5. Tn.

Tri Wantoro 46 tahun/ Bed 6/ HP ICU 5/ HP RS 5

OBJECTIVE ASSESMENT PLANNING
CNS: E4M5V6 Diagnosis: Terapi:
ICH, HT Emergency RL 16-20 tpm
DPJP: dr. Sunarto spS
Injeksi:
CVS Lab 24/3/19: Ceftriaxon 2x1g
TD 150/98 Leukosit 11 (H) Pantoprazol 3x1g
HR 84 Hb 17 Pamol 3x1
Trombosit 265 Kalnex 3x500mg R/ Hari ke 4
Ureum 44.3 (H) Mecobalamin 2x1 amp
Creatinine 1.83 (H) Citicolin 2x250mg
SGOT 23 Omz 1x40mg
Respiration
RR 25 SGPT 14
Program:
SPO2 97%
Nicardipine 10cc/jam
Diet cair 4x200cc
GIT
Distensi (-)
Bising usus (+)
NGT(-)
GUT
UO:
Balans:
 6. Tn Rukyat / Bed 9, HPICU 1/ HPRS 1
OBJECTIVE ASSESMENT PLANNING
CNS: E4M5V6 CKD stage V on HD Terapi:
DPJP: dr. Maretina SP.PD IUFD D10% 20tpm

CVS Lab 27/3/19: Injeksi:

TD 160/90 Leukosit 8.6 Pantoprazol 3x1g
HR 98 Hb 10.6 L Ceftriaxone 2x1
Eritrosit 3.5 L
HT 30 L Per-oral:
Respiration
Trombosit 322 Candesartan 16-0-0
O2 nasal/8lpm
Eosinofil 0.10 L Amlodipin 0-0-10
RR 25 Netrofil 88.6 H
Limfosit 7.20 L Program:
SPO2 97%
Kalium 7.42 HH Rontgen thorax PA
GIT HD cito besok
Natrium 130.7 L
Distensi (-) Diit cair 6x200 cc
Chlorida 106.7 H
Bising usus (+) cek HBsAG, Anti HIV
Calsium 1.13
NGT(-) SP D40% 2 flash + Humulin R 10 iu
Ureum 233.3 (H)
GUT Creatinine 16.42 (H) GDS per 8 jam
UO:
Balans:
 8. Tn. Kasri 63 tahun/ Bed 5 /HP ICU 51/ HP RS 1
OBJECTIVE ASSESMENT PLANNING
CNS: E4M6V5 Diagnosis: Terapi:
Edema paru, CHF, Dypsneu IVFD NaCl 0.9% 16 tpm
DPJP: dr. Maretina, Sp.PD O2 mask 8 lpm
Injeksi:
CVS Lab (28/03/2019): Levofloxacin 1x500 mg
TD: 130/70 mmHg Leukosit 19.2 (H) Pantoprazole 1x40 mg
HR: 105 x/menit Er 3.9 (L) furosemid 1x2 amp
Hb 11.3 (L) Oral : -
Respiration
Ht 35 (L) Program:
O2 mask 8 lpm
Trombosit 355 SP nitrat 2cc/jam
RR: 25 x/menit Ur 70.6 (H)
SpO2: 97% SGPT 73 (H)

GIT
Distensi (-)
Bising usus (+)
NGT(-)
GUT
UO:
Balans: