Gabriel Dec 22

Tanggal bangsal nama No.
RM DRP
1-Dec-22 gabriel EKARAJA MAHAGAT 44-70-48
MARCO WIRIANATA 441139
ONG TJOE NIO 44-69-48

LIEM SHAN FA NIO 43-02-56
TJU HARIMO 43-34-19
ONG LIEN TJU 43-58-01

HARIANTO 44-70-86
Ny. Raminah 44-41-60
SRI MURTINI 02-49-60
IRMA 44-59-20
DEVINA RIZALDY 41-44-39
5-Dec-22 gabriel AFFANDI JOSEPH 325557
KARNI 43-19-98
ONG LIEN TJU 43-58-01

KOEI LIAN 44-60-37
TONG MEI KHIM 00-39-16-61

ONG TJOE NIO 44-69-48
EKARAJA MAHAGAT 44-70-48

6-Dec-22 gabriel EKARAJA MAHAGAT 44-70-48
AFFANDI JOSEPH 325557

JEAN KOMALA DEWI 437873
KOEI LIAN 44-60-37
ROSALINA MAWARTI00-30-24-15
7-Dec-22 gabriel PHAN TJIE WIE 41-58-51
JEAN KOMALA DEWI 437873
NOVYANI 37-11-91
SAM SIOMPO 31-43-64

SUPRIHATIN 44-73-89
HERMAWAN SETIADI 359117
KOEI LIAN 44-60-37

8-Dec-22 gabriel SULASTRI 44-74-01
SUPRIHATIN 44-73-89
PEH GEK LAN 447360
KOEI LIAN 44-60-37

AL TEDDY SUKOJOWI 432045
BUDI PANGESTU 30-89-45
PHAN TJIE WIE 41-58-51

9-Dec-22 gabriel PEH GEK LAN 447360
SUPRIHATIN 44-73-89
SULASTRI 44-74-01 mual dan muntah

RITA SARI 23-89-12
KOEI LIAN 44-60-37
INDRAWATI RAHARD 447130

ENGA HANNA SINSK 430179
PHAN TJIE WIE 41-58-51

TAN JUVITA DEWISU 447505
12-Dec-22 gabriel RITA SARI 23-89-12
DEBBY 42-35-73
SULASTRI 44-74-01 nyeri minimal

REPUNG 44-56-94
KURSI 31-35-02
MARADIAN YACOEB C 347208

IRA RIFDA RIANITA 36-65-44
HESTU WREDAYANTO 446365
IRYANA 44-75-85
13-Dec-22 gabriel HESTU WREDAYANTO 446365
REPUNG 44-56-94
KURSI 31-35-02
SANTO 44-74-60
MARADIAN YACOEB C 347208 dyslipidemia: HDL =
CHIVIKA 44-75-97 monitoring terfacef tidak di y-site dengan ase

IRA RIFDA RIANITA 36-65-44
IRYANA 44-75-85
DEBBY 42-35-73
SULASTRI 44-74-01
RITA SARI 23-89-12 Alb = 2,66 g/dl

14-Dec-22 gabriel MARADIAN YACOEB C 347208
KURSI 31-35-02
HESTU WREDAYANTO 446365

SULASTRI 44-74-01
RITA SARI 23-89-12
CHIVIKA 44-75-97 monitoring terfacef tidak di y-site dengan ase
SANSAN SURYA 44-76-20

GUNAWAN KAMARU 447570
SANTO 44-74-60
BRYAN ELBERT JON 385119

15-Dec-22 gabriel BRYAN ELBERT JON 385119
SULASTRI 44-74-01
RITA SARI 23-89-12
SANSAN SURYA 44-76-20

CIN MIN 30-71-96
MARADIAN YACOEB C 347208
SUKIANTO JANOGOR29-84-95
ALI 44-76-64
HIN KIT SIONG 44-75-69
ROMO YULIANUS ENG

26-82-87
KURSI 31-35-02
RURI HASTUTIK 44-39-15
SANTO 44-74-60
YANNI CHANDRA 44-61-62

16-Dec-22 gabriel SANTO 44-74-60
PONIYEM 44-77-66
AL TEDDY SUKOJOWI 432045 Demam

BRYAN ELBERT JON 385119
KURSI 31-35-02
RURI HASTUTIK 44-39-15

ALI 44-76-64
ILIK SURATNO 447753
SULASTRI 44-74-01
RITA SARI 23-89-12 BATUK KERING
HIN KIT SIONG 44-75-69
19-Dec-22 gabriel RICKY ANDHIKA PUT44-78-40
HASAN 34-94-32
KARNI 43-19-98
ALI 44-76-64
PONIYEM 44-77-66
NOVYANI 37-11-91
20-Dec-22 gabriel AL TEDDY SUKOJOWI 432045

ALI 44-76-64
NOVYANI 37-11-91
RICKY ANDHIKA PUT44-78-40
KARNI 43-19-98
LINA 36-58-60
HASAN 34-94-32
DJOKO SUSILO 44-23-31

BUDHI DARMA 44-79-01 batuk berdahak
suspek HAP

21-Dec-22 gabriel HENDRA HALIM 44-78-38
AL TEDDY SUKOJOWI 432045 nyeri minimal, bel
HASAN 34-94-32
HARTONO 44-79-02 1) absorbsi dexketo
ALI 44-76-64

22-Dec-22 gabriel ANGELICA HONGARIA 408062
JUMNAIDA 39-19-90
JAP LIE LIE 35-17-55

JUNI JUSTINI 44-79-86
AL TEDDY SUKOJOWI 432045 nyeri minimal, bel

RENO PARULIAN 38-82-09
ALI 44-76-64

23-Dec-22 gabriel HASAN 34-94-32
JAP LIE LIE 35-17-55
SUKIANTO JANOGOR29-84-95 pasien dengan pen

GERRY WINARTHA K 448026
ANGELICA HONGARIA 408062

JUNI JUSTINI 44-79-86
RENO PARULIAN 38-82-09
JUMNAIDA 39-19-90

LAURENTIUS MICHAE36-10-30

Rekomendasi Keterangan
RIWAYAT ALERGI: CEFTRIAXONE --> URTIKARIA
Post op Kraniotomi evakuasi EDH(H+4)ec. EDH(R)Frontotemporal+Depressed fraktur(R)Frontotemp
pusing dan nyeri menelan sudah berkurang; nyeri post op; s = 36,4; N = 75; P = 20; TD = 130/80
Terapi yang didapatkan:
- Brainact 2x500mg IV
- Eterlox 2x 500 mg PO
- Drip manitol turun 2x100cc(iv)
- FG troches 3x1(po)
- Klisma microlax supp(2)
- lactulac 3x15 cc PO
- Dexamethasone 2x500 mg IV
- Ceftriaxone 2x2 g IV
- Kalnex 2x500 mg IV
- Pantoprazole 1x40 mg IV
- Vitamin C 1x1 g IV
- Farmadol 3x1 g IV
Simptomatik seizure
Post op Aff shunt+Excisi Cyst(H+6) d/t Epilepsi+Malfungsi Shunt
nyeri kepala membaik, kejang (-); TD 110/80 mmHg HR 64x/min RR 20x/min S 36 SpO2 99% room a
FG Troches 3x1 tab PO
acetazolamid 3x500 mg
keppra 2x1500 mg po
Depakote 1x1500 mg po
lamictal 1x25 mg po
betahistine 2x6mg po
Sumagesic 3x600mg(po)
Ceftriaxon 2x2 g
Inj. ketorolac k/p jika pusing berputar dan nyeri kepala
Pantoprazole 1x40 mg
vit C 1x1 g
- post PFN ai Close # interthrocanter femur sn

- HT
- Trombositosis et leukositasis ec inflamasi reaktif
- hypercoagulable state
- UGITB kronik ec gastropati erosif dd/ ulkus peptikum
- ISK
- mild cognitive impairment
- flebitis manus sin
nyeri post op VAS 2-3; TD 120/60 mmHg HR 92x/min RR 20x/min S 36.3 SpO2 96% room air
- IVFD RL 1000 cc/ 24 jam
- ceftriaxone 1x2 g IV
- pantoprazole 3x40 mg IV
- vit K 3x1 amp IV
- mucosta 3x1 tab po
- Xarelto+ thromboreduction + zitanid stop 5 hari
- amlodipin 1x5 mg po pagi
- coralan 2x5 mg po
- lyrica 1x75 mg po malam
- donacept 1x5 mg po
- atorvastatin 1x20 mg po
- paracetamol 2x1 g IV
memastikan pemberian lodAkut simptomatik seizure ec gliosis post stroke

Pneumoniae
kejang (-), gelisah (+); TD 130/80 mmHg HR 62x/min RR 20x/min S 36.2 SpO2 99% room air
IVFD NS 0.9 500cc/12 jam
Brainact 2x500 mg IV
Meconeuro 2x500 mcg IV
Eterlox 2x500 mg PO
Pantoprazole 1x40mg IV
CPG 1x 75 mg PO
Lodomer 1x 0.5 mg PO malam hari
Aricept 1x 2.5 mg PO
Candesartan 1x8 mg PO
Nifedipine 1x10 mg PO
Viccilin SX 4x1.5 gram iv
Fluimucyl eff 2x600mg po
Nebu combivent / 8 jam--> k/p sesak
Betadine gargle 2x sehari
Extra Soluvit 1 amp iv drip dalam NS 100 cc hari ini
- Ischialgia (Ischialgia)
nyeri pinggang masih ada skala 1-2; s = 36,2; N = 63; P = 20; TD = 120/80; SpO2 = 98%
RPO :
Methycobal 1x500mcg
Etorvel 1x120mg
atorvastatin 10 mg
norvask 1x5 mg po (malam)
myonal 2x1 g PO
Meticobal 1x500 mcg IV
Ketrobat 1x1 amp IV
hipertensi
hipertiroid
CAD
nyeri membaik; TD 130/90 mmHg HR 83x/min RR 20x/min S 36 SpO2 99% room air
IVFD RL 500 cc/ 24 jam
inj pantoprazole 1x40 mg IV
inj metoclopramid 3x1 amp IV
heparin profilaksis 2x5000 iu SC
thyrozol 1x10 mg po
rebemipide 3x1 tab po
propranol 3x30 mg po
clopidogrel 1x75 mg po
candesartan 1x8 mg po
Koledokolitiasis dengan kolangitis

Kolelitiasis multipel
kuning (+), gatal membaik; TD 130/70 mmHg HR 60x/min RR 20x/min S 36 SpO2 98% room air
-Infus Bfluid 1000 cc + Renxamin 500 cc / hari
- Terfacef 1x2 gram iv (h-3)
- Metronidazole 3x500 mg iv (h-3)
- Urdafalk 3x250 mg tab po
- Buscopan 1 amp iv (k/p nyeri)
- Curcuma force 3x1 cap po
- Pranza 1x40 mg iv
- Ramozea 1x1 amp iv drip dalam NS 100 cc --> k/p muntah
- KSR 1x1 tab (untuk 5 hari saja)
- Destavell 1x5 mg tab po
- clopidogrel 1x75 mg PO
- Coaprovel 300/12.5 mg PO
- Doloneurobion 1x1 PO
- Forneuor 1x1 PO
(sedang operasi)
Pro ORIF radius + Ulna (Kamis 1 desember 2022 pukul 12:00)
- Pneumonia (Pneumonia)
- Hipertensi (Hipertensi)
nyeri dada kiri (-), pusing berputar membaik, batuk (-); TD 110/80 mmHg HR 85x/min RR 20x/min S
- infus RL 1000 cc/24 jam
- Levofloxacin 1x750 mg iv
- Lansoprazole 2x30 mg po
- Domperidone 3x10mg po
- Paracetamol 500 mg po k/p
- Acetylsistein 3x1 tab
- Braxidin 1x1/2 tab po malam
- Grave disease, hyperthyroid (Grave dise)

- Thyfoid fever (Thyfoid fe)
- GEA ec bacterial dd/viral (GEA ec bac)
Demam (-); berdebar (-); TD 100/80 mmHg HR 63x/min RR 20x/min S 36.2 SpO2 98% room air
- IVFD Asering 1500 cc/24 jam
- Ceftriaxone 1X2 g IV
- Farmadol 1 gram IV K/P
- Thyrozol 2x20 mg PO
- Propranolol 3x20 mg PO
RIWAYAT ALERGI: GOLONGAN SULFA --> kemerahan + gatal pada kulit

DHF GRADE 1
mual membaik, demam (-); TD 110/80 mmHg HR 73x/min RR 20x/min S 36.5 SpO2 98% room air
Monell ODT 3x1 tab
Disflatyl 3x2 tab
Braxidine 0-0-1
PANVELL 2 X 40 MG PO
IMBOOST FORCE 2 X 1
POD IV subtotal thyroidectomy dengan neuropraxia RLN

nyeri post op VAS 1-2; s = 36,2;N = 91; P = 20; TD = 120/80
Asam traneksamat 3x500 mg IV
Cefazolin 3x1 g IV
Ketorolac 1 amp IV k/p nyeri
sumagesic 3x 1 tab po
omeprazole 2x 20 mg po
Mecobalamin 1 amp drip /kolf RL
CDR 1x1 larut dalam air 200 cc
vipalbumin caps 2x1 tab po
Minosep gargle
LBP
Parkinson
nyeri pada punggung skala 3-4 (0-10); TD 110/80 mmHg HR 78x/min RR 19x/min S 36 SpO2 98% roo
IVFD RL 500cc/24 jam
Drip Farmadol 3x1 gr IV
Meconeuro 1x 500 mcg IV
Candesartan 1x8 mg PO
Gabapentin 2x100 mg OO
Amlodipine 1x10 mg PO
Madopar 4x 125 mg PO (jam 07.00, 12.00, 16.00 dan 20.00 WIB)
Trihexyphenidyl 2x 2 mg untuk gemetar
Myonal 2x 50 mg PO
hipertensi
hipertiroid
CAD
tidak ada keluhan, rencana pulang; TD 140/80 mmHg HR 111x/min RR 19x/min S 36 SpO2 99% room
inj pantoprazole 1x40 mg IV
inj metoclopramid 3x1 amp IV
lovenox 1x0.4 cc SC
thyrozol 1x30 mg po
rebemipide 3x1 tab po
propranol 3x30 mg po
betahistine 2x6 mg po
obat pulang:
xarelto 1x10 mg po
thyrozol 1x 30 mg po
propranolol 3x30 mg po
ezocon 1x20 mg po
Tumor Paru Dx (susp Ca), metastasis (+) on palliative care

Syok Kardiogenik DD/ Septik (perbaikan)
Pleuropneumonia
STEMI Anterolateral
Malnutrisi
Hipoalbuminemia
Konstipasi
Hemorrhoid Interna + Eksterna
Anemia ringan NN
AKI DD/ Acute on CKD
sesak (+), gelisah (+); TD: 110/80, N: 110x/mnt, P: 28x/mnt, SpO2: 99% (O2 8-10 LPM, NRM)
- Infus : Asering 500 ml /24 jam
- Drip vascon 0.02 mcg/kgbb/mnt (titrasi turun)
- Pranza 1x40 mg iv
- Avelox 1x400 mg iv
- Nebulisasi Combivent 1 respul + Bisolvon 40 tetes per 8 jam
- Farmadol 3x1 gram (IV)
- Durogesic Patch 25 mcg (per 3 hari)
- Vipalbumin sachet 2x1 (via NGT)
- Dynastat 1x1 amp (siang, iv drip dlm NS 100 ml)
- Faktu supp 3x1
- Interlac sachet 2x1 (via NGT)
- Microlax supp k/p (bila BAB belum keluar 2 hari)
- Dexamethasone 2x 5 mg IV (2 hari)
Back pain
nyeri di bagian punggung; TD 100/80 mmHg HR 68x/min RR 19x/min S 36 SpO2 99% room air
Celebrex 2x200mg
Myonal 1x1 malam
- post PFN ai Close # interthrocanter femur sn

- HT
- Trombositosis et leukositasis ec inflamasi reaktif
- hypercoagulable state
- UGITB kronik ec gastropati erosif dd/ ulkus peptikum
- ISK
- mild cognitive impairment
- flebitis manus sin
nyeri pada tungkai kiri, rencana pulang; T120/70 N 85 R 19 S 36.8 C Sat 98% room air
- fosfomycin 2x1 g IV
- Celebrex 2x200 mg IV
- thromboreduction 1X1 PO
- coralan 2x5 mg po
obat pulang:
- monuril 1x3 g po 2 hari saja
- pantoprazole 2x40 mg po
- thromboreduction 1x1 tab po
- coralan 2x5 mg po
RIWAYAT ALERGI: PENISILIN --> URTIKARIA

Demam naik turun, nyeri saat nafas dalam, muntah (+), nyeri kepala (+); s = 37,6; N = 72; P = 19; TD
- IVFD RL 2000cc/24 jam
- Brainact 2x500mg IV
- Drip manitol naik jd 4x125cc(iv)
- lactulac 3x15 cc PO K/P
- Levofloxacin 1x750 mg IV
- Vitamin C 1x500 mg PO
- Paracetamol 3x1 g IV
- Minosep gargle 2x sehari (10cc)
- merislon tablet 2 x 12 mg po
- Drip ondansetron turun jadi 3x4mg(iv)

Demam subfebris; pusing dan mual berkurang; s = 37,4; N = 84; P = 19; TD = 130/80
- Brainact 2x500mg PO
- merislon tablet 2 x 12 mg po
- Drip ondansetron turun jadi 3x4mg(iv)
- fluconazole 1x 150 mg po
POD IV subtotal thyroidectomy dengan neuropraxia RLN

nyeri post op VAS 1-2, suara serak, batuk dahak putik; s = 36,5;N = 71; P = 19; TD = 130/80; SpO2 = 9
bisolvon sirup 2x15 cc
Ketorolac 1 amp IV k/p nyeri
sumagesic 3x 1 tab po
omeprazole 2x 20 mg po
neurobion forte 1x1 tab po
CDR 1x1 larut dalam air 200 cc
vipalbumin caps 2x1 tab po
Minosep gargle
bila monitoring tekanan darah TD > 140 sistole 2x berturut beda 1 jam --> amlodipine 5 mgpo
obat pulang:
1. sumagesic 3x1 tab po
2. bisolvon syr 2x15 cc po
3. neurobion forte 1x1 tab po
4. kolkatriol 2x1 tab po
5. omeprazole 2x20 mg po
6.vipalbimun capss 2x1 tab po
7. CDR 1x1 tab po larut air
8, amlodipine 1x5 mg po malam
Dyspepsia
nyeri perut (+), mual berkurang; s = 36,3;N = 62; P = 19; TD = 90/60; SpO2 = 98%
-IVFD Asering 1000cc/24 jam
- cernevit 1x1 amp iv
-Pranza 2x40 mg IV
- Invomit 3x4 mg IV

Pleuropneumonia
STEMI Anterolateral
Malnutrisi
Hipoalbuminemia
Konstipasi
Anemia ringan NN
sesak (+), gelisah (+), NGT berwarna hitam; s = 36; N = 98; P = 20; TD = 150/105; SpO2 = 99%
- Infus : Smofkabiven 1448 ml/ 24
- Drip vascon 0.1 mcg/kgbb/mnt
- Pranza 2x40 mg iv
- Vipalbumin sachet -TUNDA
- Faktu supp 3x1
- Interlac sachet -TUNDA
- Inpepsa syr 4x15 ml
- Dexamethasone 1x 5 mg IV (2 hari) lalu di-stop
- Extra Miloz 2 ml (bolus IV perlahan) -sudah diberikan
RIWAYAT ALERGI: CRAVIT --> GATAL, MERAH

Atypical chest pain
Pneumonia
Asma dgn derajat serangan ringan-sedang
nyeri dada dan sesak membaik namun sempat memberat; TD 110/60, HR 80, RR 30, SpO2 100% O2
Viccilin SX 4x1.5gr iv --> besok rencana di-stop
Zithromax 1x500mg po
Drip cernevit 1 amp dalam sa;ah satu asering --> besok di-stop
Paracetamol 3x1 gram iv
Codipront expectorant 2x1 tab po
Prove D 1x5000 u po
Nebu Combivent : Pulmicort : NaCl 0.9% 2 cc tiap 8 jam
Metilprednisolone 3x4 mg po
- Ca buli on DJ stent D ( Ca buli o)

- AKI on CKD DD/ CKD st III (AKI on CKD)
nyeri saat BAK skala 1-2, RPO rutin (-); s = 36,2; N = 82; P = 20; TD = 120/80
- Infus NaCl 1000 cc/24 jam
-Inj Ceftriaxone 2x1 gr iv
-Inj Ranitidine 2x1 amp iv
-Urispas 2x1 tab po
- prorenal 3x1 tab po
Dyspepsia
kadang mules, mual berkurang; s = 36;N = 80; P = 20; TD = 110/80; SpO2 = 99%
- cernevit 1x1 amp iv
-Pranza 3x40 mg IV
- Invomit 3x8 mg IV
-rillus 3x1 tab
obat pulang:
-pariet 2x20 mg
-narfoz 3x4 mg
-rillus 3x1
monitoring natrium dan k - Hiperkalemia (6.6) (Hiperkalem)

