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Hari Rawatan 2
(15April 2014)
Keluhan
Sensorium
KU/KP/KG
TD
HR
RR
Temperatur
Diagnosa
sementara
Therapy
110/70 mmHg
88 x/i
26 x/i
36,9 C
TB putus obat + DM tipe 2 +
Usul
Gangguan elektrolit
Tirah baring
Diet DM 1300 kkal
O2 1-4 l/i
IVFD nacl 0,9 % 30 gtt/i
Inj Ceftriaxone 1 gr / 12 jam iv
Inj ranitidine 50 mg / 12
jam/iv
Inj Novorapid 8-8-8 unit
Inj Levemir 12 unit malam
GG tab 3 x 100 mg
Tirah baring
Diet DM 1300 kkal
O2 1-4 l/i
IVFD nacl 0,9 %20 gtt/i
Inj Ceftriaxone 1 gr / 12 jam
iv
Inj ranitidine 50 mg /
12jam/iv
InjNovorapid 8-8-8 unit
InjLevemir 12 unit malam
GG tab 3 x 100 mg
Foto thorak
BTA
DR,LFT,RFT,KGD N,KGD 2 Jam PP,KGD Puasa,HbA1c
Lipid profil
Konsul PAI Konsul Endokrin
Urinalisa
Tranfusi PRC @ 175 cc sebanyak 4 bag
WBC
RBC
HGB
HCT
Hari Rawatan 3
(16April 2014)
:8300 ul
:2,36 106 ul
: 6,3 gr/dl
: 18,5 %
Page 1
Follow Up
MCV
MCH
MCHC
PLT
RDW-CV
: 78,4fl
:26,7pg
:34,1 dl
: 424000 ul
: 12,7 %
Kimia klinik
SGOT
: 23 u/l
SGPT
: 18 u/l
Alkaline Phosphatase: 146 u/l
Total bilirubin : 0,32 mg/dl
Direct bilirubin : 0,16 mg/dl
Ureum
: 37 mg/dl
Kreatinin
: 0,62 mg/dl
KGD puasa : 205 mg/dl
2 jam pp
: 245 mg/dl
HbA1C : 4,6
Elektrolit
Natrium
Kalium
Chlorida
: 130mmol/dl
: 2,8mmol/dl
: 83 mmol/dl
Hari Rawatan 4
(17April 2014)
Keluhan
Sensorium
KU/KP/KG
TD
HR
RR
Temperatur
110/60 mmHg
86 x/i
28 x/i
36,7 C
Hari Rawatan 5
(18 April 2014)
KU : Batuk(+),Dahak(+),
KT : Badan lemas (+),Pucat(-)
Status Presens
Composmentis
Sedang/Sedang/sedang
110/70 mmHg
88 x/i
27 x/i
36,7 C
Page 2
Follow Up
Diagnosa
sementara
TB putusobat + DM tipe 2 +
Anemia ecpenyakitkronis +
Gangguan elektrolit
Tirah baring
Diet DM 1300 kkal
O2 1-4 l/i
IVFD nacl 0,9 % 30 gtt/i
Inj Ceftriaxone 1 gr / 12 jam
iv
Inj ranitidine 50 mg / 12
jam/iv
Inj Novorapid 8-8-8 unit
Inj Levemir 12 unit
malam
GG tab 3 x 100 mg
Usul
Cek DR post tranfusi
KGD ad random
Darahrutintanggal 18 April 2014
Therapy
Gangguanelektrolit
Tirah baring
Diet DM 1300 kkal
O2 1-4 l/i
IVFD nacl 0,9 % 30 gtt/i
Inj Ceftriaxone 1 gr / 12 jam iv
Inj ranitidine 50 mg / 12
jam/iv
InjNovorapid 8-8-8 unit
InjLevemir 12 unit malam
GG tab 3 x 100 mg
WBC
: 13600 ul
RBC
: 4,54 106 ul
HGB
: 12,6 gr/dl
HCT
: 39,3 %
MCV
: 87fl
MCH
: 27,8pg
MCHC
: 32,1 dl
PLT
: 226000 ul
Tanggal
(Hari
Rawatan)
Keluhan
Sensorium
KU/KP/KG
TD
HR
RR
Temperatur
Diagnosa
sementara
Hari Rawatan 6
(19April 2014)
Hari Rawatan 7
(20 April 2014)
KU : Batuk(+),Dahak(+),
KT :Badan lemas (+)
Status Presens
Composmentis
Sedang/Sedang/sedang
110/70 mmHg
100/70 mmhg
88 x/i
80 x/i
26 x/i
28 x/ i
36,7 C
37,3 C
TB putus obat + DM tipe 2 +
TB putusobat + DM tipe 2 +
Anemia ec penyakit kronis +
Page 3
Follow Up
Gangguan elektrolit
Gangguan elektrolit
Therapy
Tirah baring
Tirah baring
Tirah baring
Tirah baring
Diet DM 1300 kkal
Diet DM 1300 kkal
O2 1-4 l/i
O2 1-4 l/i
IVFD nacl 0,9 % 30 gtt/i
IVFD nacl 0,9 % 30 gtt/i
IVFD AminofusinL 600
IVFD AminofusinL 600 600
600 ml /hari
ml /hari
Inj Ceftriaxone 1 gr / 12 jam iv
Inj Ceftriaxone 1 gr / 12 jam
Inj ranitidine 50 mg /12 jam/iv
iv
Inj Novorapid 8-8-8 unit
Inj ranitidine 50 mg /12
Inj Levemir 12 unit malam
jam/iv
GG tab 3 x 100 mg
InjNovorapid 8-8-8 unit
InjLevemir 12 unit malam
GG tab 3 x 100 mg
Usul
- KGD ad random
KGD tanggal 19 april : 158 mg/dl
KGD tanggal 20 April 168 mg/dl
Tanggal
(Hari
Rawatan)
Keluhan
Sensorium
KU/KP/KG
TD
HR
RR
Temperatur
Diagnosa
sementara
Therapy
Hari Rawatan 8
(21April 2014)
Hari Rawatan 9
(22 April 2014)
KU : Batuk(+),Dahak(+),
KT :Badan lemas (+)
Status Presens
Composmentis
Sedang/Sedang/sedang
110/70 mmHg
100/70 mmhg
88 x/i
80 x/i
26 x/i
28 x/ i
36,7 C
37,3 C
TB putus obat + DM tipe 2 +
TB putusobat + DM tipe 2 +
Anemia ec penyakit kronis +
Gangguan elektrolit
Gangguan elektrolit
Tirah baring
Tirah baring
Tirah baring
Tirah baring
Diet DM 1300 kkal
Diet DM 1300 kkal
O2 1-4 l/i
O2 1-4 l/i
IVFD nacl 0,9 % 30 gtt/i
IVFD nacl 0,9 % 30 gtt/i
IVFD Aminofusin L 600
IVFD AminofusinL 600 600
600 ml /hari
ml / hari
Inj Ceftriaxone 1 gr / 12 jam
Inj Ceftriaxone 1 gr / 12 jam iv
Inj ranitidine 50 mg /12 jam/iv
iv
Page 4
Follow Up
Usul
- KGD ad random
- CT thorax
Tanggal
(Hari
Rawatan)
Keluhan
Sensorium
KU/KP/KG
TD
HR
RR
Temperatur
Diagnosa
sementara
Therapy
Hari Rawatan 10
(23April 2014)
Hari Rawatan 11
(24 April 2014)
KU : Penurunankesadaran
KT :Batuk(+).dahak(+).
Status Presens
Apatis
Sedang/Sedang/sedang
100/70 mmHg
90/60 mmhg
88 x/i
80 x/i
26 x/i
28 x/ i
36,7 C
37,3 C
Penurunan kesadaran ec
TB putusobat + DM tipe 2 +
hipoglikemi + TB putus obat + DM
Anemia ec penyakitkronis +
Gangguanelektrolit
+ Gangguan elektrolit
Tirah baring
Tirah baring
Diet DM 1300 kkal
O2 1-4 l/i
IVFD nacl 0,9 % 30 gtt/i
IVFD Aminofusin L 600
600 ml/hari
Inj Ceftriaxone 1 gr / 12 jam iv
Inj ranitidine 50 mg /12 jam/iv
Inj Novorapid 8-8-8 unit
Inj Levemir 12 unit malam
GG tab 3 x 100 mg
Tirah baring
Tirah baring
Diet DM 1300 kkal
O2 1-4 l/i
IVFD nacl 0,9 % 30 gtt/i
IVFD Aminofusin L 600 600
ml / hari
Inj Ceftriaxone 1 gr / 12 jam
iv
Inj ranitidine 50 mg /12
jam/iv
Inj Novorapid 8-8-8 unit
Page 5
Follow Up
Usul
Page 6