Professional Documents
Culture Documents
1) Pada tiga resep berikut ini, terdapat singkatan dalam bidang farmasi. Temukan singkatan
tersebut dan tuliskan pada tabel lembar kerja 1.
Tabel Lembar Kerja 1.
A. Resep 1
B. Resep 2
C. Resep 3
Praktikum 2:
1) Pada rekam medis berikut ini, terdapat singkatan dalam bidang kedokteran. Temukan
singkatan tersebut dan tuliskan pada tabel lembar kerja 2.
PATIENT PRESENTATION
Chief Complaint
“I have been short of breath and have been coughing up brown mucus for the past 3 days.”
HPI
James Thompson is a 55-year-old man with a 3-day history of worsening shortness of breath,
subjective fevers, chills, right-sided chest pain, and a productive cough. The patient states that
his initial symptom of shortness of breath began approximately 1 week ago after delivering
mail on an extremely cold winter day. After several days of not feeling well, he went to an
immediate care clinic and received a prescription for levofloxacin 750 mg po for 5 days, which
he never filled due to financial reasons. He has been taking acetaminophen and an over-the-
counter cough and cold preparation, but feels that his symptoms are getting “much worse.”
The patient began experiencing pleuritic chest pain and a productive cough over the past 3
days, and feels that he has been feverish with chills, although he did not take his temperature.
Upon presentation to the ED, he is febrile and appears to be visibly short of breath.
PMH
HTN × 15 years
COPD × 10 years
SH
Lives with wife and four children. Employed as a mail carrier for the U.S. Postal Service
Smokes 2 pack/day for the past 30 years. Denies alcohol use or IV drug use
Meds
Patient states that he has only been sporadically taking his medications due to financial
issues.
- Lisinopril 10 mg po once daily
- Hydrochlorothiazide 12.5 mg po once daily
- Ipratropium/albuterol MDI two inhalations four times daily
- Albuterol MDI two inhalations PRN shortness of breath
- Acetaminophen 650 mg po Q 6 h PRN pain
- Guaifenesin/dextromethorphan (100 mg/10 mg/5 mL) 2 teaspoonfuls
Q 4 h PRN cough
All
NKDA
Physical Examination
Gen
Patient is a well-developed, well-nourished, African-American man in moderate respiratory
distress appearing somewhat anxious and uncomfortable.
VS
BP 156/90, P 127, RR 31, T 39.1°C; Wt 88 kg, Ht 6'1''
Skin
Warm to the touch; poor skin turgor
Labs on Admission
- Na 140 mEq/L - Hgb 12.1 g/dL - WBC 17.2 ×
- K 4.3 mEq/L - Hct 35% 103mm3
- Cl 102 mEq/L - RBC 3.8 × -
- CO2 22 mEq/L 106/mm3
- BUN 31 mg/dL - Plt 220 × 103mm3
- SCr 1.4 mg/dL - MCV 91 μm3
- Glu 101 mg/dL - MCHC 35 g/dL
ABG
pH 7.410; pCO2 29; pO2 65 with 85% O2 saturation on room air
Chest X-Ray
Right middle and lower lobe airspace disease, likely pneumonia. Left lung is clear. Heart
size is normal.
Assessment
Probable multilobar community-acquired pneumonia involving the RML and RLL
Hypoxemia