NO Nama Pasien/RM/Tgl lahir Ruangan Terapi Sebelumnya Terapi Terbaru SOAP Keterangan/planning

1 NY. RUPIAH 13B Tx dr. Arifin Sp.P : R/ visite dr. Arifin Sp.P
384163/ 1940-07-31 Inf. RL + Amino 1 amp 20 R/ nebul lasalcom
Dx : tpm R/ obs k/u
Pneumonia dd TB Paru Ceftriaxon 2x1 g R/pindah isolasi TB
Inj dexamethasone 3x1 amp
Dpjp : Inj. Ranitidin 2x1 amp
dr. Arifin Sp.P Lasalcom nebul/8 jam
po lacoldin 3x1
Codein 3x20mg
2 TN. TUMIRAN 33B Tx. dr. Arifin, Sp.P: R/visite dr.Ririn
335569/ 2808-1955 Inf. RL 7 tpm R/balance Cairan
Dx : Inj ranitidine 2x1
Efusi pleura Inj furosemide 1x1
Po lacoldin 3x1
Dpjp : Lasalcom nebul k/p
dr. Arifin,Sp.P
c/ dr. Ririn,Sp.JP Tx. dr. Ririn,Sp.JP
HHD
inj furosemid 1x1 amp
amlodipin 1x5 mg
diit rendah garam
balance cairan
3 TN. MUHADI 31A Tx dr. Hanafi Sp.B : R/GDA Pagi
357626/12-101969 inj ceftri 2x1 RPO : Novorapid 3x10 unit
Dx : inj ketorolac 3x30
GANGREN PEDIS post debrid
tx dr. robby,Sp.S :
Infus RL 20 tpm
Dpjp :
Inj Ketorolac 30 mg / 8 jam iv
dr. Hanafi,Sp.B
selama 2 hari
Bila mual, inj Metoklopramid
10 mg iv
Post op mobilisasi bertahap
4 NY. NISWATIN 33C Tx. dr Nirmala,Sp.S R/2JPP
377183 / 01-05-1962 Inf RL 2 kolf/24 jam habis aff
Dx : PO asmef 2x500 mg R/konsul IPD setelah ada
LBP+ischialgia kanan PO neurodex 2x1 tab hasil GDP 2JPP
Gabapentin 200mg/Eperison Foto Lumbosacral :
Dpjp : 50mg 2x1 caps
dr. Nirmala,Sp.S -1.Spondylitis L5-S1 +Partiel
HNP.
-2.Un Stable LS Joint

5 NY. NGATINI 32A Tx dr. Nirmala Sp.S :

387279/ 1961-12-29 Infus habis aff
Dx : PO Citicolin 2x500 mg
CVA infark 2nd attack+CAD NS drip STOP
OMI anteroseptal+KP duplex PO neurodex 1x1 tab
lama aktif (dr. Nirmala Sp.S) Cefixim 2x100mg PO-->besok
pagi
Kardiomegali/ LVH pro
evaluasi --> HHD Tx dr. ririn Sp.JP :
(dr. Ririn Sp.Jp)
Nitrokaf 1x2,5 mg (jk TDS >
100 mmHg)
Double hemiparese ec cva infark
3rd attack h6 (dr.Vita) Advice dr arifin Sp.P :
Tx ~ dr. Nirmala, SpS & dr.
TB Paru (dr.Arifin Sp.P) Ririn, SpJP
Ceftriaxon 2x1
Nebul lasalcom (K/P)
Ambroxol syr 3xCI
Dpjp :
dr. Nirmala Sp.S
 C/ dr. Ririn Sp.JP Advice dr. Vita :
C/ dr. Arifin Sp.P
mobilisasi duduk bertahap, bea,
C/ dr. Vita
prom, turning/ 2jam, proper
positioning
inhibisi spastik
exc jika stabil
6 NY. JAMAATIN 21B Terapi Sementara : Thorax AP,
348124/ 1965-09-18 Tampak adanya :-
Dx : Inf. RL loading 500 cc
-1.Pneumonia sin bwh,
maintenance 1500 cc/ 24 jam
Abdominal Pain E.C Gastritis (Ggo para cardial sin)
Inj Santagesik 3x1 gram
Akut + Vomiting -2.Severe LVH (+) &
Inj Omeprazole 2x40 mg
Dpjp : Congestif Pulmo, &
Inj Ondansentron 3x4 mg
dr. Choirina, Sp.PD Kalsifikasi Ao Knob (+)
Inj ceftriaxon 2x1 gr
PO sucralfat syr 3 x II cth

7 TN. SUBADRI 31B Tx dr Agatha Sp.PD : R/ GDA Pagi

387315 / 1969-10-10 Inf nacl 14 tpm
Dx : Inj metro 3x500mg R/ rawat luka, untuk kassa
DM + abses axilla dextra Inj ceftri 2x1 yang di ketiak, yang masuk
(dr.Agatha Sp.PD) Novorapid 3x8iu kulit di ambil saja, setelah itu
tutup dengan kassa, rawat
Gangren Regio Aksila Dekstra
luka dengan sufratul
(dr.Gute Sp.B) Advice dr gute Sp.B :
post insici abses axila dextra Post Debridement
(dr.Freddy Hernawan Sp.An) IVFD NaCl 0,9% 20 tpm
Inj. Ceftrixon 1 gr/12 jam
Dpjp : Inj. Santagesic 1 gr/8 jam
dr.Agatha Sp.PD Inj. Ranitidin 50 mg/12 jam
 Raber/ dr. Gute Sp.B Diet TKTP bila sadar penuh

Advice dr. freddy Sp.An :

Ketorolac 30mg/8 jam iv

Analtram 3x1

8 NY. ISTIBSAROH 31C Tx dr. Agatha Sp.PD : Hasil SE post wida kn

387293/ 1974-03-22 Na 131
Dx : Inf wida Kn 2000/24 jam, K 3,9
Hipo N+hipoK+low habis cek SE Cl 109
intake+GEA+iskemia Inj samta 3x1
Inj ranit 2x1
(dr.Agatha Sp.PD) Inj ondan 3x1
Amlo 1x5mg
Biso 1x5 mg
HHD (dr.Ririn Sp.JP) New diatab 2 tab/diare

Dpjp : Tx dr. ririn Sp.Jp :

dr. choirina. Sp. PD amlodipin 1x5 dilanjutkan
C/ dr. ririn. Sp.JP bisoprolol 1x5 dilanjutkan

9 TN. SUCIPTO 32B Tx dr. Agatha Sp.PD :

387296/21.08.62 PO analsik 3x1
Dx : Inf RL 20 tpm
Abdominal pain + fatty liver Inj keto 3x1
Inj ranit 2x1
Dpjp : Inj ondan 3x1
 dr. choirina Sp.PD Sucralfat 3x1
UDCA 1x1

Tx. dr. Nirmala,Sp.S

PO dramamin 3x1
PO eperison 2x1
PO paracetamol
400mg/diazepam 2mg 2x1
caps

10 NY. YULIATI 33A Tx. dr. agatha, Sp.PD : R/GDA Pagi

329471/ 1976-07-08 Inf Nacl 1000/24 jam SE awal masuk
Dx : Inj santa 3x1 Na 123.70
DM hipergpikemia + low intake Inj omz 2x1 K 4,96
+ hipo na PO furo 1x1 Cl 1107,60
Novorapid 3x8U
Dpjp : Metformin 3x1
dr. Agatha Sp.PD Prorenal 3x1

11 TN. RICO SAPUTRA 33E Tx dr. Agatha Sp.PD : Hasil DL kemarin

387260 / 2000-10-23 Inf RL 1000/24 jam Hb 15,6
Dx : Inj santa STOP Lekosit 12.060
DHF Inj ranit 2x1 HCT 45.5
PO caviplex 1x1 Eritrosit 6.2
PLT 58.000
Dpjp :
Hasil DL hari ini
dr. Agatha Sp.PD
Hb
Lekosit
HCT
Eritrosit
PLT
12 NN. ANA SEPTIANINGSIH 33F Tx dr. Agatha Sp.PD :
387375/1999-09-20 Inf. RL lanjut 14 tpm
Dx : Inj. Santagesik 3x1 amp
GEA + Vomiting + OF H3 Inj. Ranitidin 2x1 amp
Inj. Ondansetron 3x1 amp
Dpjp : PO lodia 3x1
dr.Agatha Sp.PD

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