Penatalaksanaan (1) (2) (3) (4) (5) (6) (7) (8) 1 dr. Layali fase laten. persalinan Kala II

(1)

Tanggal Kode Kegiatan

Topik Kegiatan Catatan

Pendamping

Tanda Tangan Pendamping

Keterangan

Tambahan No Diagnosis Penatalaksanaan

(1) (2) (3) (4) (5) (6) (7) (8)

07/09/2013 A

Ny. S, 33 tahun, G2P1A0 uk 38 minggu, JTHIU prekep puki in partu kala I fase laten

- Rawat Inap Kebidanan - Observasi kemajuan

persalinan, awasi tanda-tanda persalinan Kala II

dr. Layali Musafiroh

1

07/09/2013 A

Ny. A, 22 th, G1P0A0 uk 12 minggu dengan HEG

- Rawat Inap

- IVFD D5% 20 tpm - Inj. Ranitidin 3x1A - Inj. Ondansetron 3x1A - po Antacyd syr 3x2 cth

2

07/09/2013 C

Ny. T, 40 th, Dispneu ec susp CHF

- Rawat Inap - O2 2-4 l/m

- IVFD D5% 15 tpm

- Inj. Furosemide 2x1 A (iv) - pasang DC

- Plan: EKG, Ro Thorax PA

3

07/09/2013 A

Ny. P, 20 th, G1P0A0 uk 39 minggu, JTHIU, preskep, puka, belum in partu dengan hipertensi gestasional susp PER dd PEB

- Rawat inap - IVFD RL 20 tpm - Nifedipin 2x10 mg

- Plan: Darah Lengkap, Protein urin

4

09/09/2013 A

Tn. S, 51 th, susp TB paru kasus putus obat

- Rawat Jalan - Ambroxol 3x1 tab - Neurodex 3x1 tab

5

(2)

- Plan: Ro Thorax PA, sputum BTA SPS

09/09/2013 A

Ny. M, 24 th, Artralgia susp CTS

- Rawat jalan

- Na diclofenac 3x25 mg - Neurodex 1x1 tab - Ranitidin 3x1 tab - Plan: Fisioterapi

- Edukasi: hindari aktifitas tangan berlebih

6

09/09/2013 A

An. S, perempuan, 2 th, 15 kg, DATD+ISPA

- Rawat jalan - Lacto-B 2x1 sach - Zinc tab 1x1 tab - Coparcetin syr 3x1 cth

7

09/09/2013 B

Tn. S, 55 th, kontrol post Closed Fraktur os Clavicula Dextra + VL digiti IV manus dextra

- Rawat jalan

- Clindamycin 300 mg 3x1 cap - Asam mefenamat 3x500 mg - Ranitidin 3x150 mg

- Edukasi : jaga luka tetap kering, diet tinggi protein karena luka lama kering

8

09/09/2013 A

Tn. S, 40 th, Hipertensi Stage I, ISPA. TD: 150/90 mmHg

- Rawat Jalan

- Captopril tab 2x12,5 mg - Ambroxol 3x1 tab - Bufantacyd 3x2 cth - Edukasi: diet rendah garam

9

09/09/2013 B

Tn. S, 40 th, kontrol VL plantar pedis sinistra

- Rawat Jalan

- Ciprofloxacin 2x500 mg - Dexamethason 3x0,5mg

10

(3)

- Asam Mefenamat 3500 mg - Ranitidin 3x150 mg

- Edukasi : kontrol 3 hari, jaga luka tetap kering, diet tinggi protein

09/09/2013 B

Tn. D, 32 th, kontrol VL cruris dextra

- Rawat jalan

- Amoxicillin 3x500 mg - Asam mefenamat 3x500 mg - Ranitidin 3x150 mg

-Edukasi : antibiotik dihabiskan, jaga luka tetap kering

11

09/09/2013 B

Ny. K, 41 th, LBP post trauma susp. Fraktur Kompresi Vertebra Lumbal

- Rawat Jalan

- Na diclofenac 3x25 mg - Ranitidin 3x150 mg - Plan: Ro Vertebra

Lumbosacral AP, Konsultasi Dokter Spesialis Bedah

12

09/09/2013 B

Tn. M, 34 th, Appendiksitis kronik

- Rawat Jalan

- Amoxicillin 3x500 mg - Spasminal 3x1 tab - Konsultasi Sp.B

13

09/09/2013 B

Tn. I, 31 th, kontrol VL palpebra superior sinistra

- Rawat jalan - Aff hecting 2 - Neurodex 1x1 tab - Vitalong C 1x1 tab

14

09/09/2013 A Ny. R, 40 th, Hipertensi Urgensi, TD: 200/100 mHg

- Rawat jalan (pasien menolak rawat inap)

dr. Layali

Musafiroh 15

(4)

- Amlodipin 1x10 mg - Captopril 3x25 mg - Neurodex 1x1 tab

09/09/2013 A

Ny. M, 45 th, Mialgia - Rawat jalan

- Meloxicam 3x1 tab - Neurodex 1x1 tab - Ranitidin 3x150 mg

16

09/09/2013 A

Ny. M, 31 th, Obs febris susp Chikungunya BBPV

- Rawat jalan (menolak rawat inap)

- Betahistine mesylate 2x1ab - Paracetamol 4x500 mg kp - Stimuno 2x1 tab

17

10/09/2013 A

An.P, Perempuan, 9 bl, 7,2

kg. DADRS dan

Rhinofaringitis akut

- Rawat inap

- IVFD RL 36 tpm (mikro) - Inj. Ranitidin 3x1/3A - Inj. Ondansetron 3x1/3a - Lacto-B 2x1 sachet - Zinc 20 mg 1x1/2 tab - Erlamol syr 3x1 cth

18

10/09/2013 B

Ny. K, 55 th, kontrol post Close fraktur humerus sinistra 1/3 proximal

- Rawat Jalan

- Asam mefenamat 3x500 mg dr. Layali

Musafiroh

19

10/09/2013 A

Ny. P, 25 th, G3P0A2 uk 13 minggu dengan HEG derajat II

- Rawat inap

- IVFD RL loading 500 cc -->

30 tpm

- RL:D5%:NaCl 0,9% 1:1:1 30 tpm

- Inj. Ranitidin 3x1A

20

(5)

- Inj. Ondansetron 3x1A - Neurosanbe drip 1A/24 jam

10/09/2013 A

An. R, 7 th, 20 kg, DADRS, obs febris susp Thyfoid fever

- Rawat Inap - IVFD RL loading 200 cc--> 30 tpm -->15 tpm

- Inj. Chlorampheniol 4x250 mg (iv)

- Inj. Ranitidin 3x1/2A - Inj Ondansetron 3x1/2A - Sanmol syr 3x2 cth - L-Bio 3x1 sachet - Plan: DL, widal

21

10/09/2013 A

An. E, 7 th, 23 kg, Ob Vomitus suspek intoksikasi makanan

Rawat Jalan

- Antasida doen syr 3x1 cth - Ranitidin III, Papverin III, Vit BC III, