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  • DR 1 Ags

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    This medical record documents the diagnosis and treatment plan for a 14-year-old male patient, Michael Owen. He was diagnosed with anemia of inflammation, sepsis, thrombocytopenia, oral candidiasis, and folliculitis. Laboratory tests showed low hemoglobin and platelet counts. The treatment plan included IV fluids, antibiotics, antifungals, and a transfusion of 5 units of packed red blood cells over several days. Follow up consultations and tests were also scheduled to monitor the patient's progress.

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    This medical record documents the diagnosis and treatment plan for a 14-year-old male patient, Michael Owen. He was diagnosed with anemia of inflammation, sepsis, thrombocytopenia, oral candidiasis, and folliculitis. Laboratory tests showed low hemoglobin and platelet counts. The treatment plan included IV fluids, antibiotics, antifungals, and a transfusion of 5 units of packed red blood cells over several days. Follow up consultations and tests were also scheduled to monitor the patient's progress.

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    © All Rights Reserved
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    8 views2 pages

    DR 1 Ags

    Uploaded by

    maria
    This medical record documents the diagnosis and treatment plan for a 14-year-old male patient, Michael Owen. He was diagnosed with anemia of inflammation, sepsis, thrombocytopenia, oral candidiasis, and folliculitis. Laboratory tests showed low hemoglobin and platelet counts. The treatment plan included IV fluids, antibiotics, antifungals, and a transfusion of 5 units of packed red blood cells over several days. Follow up consultations and tests were also scheduled to monitor the patient's progress.

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    © All Rights Reserved
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    of 2

    Dr.

    SEN 31/08/2020

    KAMAR NAMA/USIA/BB/TB DIAGNOSA LABORATORIUM TERAPI RENCANA

    - O2 nc 1 lpm
    - IVFD D5% NaCl 0.45 % 20
    cc/jam
    3.2.1 Michael Owen DD/ Anemia of 29/8 - Inj. Cefriaxone 1 gr /12 jam/iv - Transfusi
    Dr SEN 81.64.14 Inflamation / MDS + Hb 4.7/Ht 14/Leu 11810/PLT (29/8) H3 PRC I 125
    265 L, 14 thn 2 bln Sang Sepsis+ Trom 20.000 - Nystatin 4x1 ml PRC II 150
    MCV 91/MCH 31.1/MCHC 34.1 - Cetirizine 2 x 10 mg PRC III 200
    29/8 BB: 40,6 kg bositopenia + Oral
    E 0/B 0/L 29.6/M 48.9/N 21.5 PRC IV 200
    TB: 159 cm Kandidiasis + PT 11.7 (13.6)/INR 0.69/APTT 29.8 PRC V 200
    Folikulitis (32.6)/TT 15.5 (17.9) TC 4 unit
    GDS 114/BUN 11/Ur 24/Cr 0.73 - Cek Serum besi 31/8
    Na 136/K 3.9/Cl 103/Ca 7.2
    PCT 0.82
    IgG/IgM AntiCovid-19: non reaktif
    - Konsul Kulit 31/8
    - Susul Kultur darah (29/8)
    - Susul rontgen thorax 29/8

    1
    Dr. SEN 31/08/2020

    Riwayat:
    - Koreksi Hipokalsemi 29/8

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