- Post SC P2 A0 (Post SC P2)
- AKI dd Susp ACKD (AKI dd Sus)
nyeri ulu hati dan mual; s = 36,4; N = 82; P = 18; TD = 130/80; SpO2 = 98%
- nacl 0.9% 10 tpm
- Ca Gluconas 1 amp (diberikan pelan) setelah itu selang 15 menit berikan 1 amp lagi --> Sudah seles
- Setelah diberikan Ca Gluconas ke 2. Lanjut Dextrose 5% 100cc + Dextrose 40% 3 flask + Novorapid
- Ceftriaxone 1x2 gr IV
- Asam folat 2x1 tablet
- Natrium Bicarbonat 3x500 mg PO
- Calcium Carbonat 3x500 mg PO
- Kalitake 3x1 sachet
- pantoprazol 2x40mg IV
- metoclopramid 3x10mg IV
- Lipoma subkutis suprahyoid sinistra (Lipoma sub)

nyeri post op minimal skala 2 (0-10); s = 36,3; N = 84; P = 18; TD = 120/80; SpO2 = 97%
-infus RL 1500/24 jam
- besok mulai levofloxacin 1 x 500 mg oral
- omeprazole 1 x 20 mg oral
- gentamicin salep pro rawat luka
- ketorolac 3x1 amp IV

demam membaik, pusing berkurang, mual (-); s = 36,6; N = 75; P = 20; TD = 110/70
- Brainact 2x500mg PO
- Drip manitol naik jd 3x125cc(iv) --> besok turun menjadi 2x125 cc IV
- merislon tablet 12 mg po k/p pusing berputar
- ondansetron turun jadi 2x4mg po
- Durogesic patch 12 mcg tempel, mulai besok anti nyeri PCT mulai tapp off --> 1x1 gram i.v drip sam
- profenid supp ekstra

Atypical chest pain
BRONKHITIS AKUT
sesak (-), nyeri dada (-), batuk (+); s = 36; N = 80; P = 22; TD = 110/70; SpO2 = 99%
Prove D 1x5000 u po
Daylax 1x1 sachet po campur dengan air
drip tramadol 50 mg iv dalam nacl 0.9% 100cc habis dalam 2 jam K/P nyeri dada
Demam dengue dd/viral infection dengan liver involvement

ISK
Hipokalemia ec low intake
saat ini demam (-), mual muntah (-); RPO: pct dan cefadroxil; S = 36,4; N = 80; P = 20; TD = 100/60; S
- IVFD RL 2000 cc/24 jam
- levofloxacin 1x500 mg IV
- metoclopramid 3x1 amp IV
- Lansoprazole 1x30 mg IV
- BecomC2x1 tab PO
- Paracetamol 3x1 gram PO
- Curcuma 3x1 tab PO
- Aspar K 2x300 mg PO
AF RVR
nyeri dada perbaikan; s= 36,2; N = 88; P = 20; TD = 100/60
- Bisoprolol 1x2,5 mg PO
- Digoxin 1x1/2 tab PO
- Asam folat 2x1 mg PO
- Heparin 10.000 U/24 jam
obat pulang:
simarc 1x2 mg
clopidogrel 1x1
bisoprolol 1x2.5 mg
digoxin 1x1 tab
asam folat 2x1 mg
bicnat 3x500 mg
candesartan 1x8 mg

Pleuropneumonia
STEMI Anterolateral
Malnutrisi
Hipoalbuminemia
Konstipasi
Anemia ringan NN
kontak menurun; NGT kecoklatan; TD: 100/60, N: 90x/mnt, P: 28x/mnt, SpO2: 95% (O2 13 LPM)
- Pranza 2x40 mg iv
- Vipalbumin sachet -TUNDA
- Faktu supp 3x1
- Interlac sachet -TUNDA
- ramozea 1amp IV drip dalam NS 100cc
memastikan pemberian vi POD 1 dengan hipovolemik

nyeri post op minimal, mual (-); Alb = 2,71; Hb = 9,2; Hct = 28; Eritrosit = 3,12; leukosit = 12,31; TD 1
- IVF RL 1500 cc dan B fluid 1000 cc
- Ceftriaxone 2x2 gram IV
- Metronidazol 3x500 mg IV
- Paracetamol 3x1 IV
- Omeprazole 2x40 mg IV
- Ondansetron 1x8 mg IV
- VIP ALBUMIN Sachet 2x1 sachet per NGT lsrut dalam 10 cc air
- Asam tranexamat inj sd 3 dosis stop
- Ketorolac turun menjadi 2x30 mg IV --> tunda
- Rencana masuk Octalbin 25% 100 CC
- Rencana masuk Tranfusi PRC 2 unit

Atypical chest pain
BRONKHITIS AKUT
nyeri dada dan sesak tidak ada; TD 100/80 HR 88 RR 18 S 36.2 SatO2 99%
Prove D 1x5000 u po
Pranza 1x40 mg iv
Daylax 1x1 sachet po campur dengan air
drip tramadol 50 mg iv dalam nacl 0.9% 100cc habis dalam 2 jam K/P nyeri dada
Microlax supp I+ gliserin 50cc

ISK
demam (-), mual muntah (-), begah (+); TD 140/90 HR 92 RR 21 S 36.4 SatO2 98%
- BecomC2x1 tab PO
- Paracetamol 3x1 gram PO
GEA bacterial dd/ viral dengan dehidrasi sedang (perbaikan)

AKI st 1 dd/ CKD st 3a ec hypertensive nephrosclerosis
Dislipidemia
Hipertensi (dalam terapi)
mual (+), bab cair pagi ini (-); TD 140/90 HR 80 RR 20 S 36.2 SatO2 97%
IVFD RL 2000cc/24 jam
Ceftriaxone 1x2 gram iv
Metronidazole 3x500mg po
Ranitidine 2x50mg iv
Paracetamol 4x500mg po
New diatab menjadi 2 tab kp BAB cair max 12 tab
rillus 2x1 cap po
simvastatin 1x10 mg PO (malam)
metoclopramide 1 amp k/p muntah

Pleuropneumonia
STEMI Anterolateral
Malnutrisi
Hipoalbuminemia
Konstipasi
Anemia ringan NN
kontak minimal; TD: 100/50 ( on vasopressor), N: 110x/mnt, P: 28x/mnt, SpO2: 96% ( O2 15 LPM)
- Pranza 2x40 mg iv
- Faktu supp 3x1
- burnazin cream, tutup pakai sofra tulle + kassa pada bagian luka

demam membaik, nyeri di tungkai bawah, mual dan nyeri ulu hati perbaikan, gatal perbaikan; TD 12
- Brainact 2x500mg PO --> besok di-stop
- PCT 500 mg k/p jika suhu >37.5
- Cetirizine 2x1(po)
- Durogesic patch 12 mcg tempel
- Monell ODT 3x1 tab hisap AC
- Besanmag 1x1 tab po malam
Urolithiasis Dextra
BPH
nyeri post op skala 2(0-10); TD 110/70 HR 85 RR 20 S 36.4 SatO2 98%
- IVFD RL 1000 cc / 24 jam
- Paracetamol 3x1 gr IV
- Ranitidin 2 x 1 amp IV
- Harnal Ocas 1x1 po
- Furosemide 1 x 1amp IV
- UGIB + varises esofagus (UGIB + var)

- Sirosis hepatis (Sirosis he)
- Anemia mikrositik hipokrom (Anemia mik)
datang dengan keluhan nyeri perut skala nyeri 2-3, post endoskopi; TD 110/70 HR 76 RR 19 S 36 SpO
Transfusi PRC 1 bag
NaCl 0.9% 1000 cc/24 jam
Propanolol 3x10 mg po
Omeprazole 1x20 mg po
Spironolactone 1x100 mg po
Furosemide 1x40 mg po/selang seling setiap hari

nyeri saat BAK skala 1-2, TD 110/70 HR 80 RR 18 S 36.4 SatO2 98%
-Urispas 2x1 tab po
- Inj Paracetamol 3x1 gr iv
Tx rawat jalan :
- Cotrimoxazole 960 mg 2x1 tab po
- Urispas 2x1 tab po
- Paracetamol 3x500 mg tab po
- Tamsulosin 0,4 0-0-1 tab po
GEA bacterial dd/ viral dengan dehidrasi sedang (perbaikan)

AKI st 1 dd/ CKD st 3a ec hypertensive nephrosclerosis
Dislipidemia
Hipertensi (dalam terapi)
BAB cair (-), mual membaik, kembung membaik; s = 35,1; N = 83; P = 20; TD = 140/90
IVFD RL 500cc/24 jam + neurobion 1 amp
Ceftriaxone 1x2 gram iv
Metronidazole 3x500mg po
lansoprazole 1x30 mg IV
rillus 2x1 cap po
simvastatin 1x10 mg PO (malam)
metoclopramide 1 amp k/p muntah
disflatyl 2x1tab

ISK
demam (-), mual perbaikan, TD 100/70 mmHg HR 74x/min RR 20x/min S 36.3 SpO2 100% room air
- BecomC2x1 tab PO
saran: meningkatkan dosisPOD 1 dengan hipovolemik

nyeri post op VAS 3-4, muntah (+), nyeri tenggorokan; TD 100/70 mmHg HR 74x/min RR 20x/min S 3
- IVF RL 1500 cc dan B fluid 1000 cc
- Paracetamol 3x1 IV
- Omeprazole 2x40 mg IV
- Ondansetron 1x8 mg IV
- Ketorolac turun menjadi 2x30 mg IV
- metoclopramide 1 amp IV (ekstra)
- sucralfat 3x20 cc via oral
Trauma ginjal gr 3-4 Sin hari ke 2

nyeri perut sebelah kiri skala 2-4, badan lemas; TD 110/70 mmHg HR 85x/min RR 20x/min S 37.2 pO
Infus Asering 1500 cc/24 jam
Inj Cefoperazone 2x1 gr iv
Inj Paracetamol 3x1 gr iv drip
Inj Vit. K 3x1 amp iv
Inj Adona 3x1 amp iv
Inj Ketorolac 3x1 amp dlm Asering
Inj Omeprazole 2x1 amp iv
Sucralfat syrup 3x1 sdk makan po

Pleuropneumonia
STEMI Anterolateral
Malnutrisi
Hipoalbuminemia
Konstipasi
Anemia ringan NN
sesak (+), kontak (-); TD 110/60, HR 110 (vascon 0.1 mcg/kgBB/min)
- Pranza 2x40 mg iv
- Faktu supp 3x1
- burnazin cream, tutup pakai sofra tulle + kassa pada bagian luka
RIWAYAT ALERGI: VELOSEF (Sefalosporin gen. 1) --> URTIKARIA

- fraktur distal end radius dx (fraktur di)
nyeri tangan kanan post kecelakaan, pre op; TD 125/85 mmHg HR 74x/min RR 20x/min S 36.3 SpO2
- infus RL 1000/24 jam
- cefazol 1 gr 1 jam pre op
- paracetamol 2x1 gr
- omeprazol 2x1amp IV
ISK
Phlebitis gr 2
RIWAYAT ALERGI: RANITIDIN --> MERAH
demam naik turun; mual perbaikan; TD 110/70 HR 84 RR 18 S 36 SpO2 99%
RL 1500 cc/24 jam
Ciprofloxacin 2x400 mg iv (H2D3-4)
Paracetamol 3x1 gr iv
Metoclopramide 3x10 mg iv kp mual muntah
Lansoprazole 1x30 mg po ac

nyeri saat BAK skala 1-2, demam (-), mual membaik, TD 110/65 mmHg HR 71x/min RR 19x/min S 36
-Urispas 2x1 tab po
- Inj Paracetamol 3x1 gr iv
- Inj Primperan 2x1 amp iv
- Inj Levofloxacin 1x500 mg / 24 jam
Urolithiasis Dextra
BPH
nyeri post op skala 2(0-10); TD 120/80 mmHg HR 80x/min RR 20x/min S 36.3 SpO2 97% room air
- IVFD RL 1000 cc / 24 jam
- Paracetamol 3x1 gr IV
- Ranitidin 2 x 1 amp IV
- Harnal Ocas 1x1 po
- Furosemide 1 x 1amp IV
- Bicnat 3 x 500 mg diteruskan
- Folic acid 2x1 tab PO
- Kolkatriol 1x1 tab PO
Memastikan pemberian levRIWAYAT ALERGI: PENISILIN --> URTIKARIA

memastikan ceftriaxone daPost op Kraniotomi evakuasi EDH(H+4)ec. EDH(R)Frontotemporal+Depressed fraktur(R)Frontotemp
saat ini demam (-), mual perbaikan, gatal perbaikan, kemerahan pada kulit; TD 120/80 mmHg HR 10
- Levofloxacin 1x750 mg PO
- PCT 500 mg k/p jika suhu >37.5
- Cetirizine 2x1(po)
- Durogesic patch 12 mcg tempel
DHF gr 2 dengan liver involvement

saat ini demam (-); TD 110/80 mmHg HR 81x/min RR 20x/min S 35.6 SpO2 97% room air
- Infus Asering 2000 cc/hari
- Pranza 1x40 mg iv
- Granisetron 1x3 mg iv drip dalam NS 100 cc
- Soluvit 1x1 amp iv drip dalam NS 100 cc
- Sumagesic 600 mg tab k/p demam
monitoring ketorolac, besoTrauma ginjal gr 3-4 Sin hari ke 2

nyeri masih dirasa skal 2 (0-10),lemas masih dirasa; s = 37,1; N = 93; P = 20; TD = 120/80; SpO2 = 97
Inj. Levofloxacin 1x500 mg IV
Inj Ketorolac 3x1 amp dlm Asering
Sucralfat syrup 3x1 sdk makan po
- Union fracture distal radius sinistra (Union frac)

nyeri tangan kiri vas 1; s = 36,8; N = 80; P = 20; TD = 110/80
IVFD RL 1000ml/24 jam
Cefazol 2x1gr IV
Paracetamol 2x1gr IV
saran: ketorolac di-stop POD V dengan perbaikan dan hipoalbuminemia terkoreksi dan Anemia dlm koreksi,
nyeri masih dirasa namun sudah berkurang, skala nyeri 2, mual muntah (-); s = 37,1; N = 91; P = 20;
- IVF NS 500 cc dan B fluid 1000 cc
- setiap 2 hari berikan clinoleic 20% 100 ml
- Meropenem 3x1 gram IV
- Paracetamol 1 IV k/p demam / nyeri
- Ramozea 1x1 amp IV
- Ketorolac turun menjadi 2x30 mg IV
- furamin 1x1 amp IV
- Gangren digiti 1 pedis Sx (Gangren di)

nyeri pada kaki masih dirasa skala 2 (0-10); s = 36,5; N = 85; P = 20; TD = 140/80
IVFD RL 1000cc
Ceftriaxone 1x2 gr i,v
Omeprazole 2x20mg i.v
Cilostazol 2x100mg
Plavix 1x75mg
Tramadol 100mg /24jam
PCT 3x1 gr i.v
Ketoroalc 30mg k/p nyeri
Obs. jaundice ec?

nyeri ulu hati skala nyeri 2-3 (0-10); RPO rutin (-); s= 36; N = 81; P = 19; TD = 110/70; SpO2 = 98%
-IVFD Asering 1000cc + Renosan 500cc /24 jam (threeway)
-SNMC 2x1 amp IV drip dalam NS 100cc
-Liverprime 3x1 caps PO
Stroke hemoragik minimal

Hipertensi
DM tipe 2
AKI dd/ ACKD
datang dengan keluhan lemas sisi kanan sejak pagi hari SMRS, saat ini keluhan membaik; s = 36; N =
RPO :
amlodipin 1x10 mg (pagi)
metformin 1-2x500 mg (tergantung pasien)
simvastatin
Infus asering 1500 cc/hari
Farmadol 1 gram IV kalau nyeri kepala
Lactulax 2x 5 cc PO
Amlodipin 1x 10 mg PO
Apidra 4 u SC bila GDS >180 mg/dl; 8 u SC bila >250 mg/dl
- Febris ec. viral infection, suspek dengue (Febris ec.)
- Transaminitis (Transamini)
demam (-); RPO: obat lambung (lupa nama); s = 36; N = 83; P = 19; TD = 120/70; SpO2 = 98%
- INFUS ASERING 1500 CC/24 JAM
-Pantoprazole 2x40 mg IV
-Ondansetron 3x4 mg IV
-Sumagesic 3x1 tab PO, k/p demam
-Analsik 1/2 - 1/2 - 1 tab PO
Post Pielolitotomi + ureterolitomi + Nefrolitotomi + Dj sent kiri H-3

Keluhan (-); Rencana pulang; s = 36,2; N = 78; P = 19; TD = 120/80; SpO2 = 98%
Obat pulang:
Cefixime 200 mg 2 x1
Parasetamol 500 mg 3 x 1
VL pedis sx, post debridement + explorasi POD 1

nyeri post op vas 2; besok rencana pulang; TD : 100/70 mmHg HR : 80x/m RR: 18x/m T: 36.7C SaO2
IVFD RL 1500 cc/ 24 jam--> habis STOP
Ceftizoxime 2 x 1 g IV
Ketorolac 2 x 30 mg iv
Paracetamol 3 x 1 g iv drip --> k/p nyeri
Ranitidin 2 x 50 mg iv
Obat pulang:
- Cefixime 2 x 200 mg po
- Asam mefenamat 3 x 500 mg po
- Sumagesic 3 x 1 tab po
- Becom C 2 x 1 tab po

nyeri post op minimal; TD : 120/70 mmHg HR : 100x/m RR: 20x/m T: 36.6C SaO2: 97% ROOM AIR
- Gangren digiti 1 pedis Sx (Gangren di)

nyeri pada kaki masih dirasa skala 1; s = 36; N = 87; P = 19; TD = 140/90
IVFD RL 1000cc
Ceftriaxone 1x2 gr i,v
Omeprazole 1x40mg i.v
Cilostazol 2x100mg
Plavix 1x75mg
Tramadol 100mg /24jam
PCT 3x1 gr i.v
Ketoroalc 30mg k/p nyeri
hepatitis akut
nyeri ulu hati perbaikan; s= 36,5; N = 92; P = 20; TD = 120/80; SpO2 = 98%
Febris ec?
demam masih naik turun, nyeri kepala; RPO rutin (-); TD: 110/80 mmHg HR: 84x/m RR: 20x/m T:36
-Levofloxacin 1x750 mg IV
-Ondansetron 3x4 mg IV, k/p mual
-vestein 2x1 cap
saran: pemberian atorvastStroke hemoragik minimal

Memastikan pemberian cloHipertensi
DM tipe 2
AKI dd/ ACKD
lemas, mual muntah tidak ada; s = 36; N = 79; P = 19; TD = 160/100
Lactulax 2x 5 cc PO
candesartan 1x16mg sekarang
Clonidine 1x0.075 mg
zypraz 0.25 mg po k/p sulit tidur
Festaric 1x40 mg PO
ing terfacef tidak di y-site dengan aseColic abdomen ec. suspek cholelitiasis cholecystitis akut
nyeri ulu hati (+) hilang timbul; TD: 110/80 mmHg HR:82 x/m RR: 18x/m T: 36.2C SaO2:97 %
-IVFD Asering 1000cc + Tutosol 500cc/24 jam (threeway)
-Terfacef 2x1 gram IV
-Pranza 2x40 mg IV
-Buscopan 1 amp IV, k/p nyeri perut
-Sanmag syr 4x10cc PO
-Xepazym 3x1 tab PO
- DHF GRADE 1
- Transaminitis (Transamini)
demam tidak ada, mual berkurang; TD : 120/80 mmHg HR :90 x/m RR: 20x/m T: 36.2 C SaO2: 98%
- INFUS ASERING 1500 CC/24 JAM
-Analsik 1/2 - 1/2 - 1 tab PO
VL pedis sx, post debridement + explorasi POD 1

nyeri post op minimal; TD : 120/80 mmHg HR : 78x/m RR: 20x/m T: 36.2C SaO2: 99%
Ceftizoxime 2 x 1 g IV
Ketorolac 2 x 30 mg iv
Paracetamol 1 g iv drip --> k/p nyeri
Ranitidin 2 x 50 mg iv
Obat pulang:
- Cefixime 2 x 200 mg po
- Asam mefenamat 3 x 500 mg po
- Sumagesic 3 x 1 tab po
- Becom C 2 x 1 tab po
- Union fracture distal radius sinistra (Union frac)

nyeri post op minimal; TD : 120/80 mmHg HR : 78x/m RR: 19 x/m T: 36.3C SaO2:98 %
IVFD RL 1000ml/24 jam
Cefazol 2x1gr IV
Paracetamol 2x1gr IV
POD VI dengan perbaikan dan hipoalbuminemia terkoreksi dan Anemia dlm koreksi,
nyeri masih dirasa namun sudah berkurang, skala nyeri 2, mual muntah (-), saat ini demam (-); TD :
- IVF NS 500 cc dan B fluid 1000 cc
Saran: menambah vipalbuTrauma ginjal gr 3-4 Sin hari ke 2

nyeri masih dirasa saat bergerak, skala nyeri 2 (0-10); TD : 120/70 mmHg HR : 88x/m RR: 20x/m T: 3
Sucralfat syrup 3x15 cc po

Hipertensi
DM tipe 2
AKI dd/ ACKD
lemas membaik; s = 36,1; N = 71; P = 19; TD = 150/80; SpO2 = 97%
Lactulax 2x 5 cc PO
Clonidine 2x 0.075 mg PO
Festaric 1x40 mg PO
CaCO3 3x500 mg po
BicNat 3x500 mg po
Asam folat 3x1 tab po
Ketosteril 3x2 cap po
NYERI PERUT EC KOLESISTITIS AKUT

KOLELITIASIS/ SLUDGE
nyeri ulu hati perbaikan; s= 36,2; N = 93; P = 19; TD = 110/80; SpO2 = 99%
- urdafalk 2x1 kapsul
- Ceftriaxone 2X1 GRAM IV

nyeri post op minimal; s = 36,5; N = 90; P = 20; TD = 140/70; SpO2 = 98%
atorvastatin 1x20 mg po (malam)
POD VII dengan perbaikan dan hipoalbuminemia terkoreksi dan Anemia dlm koreksi,
nyeri sudah berkurang, skala nyeri 2, mual muntah (-), sdemam (-); S = 37; N = 86; P = 20; TD = 120/
- IVF NS 500 cc, B fluid 1000 cc, RL 1000 cc per 24 jam
monitoring albumin berkeTrauma ginjal gr 3-4 Sin hari ke 2

ada batuk kering, nyeri saat batuk dan posisi duduk, skala 2-3 ( 0-10 ); S = 36,1; N = 83; P = 22; TD =
Acetylcystein 3x1 tab PO
ing terfacef tidak di y-site dengan aseColic abdomen ec. suspek cholelitiasis cholecystitis akut
nyeri berkurang, skala 1-2 ( 0-10 ) sakit kepala mulai berkurang; s = 36,6; N = 82; P = 19; TD = 110/70
-IVFD Asering 1000cc + Tutosol 500cc/24 jam (threeway)
-Terfacef 2x1 gram IV
-Pranza 2x40 mg IV
-Buscopan 1 amp IV, k/p nyeri perut
-Sanmag syr 4x10cc PO
-Xepazym 3x1 tab PO
app Akut
nyeri post op skala2-3(0-10); s = 36,5; N = 70; P = 19; TD = 110/70; SpO2 = 99%
Infus RL 1500 cc/24 jam IV
Terfacef 2 g/24 jam IV
Pantoprazole 40 mg/24 jam IV
Farmadol 1 g/8 jam IV
Dynastat 40 mg/12 jam IV
Ondavell 8 mg/ 8 jam IV jika mual
Closed fraktur neck MC V dx, post ORIF Inion

nyeri post op skala 2 (0-10); RPO (-); S = 36,1; N = 74; P = 19; TD = 120/80; SpO2 = 99%
- Cefazol 2g iv drip (jam 23.00)
- Ketesse 3 x 1 amp IV
- Farmadol 3 x 1 g IV drip
- Pranza 1 x 40 mg iv
Obat pulang:
- Meiact 2 x 200 mg po
- Celebrex 2 x 200 mg po
- Univoxy 2 x 1 tab po
Urolithiasis Dextra
BPH
nyeri post op skala 2(0-10); TD 120/80 mmHg HR 80x/min RR 20x/min S 36.3 SpO2 97% room air
RPO :
Vit B12 2x1 tab
Bicnat 3x500 mg
Osfiocal 2x1 tab
Avodart 1x1 tab
Folic Acid 2x1 mg
Colcatriol F 1x1 tab
Harnal Ocas 1x1 tab
Alopurinol 1x100 mg
Furosemide 2x1 amp iv
Febris ec?
Demam naik turun; s = 37,7; N = 89; P = 20; TD = 100/70; SpO2 = 97%
-Pantoprazole 2x40 mg PO
-Farmadol 1 g IV K/P
-vestein 2x1 cap
- MONEL ODT 3 X 1
Memastikan pemberian mSusp enteric fever

Dispepsia
demam naik turun, nyeri ulu hati perbaikan; RPO: Sanmol; s = 36,1; N = 79; P = 19; TD = 110/70; SpO
- Terfacef 1x2 gram iv drip
- Sanmol 3x1 gram iv drip
- Pranza 2x40 mg iv
- Ramozea 1x1 amp iv drip dalam NS 100 cc
- Mecobalamin 1x1 amp iv bolus dalam NS 5 cc
Susp enteric fever

Dispepsia
Saat ini demam (-), nyeri ulu hati perbaikan; s = 36,6; N = 78; P = 20; TD = 120/70; SpO2 = 98%
- Sanmol 3x1 gram iv drip
- Pranza 2x40 mg iv
POD VIII dengan perbaikan dan hipoalbuminemia terkoreksi dan Anemia dlm koreksi,
demam (-), keluhan (-); s = 36,5;N = 80; P = 19; TD = 120/80; SpO2 = 99%
- IVF NS 500 cc, B fluid 1000 cc, RL 1000 cc per 24 jam
- Vipalbumin caps 3x2 caps po
monitoring albumin berkeTrauma ginjal gr 3-4 Sin hari ke 2

ada batuk kering masih ada nyeri minimal; s = 36,1; N = 80; P = 19; TD = 110/70; SpO2 = 99%
app Akut
nyeri post op minimal, rencana pulang
Infus RL 1500 cc/24 jam IV
Terfacef 2 g/24 jam IV
Pantoprazole 40 mg/24 jam IV
Farmadol 1 g/8 jam IV
Dynastat 40 mg/12 jam IV
Ondavell 8 mg/ 8 jam IV jika mual
Inpepsa 15 cc/6 jam PO AC
Obat Pulang:
- Cefspan 2x200 mg PO
- Ketesse 3x25 mg PO
- Pantoprazole 2x40 mg PO AC
- Ulsicral syr 4x 15 cc PO AC
(SEDANG ENDOSKOPI)
- Hematochezia (Hematochez)
keluhan BAB disertai darah segar (+) hilang timbul selama 3 bulan yang lalu; RPO: (-)
- IV Pantoprazole 2x40 mg

Hipertensi
DM tipe 2
AKI dd/ ACKD
lemas membaik; s = 36,4; N = 76; P = 20; TD = 130/80; SpO2 = 98%
Lactulax 2x 5 cc PO
Clonidine 2x 0.075 mg PO
Festaric 1x40 mg PO
CaCO3 3x500 mg po
BicNat 3x500 mg po
Asam folat 3x1 tab po
Ketosteril 3x2 cap po
Bronkopneumonia
Vomitus berulag
nyeri perut , mual, muntah ada, demam (+); s = 37,6; N = 85; P = 19; TD = 130/80
Asering 1000 cc/24 jam
CRAVIT 1X 500 MG IV
Drip Ramozea 1 ampul dlm NS 100 cc per hari
Sumagesic 3x1 tab rutin, kalau masih suhu >38, extrakan Sanmol 1 gram iv
INJ, NEXIUM 2X 40 MG IV
INJ. KETOROLAC 2X 30 MG IV
XEPAZYM 3X1 TAB PC
VOMETA FT 3X1 TAB
memastikan dosis pemberHematopneumothorax sin post CTT WSD H-0

Fraktur costae 4 post sin
Susp trauma tumpul abdomen dd/ kontraksi otot ec/ pain
Closed fraktur phalang proximal digiiti V manus dx
Post KLL; RPO (-); S = 36,6; N = 82; P = 21; TD = 144/75; SpO2 = 98%
-Infus RL 1000 cc/24 jam IV
-Ceftriaxone 1 g/12 jam IV
-As tranexamat 1 g/8 jam IV
-Vit K 1 amp/8 jam IV
-Pantoprazole 40 mg/24 jam IV
-Paracetamol 1 g/8 jam IV
-Tramadol drip 200 mg/24 jam IV
-Methylprednisolone 3x125 mg IV
-NAC 3x200 mg PO
-Gentamicin 2x1 dioles pada luka
- CA buli (CA buli)

- PPOK (PPOK)
nyeri post op vas 1; RPO: Esilgan 1 mg; s = 36,4; N = 82; P = 19; TD = 120/80; SpO2 = 99%
Infus NaCl 1000 cc/24 jam
Inj Terfacef 2x1 gr iv
Inj Lanzoprazole 1x1 amp iv
Inj Vit K 3x1 amp iv
Combiven + NS / 8 jam jika sesak
- diare (diare)
diare; s = 36,6; N = 82; P = 19; TD = 120/70; SpO2 = 99%
IVFD RL 1500 cc/24 jam + neurobion 1 amp
IV Omeprazole 1x40 mg

nyeri perut dan uluh hati masih dirasa; s = 36,6; N = 82; P = 19; TD = 120/70; SpO2 = 98%
-IVFD Asering 1000cc
- HP PRO PLUS 3X1 KAPS
- DISFLATYL 3X2 TAB
memastikan penggantian pAsma Bronkiale dalam serangan derajat sedang

batuk kering perbaikan, sesak (-), demam (-); s = 36,6; N = 78; P = 19; TD = 110/70; SpO2 = 98%
- Nebulisasi dengan combivent + pulmicort tiap 8 jam
- Ezocon 1x40 mg po AC pagi
- Granisetron 1x3 mg iv drip dalam NS 100 cc
- Cravit 1x500 mg iv drip
- Seretide diskus 500/50 2x1 hisap
- Codein 1x15 mg tab malam
DEMAM? OBS FEBRIS --> BAKTERIAL INFEKSI

Demam naik turun; s = 37,7; N = 89; P = 20; TD = 100/70; SpO2 = 97%
-vestein 2x1 cap
- MONEL ODT 3 X 1
D-dimer tinggi - Pneumonia (Pneumonia)

- Dehidrasi (Dehidrasi)
- Ca mammae st 4 dengan metastasis paru dan hati (Ca mammae )
- Post op fr humerus kiri (Post op fr)
sesak nafas perbaikan, lemas maish ada , mual, nafsu makan berkurang, batuk berdahak ada; s = 36
Terapi yang didapatkan;
- Infus Bfluid 1000 cc + Asering 500 cc /hari
- Viccilin sx 4x1,5 gram iv
- Sanmol 1 gram iv bila demam/ nyeri
- Fluimucyl eff 1x600 mg po
- Pranza 1x40 mg iv
- VIP albumin 1x1 sachet po
- ekstra Soluvit 1x1 amp iv drip dalam NS 100 cc
- ekstra Mecobalamin 1x1 amp iv bolus dalam NS 5 cc
OBS FEBRIS --> BAKTERIAL INFEKSI

demam (-); s = 36,8; N = 81; P = 19; TD = 120/80
- Meropenem 3x1 g IV
-vestein 2x1 cap
- MONEL ODT 3 X 1
Bronkopneumonia
KOLELITIASIS
nyeri pada perut hilang timbul; s = 36,5; N = 89; P = 20; TD = 120/80; SpO2 = 97%
CRAVIT 1X 500 MG IV
Drip Ramozea 1 ampul dlm NS 100 cc per hari
Sumagesic 3x1 tab rutin, kalau masih suhu >38, extrakan Sanmol 1 gram iv
INJ, NEXIUM 2X 40 MG IV
INJ. KETOROLAC 2X 30 MG IV
XEPAZYM 3X1 TAB PC
VOMETA FT 3X1 TAB
Urdafalk 3x1 kapsul
HP Pro Plus 3x1 kapsul
Dengue fever, koinfeksi tifoid

Transaminitis
pusing (+), demam (-); s = 36,2; N = 80; P = 19; TD = 120/80
-Cravit 1x500 mg IV
-Soluvit 1x1 vial IV drip dalam NS 100cc
-Sumagesic 3x600 mg PO
-Curcuma Force 3x1 cap PO
saran: penambahan ceftriaUrolithiasis Dextra

BPH
nyeri post pemasangan ctl hilang timbul; Rencana HD 3 kali seminggu; semalam ada demam, batuk
Vit B12 2x1 tab
Bicnat 3x500 mg
Osfiocal 2x1 tab
Avodart 1x1 tab
Folic Acid 2x1 mg
Harnal Ocas 1x1 tab
Alopurinol 1x100 mg
Furosemide 2x1 amp iv (tunda)
tramadol 2x1 amp IV
pantoprazole 2x20 mg PO
Codein 3x10 mg PO
Susp enteric fever

