| Nama Pasien |
: SYAHRUL III |
No.RM |
: 010582 |
| NIK |
: 1219043112580163 |
Pekerjaan |
: Wiraswasta |
| Tgl.Lahir |
: 1958-12-31 Usia : 65 tahun 7 bulan 21 hari |
Warga Negara |
: WNI |
| Jenis Kelamin |
: Laki Laki |
Agama |
: Islam |
| No.Handphone |
: 085262815338 |
Status Pernikahan |
: Kawin |
| No.Telepon |
: |
Nama Dokter |
: dr. SILVIA BUKIT, Sp. PD |
| Jaminan |
: BPJS Kesehatan |
Tanggal Kunjungan |
: 2024-08-20 22:00 |
| TD |
: mmHg |
| Nadi |
: x/menit |
RR |
: x/menit |
| Suhu |
: oC |
Spo |
: % |
| TB |
: cm |
BB |
: Kg |
| Rujukan Dari |
:
- |
| Anamnesa |
: |
| Pemeriksaan Fisik |
: Kepala (), Gigi & Mulut (), THT (), Thoraks (), Abdomen (), Genital & Anus (), Ekstremitas (), Kulit (). Catatan : |
| Laboratorium |
:
(1) kgd/hari (2) UR/CR (3) KGD PUASA DAN 2 JAM PP (4) KGD PUASA DAN 2 JAM PP (5) Glukosa 2 Jam PP (6) Glukosa 2 Jam PP (7) KGD PUASA DAN 2 JAM PP |
| Radiologi |
: AS |
| USG |
: |
| EKG |
: |
| Diagnosa |
:
ICD 10 :
ganggren diabetik a/t ( R ) pedis | , Dm | , nefrolithiasis | |
| Tindakan Medis |
:
ICD 09 :
Debridement | |
| Therapy / Resep |
:
Metronidazole 500 mg (3 x 1 21 tablet)
,
Omeprazole 20 mg (2x1 28 tablet)
,
Paracetamol 500 mg (3 x 500 mg 5 tablet)
,
Paracetamol 500 mg (3 x 1 8 tablet)
,
Paracetamol 500 mg (3x500mg 2 tablet)
,
Aqua pro injection (k/p 1 Vial)
,
Aqua pro injection (- 4 Vial)
,
Aqua pro injection (Per 8 Jam 1 Vial)
,
Aqua pro injection (per 12 jam 2 Vial)
,
Ceftiaxiason inj (1gr/12jam 3 Vial)
,
Ceftiaxiason inj (per 12 jam 11 Vial)
,
Ketorolac inj (Per 8 Jam 20 Ampul)
,
Ketorolac inj (8mg / 8 jam 2 Ampul)
,
Metronidazole infus (Per 8 Jam 8 botol)
,
Paracetamol infus/ drip (Per 8 Jam 1 botol)
,
Ranitidin inj (per 12 jam 9 Ampul)
,
Ranitidin inj (per 12 jam1 1 Ampul)
,
Tramadol inj (/fls 1 Ampul)
,
Tramadol inj (/ FLS 1 Ampul)
,
Tramadol inj (Per 8 Jam 5 Ampul)
,
NAC/ N-Acetylcystyne/ Acetylcysteine (3x 200mg 10 Tablet)
,
NAC/ N-Acetylcystyne/ Acetylcysteine (3x200 mg 1 Tablet)
,
NAC/ N-Acetylcystyne/ Acetylcysteine (3 x 1 3 Tablet)
,
NaCl 0.9% (20gtt/i 4 fls)
,
NaCl 0.9% (fls 8 fls)
,
NaCl 0.9% (per 12 jam 5 fls)
,
NaCl 0.9% (signa;20gtt/i 2 fls)
,
Ringer Lactat / RL (fls 2 fls)
,
Ringer Lactat / RL (20gtt/i 2 fls)
,
Ringer Lactat / RL (per 12 jam 1 fls)
,
Gabapentin tab 300 mg (1 x 1 11 tablet)
,
Gabapentin tab 300 mg (1x300 mg 1 tablet)
,
Sucralfate 500 mg / SUKRALFAT (3x c1 1 tablet)
,
Tamsulosin Hydroclorid (Harnal) 0,4mg (1 x 1 7 tablet)
,
Cefixime 200 mg (2x1 14 tablet)
|
| Instruksi |
: |
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