 22x/ i x/menit |
| Suhu |
: 36,5 c 0C |
Spo |
: 99% % |
| TB |
: 155 cm |
BB |
: 50 Kg |
| Rujukan Dari |
: |
| Anamnesa |
: Sesak Nafas (+), Batuk (+), Dahak purulent (+), Nyeri dada (+), Riwayat Demam (+)
Mual (+), Muntah (-), Tidak selera makan
Neri perut kanan atas (+), Mual (+), Muntah (+)
Tidak selera makan. |
| Pemeriksaan Fisik |
: |
| Laboratorium |
:
|
| Radiologi |
: (1)
USG UPPER+LOWER ABDOMEN (2)
Thorax PA |
| USG |
: |
| EKG |
: |
| Diagnosa |
:
Hipertensi urgency
Abd pain
Profuse vomitus- -
ICD 10 :
K81.9 | Cholecystitis, unspecified, N18.9 | Chronic renal failure, unspecified, N20.0 | Calculus of kidney, I10 | Essential (primary) hypertension |
| Tindakan Medis |
:
ICD 09 :
|
| Therapy / Resep |
:
Ambroxol HCl (3x1 1 tablet)
,
Ambroxol HCl (3 x 1 2 tablet)
,
Amlodipin Besilate 10mg (1 x 1 1 Pcs)
,
Amlodipin Besilate 10mg (tablet 1 Pcs)
,
Amlodipin Besilate 10mg (1x10 1 Pcs)
,
Candesartan Cilexetil 8 mg (1 x 1 1 tablet)
,
Candesartan Cilexetil 8 mg (1x8 2 tablet)
,
Candesartan Cilexetil 8 mg (tablet 1 tablet)
,
Aqua pro injection (Pcs 2 Vial)
,
Ceftiaxiason inj (Per12jam 3 Vial)
,
Ceftiaxiason inj (1gr/12jam 1 Vial)
,
Ceftiaxiason inj (per 12 jam 2 Vial)
,
Omeprazole inj (Per12jam 3 Ampul)
,
Omeprazole inj (40mg/12j 1 Ampul)
,
Omeprazole inj (per 12 jam 3 Ampul)
,
Omeprazole inj (vial 1 Ampul)
,
Omeprazole inj (40mg/12jam 1 Ampul)
,
Ondansentron inj (Per8jam 2 Ampul)
,
Ondansentron inj (Per 8 Jam 7 Ampul)
,
Ondansentron inj (per 8jam 2 Ampul)
,
Ondansentron inj (ampul 2 Ampul)
,
NAC/ N-Acetylcystyne/ Acetylcysteine (3x200 mg 3 Tablet)
,
NAC/ N-Acetylcystyne/ Acetylcysteine (3x200mg 1 Tablet)
,
NAC/ N-Acetylcystyne/ Acetylcysteine (3x1 2 Tablet)
,
Ringer Lactat / RL (20gtt/i 6 fls)
,
Ringer Lactat / RL (Per 8 jam 4 fls)
,
Ringer Lactat / RL (fls 2 fls)
,
Sucralfate 500 mg / SUKRALFAT (tablet 2 tablet)
,
Sucralfate 500 mg / SUKRALFAT (3x1 3 tablet)
|
| Instruksi |
: |
|
