| Nama Pasien |
: EDI SYAHPUTRA |
No.RM |
: 055244 |
| NIK |
: 1219060107810004 |
Pekerjaan |
: Nelayan |
| Tgl.Lahir |
: 1979-09-03 Usia : 45 tahun 8 bulan 13 hari |
Warga Negara |
: WNI |
| Jenis Kelamin |
: Laki Laki |
Agama |
: Islam |
| No.Handphone |
: 083833872417 |
Status Pernikahan |
: Kawin |
| No.Telepon |
: |
Nama Dokter |
: dr .DEDE GUNAWAN M.Ked(Paru), Sp.P, FISR |
| Jaminan |
: BPJS |
Tanggal Kunjungan |
: 2025-05-12 19:14:33 |
| 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 |
:
|
| Radiologi |
: |
| USG |
: |
| EKG |
: - |
| Diagnosa |
:
ICD 10 :
J44.0 | Chronic obstructive pulmonary disease with acute lower respiratory infection, J18.9 | Pneumonia, unspecified |
| Tindakan Medis |
:
ICD 09 :
|
| Therapy / Resep |
:
Ambroxol HCl (3x1 27 Tablet)
,
Ambroxol HCl (- 2 Tablet)
,
Levofloxacin Hemihydrate 500 mg (1x500mg 9 tablet)
,
Ranitidin HCl 150 mg (2x1 14 Pcs)
,
Ceftiaxiason inj (Per12jam 2 Vial)
,
Ceftiaxiason inj (- 2 Vial)
,
Ceftiaxiason inj (1gr/12 jam 1 Vial)
,
Ceftiaxiason inj (12 jam 1 Vial)
,
Dexamethason inj (Per12jam 2 Ampul)
,
Dexamethason inj (- 2 Ampul)
,
Dexamethason inj (12 jam 1 Ampul)
,
Ranitidin inj (Per12jam 3 Ampul)
,
Ranitidin inj (- 2 Ampul)
,
Ranitidin inj (12 jam 1 Ampul)
,
Asering (20gtt/i 5 fls)
,
Asering (- 4 fls)
,
Combivent (Kp 1 Pcs)
,
Combivent (- 1 Pcs)
,
Combivent (per12jam 1 Pcs)
,
Combivent (12 jam 1 Pcs)
,
Levofloxacin Infus 500mg (- 1 botol)
,
Methylprednisolone 4 mg (3x4mg 21 tablet)
|
| Instruksi |
: |
|