Dispepsia
Saat ini demam (-), nyeri ulu hati perbaikan; s = 36,6; N = 78; P = 20; TD = 120/70; SpO2 = 98%
- Sanmol 3x1 gram iv drip k/p demam
- Pranza 2x40 mg iv

nyeri perut dan uluh hati masih dirasa; s = 36; N = 80; P = 20; TD = 120/90; SpO2 = 98%
-IVFD Asering 1000cc
- HP PRO PLUS 3X1 KAPS
- DISFLATYL 3X2 TAB
memastikan penggantian pAsma Bronkiale dalam serangan derajat sedang, Back pain
batuk kering perbaikan, sesak (-), demam (-); s = 36,5; N = 69; P = 20; TD = 130/80; SpO2 = 98%
- Ezocon 1x40 mg po AC pagi
- celebrex 1x 200mg
- provelyn 1x 75 mgpo
- Cravit 1x500 mg iv drip
- Seretide diskus 500/50 2x1 hisap
- Codein 1x15 mg tab malam
- monell tab ODT 3x10mg po hisap
lemas masih dirasa, sesak masih dirasa; s = 36,4; N = 112; P = 20; TD = 120/80; SpO2 = 99%
- Infus Bfluid 1000 cc + Asering 500 cc /hari
- Pranza 1x40 mg iv
- VIP albumin 1x1 sachet po
memastikan dosis pemberHematopneumothorax sin post CTT WSD H-0

nyeri pemasangan post pemasangan WSD masih dirasa, sesak berkurang; s= 36,3; N = 85; P = 19; TD
-Infus RL 1000 cc/24 jam IV
-Vit K 1 amp/8 jam IV
-Tramadol drip 200 mg/24 jam IV
-NAC 3x200 mg PO
- Vulnus amputatum digiti IV manus D + susp ruptur tendon (Vulnus amp)

- VES infrequent (VES infreq)
datang ke IGD dengan keluhan jari manis tangan kanan terkena tali tambang parasit di kapal; RPO:a
- Ketorolac 3x1 amp IV
POD IX dengan perbaikan dan hipoalbuminemia terkoreksi dan Anemia dlm koreksi,
nyeri sudah lebih berkurang; s = 36,5; N = 79; P = 19; TD = 120/80; SpO2 = 99%
- INFUS B fluid 1000 + RL 1000 cc/24 jam
- Pantoprazole cap 2x 1 caps po
- Vipalbumin caps 3x2 caps po
saran: mengganti acetylcy Trauma ginjal gr 3-4 Sin hari ke 2

CEK MASIH PAKAI KETOR ada batuk kering, nyeri minimal; s = 36,9; N = 81; P = 19; TD = 120/80; SpO2 = 99%
Cefixime 200 2x1 tab
- CA buli (CA buli)

- PPOK (PPOK)
nyeri post op vas 1; S = 36,3; N = 83; P = 19; TD = 120/80; SpO2 = 97%
Infus NaCl 1000 cc/24 jam
Inj Terfacef 2x1 gr iv
Inj Lanzoprazole 1x1 amp iv
Inj Vit K 3x1 amp iv
Combiven + NS / 8 jam jika sesak
Pregabalin 75 1x1 tab po
DHF grade I dengan liver involvement

dispepsia
demam (-), nyeri ulu hati (+); s = 36.2; N = 62; P= 19; TD = 110/70
IVFD RL NAIK 2500cc/ 24 jam
Inj Lansoprazole 1x30mg IV
Inj Metoclopramide 3x1 amp IV
Drip Soluvit 1amp dalam salah satu Kolf RL
COVID 19 terkonfirmasi derajat sedang

GEA bacterial dengan dehidrasi sedang
AKI pre renal stage 1 dd/ ACKD ec DKD dd/ Hypertensive Nephrosclerosis
DM tipe 2
Hipertensi
BPH
Geriatric syndrome (infection, immune deficiency)
BAB sudah mulai ada ampas; S = 36,4; N = 82; P = 20; TD = 160/90; SpO2 = 98%
Ceftriaxone 1x2 gr IV
Metronidazole 3x500 mg IV
Pantoprazole 2x40 mg IV
Interlac 2x1 saccb po
Forxiga 1x10 mg po pc
Janumet 50/1000 2x1 po pc
Amlodipine 1x10 mg po kp jika TD>150
Atorvastatin 1x20 mg po
New Diatab k/p saja jika BAB>10x/hari
Harnal OCAS 1x0,4 mg PO
Clopidogrel 1x1 tab PO
memastikan dosis pemberi- Syncope ec susp Vascular event dd orthostatic (Syncope ec)
- LBP (LBP)
- Parkinson (Parkinson)
lemas masih dirasa, pusing; s = 36,5; N = 84; P = 20; TD = 130/80; SpO2 = 98%
RPO :
Etorvel 1x 60 mg PO habis makan
Mecobalamin 1x 500 mcg PO
Candesartan 1x 8 mg PO
Gabapentin 3x100 mg OO
Amlodipine 1x10 mg PO
Madopar 4x 125 mg PO (jam 07.00, 12.00, 16.00 dan 20.00 WIB)
Trihexyphenidyl 2x 2 mg untuk gemetar
Myonal 2x 50 mg PO
Aspilet 1x80mg
Atorvastatin 1x20mg
Brainact 2x500mg po
Mecobalamin 1x500mcg po
Candesartan 1x8 mg
Gabapentin 3x100 mg
Amlodipin 1x10mg
Madopar 4x125 mg (7-12-16-20) - > perut kosong
Eterlox 1x60mg
Zitanid 1x2 mg
Bronkopneumonia
KOLELITIASIS
nyeri pada perut perbaikan; s = 36,3; N = 102; P = 19; TD = 130/90; SpO2 = 98%
Infus Asering 1000 cc/hari
kolf 1 + cernevit 1 amp
kolf 2 + meconeuro 1 amp
- Terfacef 1x2 gram IV
- Trogyl 3x500 mg iv
- Ramozea 1x1 amp iv drip
- Nexium 2x40 mg iv
- Sumagesic 3x1 tab po
- Besanmag 2x1 tab
- Vometa 3x1 tab po
- Urdafalk 3x1 tab po
- HP Pro 3x1 cap po
- Anti Nyeri : Extra Remopain 1 amp IV
Hematopneumothorax sin post CTT WSD H-0

nyeri minimal, sesak berkurang; s= 36,3; N = 98; P = 22; TD = 137/70; SpO2 = 96%
-Infus RL 1000 cc/24 jam IV + tramadol 100 mg/kolf drip
-NAC 3x200 mg PO

sesak berkurang, demam (-); s= 36,2; N = 102; P = 70; TD = 130/90; SpO2 = 96%
- Infus Bfluid 1000 cc
- Nebulisasi dengan combivent + pulmicort tiap 8 jam --> k/p saja
- Pantoprazole 1x40 mg tab po AC pagi
- VIP albumin naik jadi 2x1 sachet po
- Cobazym 3000 1x1 cap po
- Furosemide naik 2x20 mg iv
- Transfusi 1 u PRC, premed furosemide 20 mg iv
- Samsca 1x7.5 mg po
Dengue fever, koinfeksi tifoid

Transaminitis
nyeri kepala berkurang, mual muntah tidak ada, demam tidak ada; s= 36,3; N = 120; P = 19; TD = 13
- Infus Asering2000 cc/hari
-Cravit 1x500 mg IV
- Sumagesic 3x600 mg PO --> k/p demam
-Curcuma Force 3x1 cap PO
- Analsik 1x1 tab malam --> k/p sakit kepala
Monitoring penggunaan coUrolithiasis Dextra

BPH
nyeri minimal; s = 36,5; N = 98; P = 22; TD = 110/70
Vit B12 2x1 tab
Bicnat 3x500 mg
Osfiocal 2x1 tab
Avodart 1x1 tab
Folic Acid 2x1 tab
Harnal Ocas 1x1 tab
Alopurinol 1x100 mg
tramadol 2x1 amp IV
Codein 3x10 mg PO
memastikan vit k dan asa Sepsis ec Urosepsis + susp. HAP dengan MODS ARDS
memastikan: jika HD kapanP2 post SC IUFD, riw PEB
ACKD on HD
Hipertensi
Anemia renal (perbaikan)
Hipoalbuminemia ec inflamasi
sesak berkurang, demam (-), on HD 3x seminggu; s = 36; N = 103; P = 20; TD = 120/70; SpO2 = 96%
Meropenem 3x1 gram iv
Levofloxacin 1x750mg iv
Paracetamol 3x1 gram iv rutin
Pantoprazole 1x40mg iv
NAC 3x400 mg PO
Bicnat 3x500mg per NGT
Vip Albumin 3x1 caps
Nebu Combivent : Bisolvon 40 tetes / 8 jam --> per pagi
thrombopop gel dioles pada lebam
saran: stop codein Urolithiasis Dextra

BPH
nyeri minimal; TD 130/90 ; HR 86 ; RR 20 ; T 36 ; SpO2 98%
Vit B12 2x1 tab
Bicnat 3x500 mg
Osfiocal 2x1 tab
Avodart 1x1 tab
Folic Acid 2x1 tab
Harnal Ocas 1x1 tab
Alopurinol 1x100 mg
tramadol 2x1 amp IV
Codein 3x10 mg PO

nyeri minimal, sesak (-); s= 36; N = 109; P = 21; TD = 110/90; SpO2 = 97%
-Methylprednisolone 62,5 mg/8 jam IV
-NAC 3x200 mg PO
-Furosemid 2x 1 amp IV
-Nebulizer ventolin + NS 3x1
memastikan paracetamol d
Sepsis ec Urosepsis + susp. HAP dengan MODS ARDS
P2 post SC IUFD, riw PEB
ACKD on HD
Hipertensi
Anemia renal (perbaikan)
Hipoalbuminemia ec inflamasi
sesak (-), demam (-), batuk (-), on HD 3x seminggu; TD 130/90 ; HR 100 ; RR 20 ; T 36.4 ; SpO2 100%
Meropenem 3x1 gram iv
Levofloxacin 1x750mg iv
Pantoprazole 1x40mg iv
NAC 3x400 mg PO
Bicnat 3x500mg per NGT
Vip Albumin 3x1 caps
Nebu Combivent : Bisolvon 40 tetes / 8 jam --> per pagi
thrombopop gel dioles pada lebam
Bronkopneumonia
KOLELITIASIS
nyeri pada perut perbaikan; s = 36,4; N = 122; P = 20; TD = 140/90; SpO2 = 98%
Infus Asering 1000 cc/hari
kolf 1 + cernevit 1 amp
kolf 2 + meconeuro 1 amp
- Terfacef 1x2 gram IV
- Trogyl 3x500 mg iv
- Ramozea 1x1 amp iv drip
- Nexium 2x40 mg iv
- Besanmag 2x1 tab
- Vometa 3x1 tab po
- HP Pro 3x1 cap po
DHF grade I dengan liver involvement

dispepsia
demam (-), nyeri ulu hati (+); s = 36.2; N = 62; P= 19; TD = 110/70
IVFD RL NAIK 2000cc/ 24 jam
Inj Lansoprazole 1x30mg IV
Drip Soluvit 1amp dalam salah satu Kolf RL
- Syncope ec susp Vascular event dd orthostatic (Syncope ec)

- LBP (LBP)
- Parkinson (Parkinson)
lemas masih dirasa, nyeri pinggang (+); TD 130/90 ; HR 79 ; RR 19 ; T 36 ; SpO2 98%
Aspilet 1x80mg
Atorvastatin 1x20mg
Brainact 2x500mg po
Mecobalamin 1x500mcg po
Candesartan 1x8 mg
Gabapentin 3x100 mg
Amlodipin 1x10mg
Madopar 4x125 mg (7-12-16-20) - > perut kosong
Eterlox 1x60mg --> naik ke 1x90 mg
Zitanid 1x2 mg --> naik ke 2x2mg
GEA dehidrasi sedang

bab cair 2 x hari ini; S = 36,4; N = 79; P = 19; TD = 110/80; SpO2 = 100%
IVFD asering 1500cc/24jam
Inj Tertacef 1x2g IV
Interlac 2x1 sach
Pranza 2x40mg IV
xepazym 3x1 PO
Salofalk 3x500mg
Sumagesic k/p demam
Inj Ondansetron 3x8mg IV k/p mual
Tagyt 3x 2 tab po
POST COVID 19 terkonfirmasi derajat sedang

DM tipe 2
Hipertensi
BPH
BAB hari ini 3x, konsistensi lembek; s = 36,5; N = 75; P = 20; TD = 120/90; SpO2 = 100%
New Diatab k/p saja jika BAB>10x/hari
Domperidon 3x10 mg PO
Pneumonia
Dehidrasi
HT
Sequelae stroke iskemik
Malnutrisi
sulit dikaji; s = 36,4; N = 80; P = 20; TD = 140/80
RPO :
Aspar K 2x1 tab
Risperidone 2x1 mg
Meiact 2x200 mg
Fuilmucyl 3x1 sach
VIP Albumin 3x1 sach
CPG 1x75 mg
Lixiana 1x30 mg
Lansoprazole 1x30 mg
Prove D3 1x5 tab
Amlodipine 1x5 mg
Fluconazole 1x150 mg
- Viccilin SX 4x1,5 gram IV (skin test) (H1)
- Paracetamol 1 gram IV kp demam
- N-Acetylcysteine 3x200 mg
- Nebu Combivent 1 resp @ 8 jam
- ProveD 1x3000 iu per NGT
- Fluconazole 1x150 mg per NGT
- Amlodipine 1x5 mg per NGT
- VIP albumin 2x1 sachet per NGT
- Risperidone 2x1 mg
- CPG 1x75 mg
- Lixiana 1x30 mg
- Brainact 2x500 mg IV
saran: N-acetyl cystein 3x Stroke Iskemik OH 16

saaran: Jika HAP, maka sarSuspek pneumonia hospital acquired
(saran diterima untuk pemb kontak inadekuat, pasien ada batuk berdahak, dahak sulit di keluarkan; s = 37,2; N = 128; P = 21; TD
RPO :
- Amlodipine 1x5 mg PO
- Arcalion 1-1-0
- Atorvastatin 1x20 mg PO
- Brainact Sach 1x1000 mg PO
- Bicrolit 2x500 mg PO
- Sanmol 3x500 mg PO
- Lansoprazole 2x30mg PO
- Arcalion 1-1-0
- Bicrolid 2x500 mg PO
- Lansoprazole 2x30mg PO --> turun ke 1x30 mg

sesak berkurang, demam (-); S = 36,2; N = 127; P = 20; TD = 130/80; SpO2 = 99%
- Infus Bfluid 500 cc
- Furosemide naik 2x20 mg iv
- Samsca 1x7.5 mg po
- Cervical radiculopathy (Cervical r)

nyeri dada kanan menjalar kebelakang sejak 3bulan smrs, saat ini nyeri perbaikan; s = 36; N = 61; P
- Farmadol 2 x 1g
- Ketorolac 2 x 30mg IV
- Lansoprazole 1 x30mg IV
Saran: stop codeine Urolithiasis Dextra

BPH
nyeri minimal, belum BAB; s = 36,1; N = 90; P = 20; TD = 140/90; SpO2 = 98%
Vit B12 2x1 tab
Bicnat 3x500 mg
Osfiocal 2x1 tab
Avodart 1x1 tab
Folic Acid 2x1 tab
Harnal Ocas 1x1 tab
Alopurinol 1x100 mg
tramadol 1 amp IV K/P nyeri
Codein 3x10 mg PO
Obat pulang:
Bicnat 3 x 500 mg
Tambah darah 1 x 1
kolkatriol 1 x 1
B12 1 x 1
as folat 1 x 3 tab
Allopurinol 1 x 300 mg
Pantoprazol 1 x 20 mg
POST COVID 19 terkonfirmasi derajat sedang

DM tipe 2
Hipertensi
BPH
BAB cair (+) 3 kali hari ini; s= 36; N = 67; P = 18; TD = 110/70; SpO2 = 97%
molagit 2 tab setiap BAB
Bronkopneumonia
KOLELITIASIS
mual (+), kulit kuning; s = 36,4; N= 66; P = 20; TD = 110/80; SpO2 = 100%
- MEIACT TAB 2X 200 MG
- BAQUINOR 2X 500 MG TABLET
- CATAFLAM TAB 2 X50 MG UNTUK 2HARI
- NEXIUM 2X 40 MG TABLET
- Besanmag 2x1 tab
- Vometa 3x1 tab po
- HP Pro 3x1 cap po
Saran: 1) dexketoprofen d Fractur Os Nasal

Hipertensi
Elektrolit Imbalance
hidung tersumbat perbaikan; rencana pulang; S = 36; N = 84; P = 20; TD = 140/100; SpO2 = 98%
Amlodipine 1x10 mg po
Asam tranexamat 3x500 mg IV
Cefazolin 3x1 gram IV
Dexketoprofen 2x1 amp IV
Sumagesic 3x1 tab po
obat pulang:
Minosep gargle 3x1
HID 5000 1x1 tab po
kolkatriol 2x1 tab po
Amlodipine 1x10 mg po
Cefixime 2x200 mg Po
dexketoprofen 3x1 tab po pc
lansoprazole 2x30 mg po ac
asam tranexamat 3x500 mg po (untuk 3 hari)

nyeri minimal, sesak (-), batuk (-); TD 120/80 HR 72 RR 22 S 36.6 SAO2 97 SM 4 lpm
-NAC 3x200 mg PO
Pneumonia
Dehidrasi
HT
Malnutrisi
sulit dikaji, batuk berkurang; TD 130/90 HR 84 RR 22 S 36.0 SaO2 99 on NC 4 lpm
- IVFD Asering 1000 cc/ 24 jam
- Viccilin SX 4x1,5 gram IV
- CPG 1x75 mg
- Lixiana 1x30 mg

memastikan pemberian foSuspek pneumonia hospital acquired
batuk dahak, demam (-); TD 130/90 HR 122 RR 24 S 37,0 SaO2 100 on NRM 8lpm
- Arcalion 1-1-0
- ceftazidime 3x2 g IV
- nebu bisolvon 2 cc + combivent 1 resp / 8 jam, posisikan tegak, chest flapping dan suction setelah
- Sanmol 3x500 mg PO --> bila masih demam
- Forneuro 1x1

Memastikan pemberian in- Dehidrasi (Dehidrasi)
sesak (+), lemas; TD 100/60 HR 108 RR 22 S 35.6 saO2 98 on Nc 2lpm
- Infus RL 500 cc
- Samsca 1x15 mg po
- Cholelithiasis (K80)
post op laparascopy cholesistectomy
nyeri masih dirasa skala 2 (0-10); s = 36; N = 80; P = 20; TD = 110/70; SpO2 = 99%
- IVFD Asering 1500/24jam
- Terfacef 1x2gr IV
- Remopain 3x1amp IV
- Pranza 2x1amp IV
DHF grade 1
nyeri perut berkuang, demam tidak ada, sakit kepala berkurang; S = 36,3; N = 76; P =20; TD = 90/70
- IVFD Asering 2000 ml/24 jam
- Inj Ondansetron 2x8 mg
- Inj Pranza 2x40 mg
- Inj Terfacef 2x1 gr
- Xepaxym 3x1 tab
- Interlac 2x1
- Sanmol/paracetamol tab kp demam
monitoring nyeri, jika masiLBP

nyeri pinggang skala 2-3; TD 140/90 ; HR 78 ; RR 20 ; T 36 ; SpO2 96%
RPO :
Amlodipin sore
Simvastatin malam
Neuralgin kp nyeri
amlodipin 1x5 mg PO
Simvastatin 1x20 mg PO
Paracetamol 3x1 g IV
GERD
Dispepsia
sesak berkurang, nyeri ulu hati berkurang skala nyeri; s = 36; N = 78; P = 20; TD = 90/70; SpO2 = 100
- Infus Asering turun 1000 cc/hari
- Pranza 2x40 mg iv
- Cliad 1x1 tab siang
- Besanmag 1x1 tab malam
- Extra soluvit 1 amp iv drip dalam NS 100 cc
- Extra mecobalamin 1 amp iv bolus dalam NS 5 cc
Saran: stop codeine Urolithiasis Dextra

BPH
nyeri minimal, besok rencana pulang; s = 36,5; N = 95; P = 20; TD = 130/90; SpO2 = 98%
Vit B12 2x1 tab
Bicnat 3x500 mg
Osfiocal 2x1 tab
Avodart 1x1 tab
Folic Acid 2x1 tab
Harnal Ocas 1x1 tab
Alopurinol 1x100 mg
tramadol 1 amp IV K/P nyeri
Codein 3x10 mg PO
Obat pulang:
Bicnat 3 x 500 mg
Tambah darah 1 x 1
kolkatriol 1 x 1
B12 1 x 1
as folat 1 x 3 tab
Allopurinol 1 x 300 mg
Pantoprazol 1 x 20 mg
dulcolax 1 tab ekstra
Pneumonia
Dehidrasi
HT
Malnutrisi
sulit dikaji, batuk berkurang; s= 36,5; N = 85; P = 20; TD = 150/80; SpO2 = 96%
- CPG 1x75 mg
- Lixiana 1x30 mg
- Transfusi 1u PRC, premed furosemide 20 mg iv
memastikan pemberian onDHF gr 1 dengan liver involvement

demam naik turun, mual (+); s = 38,6; N = 77; P = 20; TD = 137/86; SpO2 = 98%
- Infus RL naik jadi 2500 cc/hari
- Sumagesic ganti Sanmol 3x1 gram iv
- Pantoprazole 1x40 mg iv
- Ondansetron 2x8 mg iv

nyeri minimal, sesak (-); s = 36,5; N = 75; P = 20; TD = 120/80; SpO2 = 99%
-NAC 3x200 mg PO

Memastikan pemberian in- Dehidrasi (Dehidrasi)
sesak berkurang, lemas; s = 36; N = 99; P = 20; TD = 100/70; SpO2 = 95%
- Infus RL 500 cc
- Nebulisasi dengan combivent + pulmicort k/p
- Samsca 1x15 mg po
GERD
GASTRITIS ANTRUM DAN KORPUS
ILEOKOLITIS
MULTIPLE POLIP KOLON POST POLIPEKTOMI
DM
CAD
Hipertensi
BPH
saat ini tidak ada keluhan; s = 36,5; N = 72; P = 20; TD = 130/80; SpO2 = 96%
SALOFALK 3 X 500MG PO
DISFLATYL 3 X 2 BILA KEMBUNG
monitoring nyeri, jika masiLBP

nyeri pinggang skala 1-2; s = 36,5; N = 80; P = 20; TD = 120/80; SpO2 = 96%
amlodipin 1x5 mg PO
Simvastatin 1x20 mg PO
Paracetamol 3x1 g IV
Saran: meiact di-stop Bronkopneumonia

KOLELITIASIS
nyeri masih dirasa, bak coklat, perut kembung, kulit kuning; s = 36,2; N = 102; P = 20; TD = 110/70; S
- MEIACT TAB 2X 200 MG
- meropenem 3x1 gram iv
- BAQUINOR 2X 500 MG TABLET
- CATAFLAM TAB 2 X50 MG UNTUK 2HARI
- NEXIUM 2X 40 MG TABLET
- Besanmag 2x1 tab
- Vometa 3x1 tab po
- HP Pro 3x1 cap po
- New diatabs 3x2 tab po
- Interlac 2x1 sachet po
- Spironolaktone 1x 100 mg ( 3 hari )
- lasix 1 ampul iv

Suspek pneumonia hospital acquired
batuk dan dahak masih sulit dikeluarkan, Demam (-), lemah tubuh sebelah kanan; s = 36,8; N = 104
- Arcalion 1-1-0
- ceftazidime 3x2 g IV
- nebu bisolvon 2 cc + combivent 1 resp / 8 jam, posisikan tegak, chest flapping dan suction setelah
- Sanmol 3x500 mg PO --> bila masih demam
DHF grade I
dengan liver involvement
obesitas
saat ini tidak ada demam, sulit tidur; s= 36,7; N = 81; P = 19; TD = 130/90; SpO2 = 97%
- IVFD RL NAIK 3000 cc/24 jam
- IV lansoprazole 1x30 mg
- IV paracetamol 3x1 gr kp nyeri kepala atau S> 38 C
- Neurobion drip dalam salah 1 kolf infus pagi hari
- Soluvit drip dalam salah 1 kolf infus pagi hari
- esilgan 1x1 mg po (21.00)
- Cholelithiasis (K80)
post op laparascopy cholesistectomy
nyeri masih dirasa skala 2 (0-10); TD 110/70 HR 55kpm S 36.1C RR 19kpm SpO2 100% on room air
- IVFD Asering 1500/24jam
- Terfacef 1x2gr IV
- Remopain 3x1amp IV
- Pranza 2x1amp IV
obat pulang:
- cefspan 2x200
- ketesse 2x25
- nexium 2x20
GERD
Dispepsia
tidak ada keluhan, rencana pulang; s = 36,1; N = 74; P = 19; TD = 120/80; SpO2 = 98%
- Infus Asering turun 1000 cc/hari
- Pranza 2x40 mg iv
obat pulang:
- Ezocon 2x40 mg po AC
- Monell ODT 3x1 tab hisap AC rutinkan
memastikan dosis pantopraz

DHF gr 1 dengan liver involvement
demam (+), mual (+); TD 100/70 HR 99kpm S 38.6C SpO2 96% on room air RR 20kpm
- Infus RL naik jadi 3000 cc/hari
- Sanmol 3x1 gram iv
- Pantoprazole 2x40 mg iv
- Ondansetron 2x8 mg iv
DHF grade 1
nyeri perut berkuang, demam tidak ada, sakit kepala berkurang; S = 36,1; N = 70; P =19; TD = 100/7
- IVFD Asering 1500 ml/24 jam
- Inj Ondansetron 2x8 mg
- Inj Pranza 2x40 mg
- Inj Terfacef 2x1 gr
- Xepaxym 3x1 tab
- Interlac 2x1
- Sanmol/paracetamol tab kp demam
Pneumonia
Dehidrasi
HT
Malnutrisi
sulit dikaji, batuk berkurang, rencana pulang; s= 36,1; N = 75; P = 20; TD = 150/90; SpO2 = 96%
- Pantoprazole 1x40 mg PO
- CPG 1x75 mg
- Lixiana 1x30 mg
Bacterial infection ec enteric fever

Dehidrasi
Dispepsia
demam naik turun, nyeri kepala, mual; TD 100/80 HR 90kpm RR 19kpm S 37.5C SpO2 96% on room
- Cravit 1x500 mg iv (siang)
- Sanmol 3x1 gram iv
- Soluvit 1x1 amp iv drip dalam NS 100 cc (siang)
- Pranza 1x40 mg iv
- Granisetron 1x3 mg iv drip dalam NS 100 cc (pagi)
- extra dynastat 1 amp iv drip dalam NS 100 cc

sesak berkurang, demam (-); s = 36,3; N = 97; P = 20; TD = 110/70; SpO2 = 96%
- Infus RL 500 cc
- Nebulisasi dengan combivent + pulmicort k/p
- Samsca 1x15 mg po
ressed fraktur(R)Frontotemporal+Contusio(L)Frontotemporal
= 75; P = 20; TD = 130/80
x/min S 36 SpO2 99% room air
3 SpO2 96% room air

2 SpO2 99% room air
80; SpO2 = 98%
99% room air

S 36 SpO2 98% room air
Hg HR 85x/min RR 20x/min S 36.5 SpO2 98% room air

36.2 SpO2 98% room air
S 36.5 SpO2 98% room air
R 19x/min S 36 SpO2 98% room air

19x/min S 36 SpO2 99% room air
(O2 8-10 LPM, NRM)
36 SpO2 99% room air

t 98% room air
); s = 37,6; N = 72; P = 19; TD = 120/70
; TD = 130/80
P = 19; TD = 130/80; SpO2 = 97%
--> amlodipine 5 mgpo

150/105; SpO2 = 99%
HR 80, RR 30, SpO2 100% O2 3 lpm NK

kan 1 amp lagi --> Sudah selesai
rose 40% 3 flask + Novorapid 10 unit habis dalam 6 jam (Cek GDS 1 jam setelah diberikan Dextrose)
80; SpO2 = 97%

TD = 110/70
p off --> 1x1 gram i.v drip sambil evaluasi nyeri
SpO2 = 99%
N = 80; P = 20; TD = 100/60; SpO2 = 98%

t, SpO2: 95% (O2 13 LPM)
= 3,12; leukosit = 12,31; TD 100/65 HR 83 RR 22 S 36.2 SatO2 100%
nt, SpO2: 96% ( O2 15 LPM)
baikan, gatal perbaikan; TD 120/70 HR 78 RR 20 S 36.2 SatO2 100%
110/70 HR 76 RR 19 S 36 SpO2 98%

0; TD = 140/90
Hg HR 74x/min RR 20x/min S 36.4 SpO2 98% room air

5x/min RR 20x/min S 37.2 pO2 100% room air
/min RR 20x/min S 36.3 SpO2 98% room air

HR 71x/min RR 19x/min S 36.8 SpO2 96% room air
kulit; TD 120/80 mmHg HR 104x/min RR 20x/min S 37 SpO2 97% room air
pO2 97% room air
= 20; TD = 120/80; SpO2 = 97%
dlm koreksi,
h (-); s = 37,1; N = 91; P = 20; TD = 130/90
TD = 110/70; SpO2 = 98%
keluhan membaik; s = 36; N = 84; P = 19; TD = 130/70; SpO2 = 97%

= 120/70; SpO2 = 98%
x/m RR: 18x/m T: 36.7C SaO2: 99%
6.6C SaO2: 97% ROOM AIR

g HR: 84x/m RR: 20x/m T:36 C Sao2: 97%
m T: 36.2C SaO2:97 %
20x/m T: 36.2 C SaO2: 98%
2C SaO2: 99%
.3C SaO2:98 %
a dlm koreksi,
h (-), saat ini demam (-); TD : 120/80 mmHg HR : 90x/m RR: 20x/m T: 36.5C SaO2: 98%
Hg HR : 88x/m RR: 20x/m T: 36.3C SaO2: 98%

a dlm koreksi,
37; N = 86; P = 20; TD = 120/80; SpO2 = 98%
S = 36,1; N = 83; P = 22; TD = 120/80; SpO2 = 98%
6; N = 82; P = 19; TD = 110/70; SpO2 = 98%

80; SpO2 = 99%
= 79; P = 19; TD = 110/70; SpO2 = 98%

D = 120/70; SpO2 = 98%
mia dlm koreksi,
= 110/70; SpO2 = 99%

g lalu; RPO: (-)
0/80; SpO2 = 99%
0/70; SpO2 = 98%

D = 110/70; SpO2 = 98%
g, batuk berdahak ada; s = 36,6; N = 111; P = 22; TD = 110/80; SpO2 = 99%

semalam ada demam, batuk kering (+)
D = 120/70; SpO2 = 98%
/90; SpO2 = 98%
D = 130/80; SpO2 = 98%

120/80; SpO2 = 99%
ng; s= 36,3; N = 85; P = 19; TD = 130/80; SpO2 = 98%
mbang parasit di kapal; RPO:ada 2 jenis jamu; s = 36,3; N = 80; P = 19; TD = 120/90; SpO2 = 99%
a dlm koreksi,
SpO2 = 99%
36,3; N = 120; P = 19; TD = 130/80; SpO2 = 99%
0; TD = 120/70; SpO2 = 96%

; RR 20 ; T 36.4 ; SpO2 100%
6 ; SpO2 98%
90; SpO2 = 100%
; s = 37,2; N = 128; P = 21; TD = 130/90; SpO2 = 97%
i perbaikan; s = 36; N = 61; P = 20; TD = 98%
D = 140/100; SpO2 = 98%
97 SM 4 lpm
flapping dan suction setelah nebu

6,3; N = 76; P =20; TD = 90/70; SpO2 = 99%
= 20; TD = 90/70; SpO2 = 100%
/90; SpO2 = 98%

= 102; P = 20; TD = 110/70; SpO2 = 96%
belah kanan; s = 36,8; N = 104; P = 20; TD = 140/100; SpO2 = 100%
flapping dan suction setelah nebu
/90; SpO2 = 97%
pm SpO2 100% on room air

0; SpO2 = 98%
m air RR 20kpm
6,1; N = 70; P =19; TD = 100/70; SpO2 = 100%

D = 150/90; SpO2 = 96%
m S 37.5C SpO2 96% on room air

Gabriel Dec 22

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MARCO WIRIANATA 441139

ONG TJOE NIO 44-69-48

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ONG LIEN TJU 43-58-01

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SULASTRI 44-74-01 mual dan muntah

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MARADIAN YACOEB C 347208 dyslipidemia: HDL =

CHIVIKA 44-75-97 monitoring terfacef tidak di y-site dengan ase

RITA SARI 23-89-12 Alb = 2,66 g/dl

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RITA SARI 23-89-12

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BRYAN ELBERT JON 385119

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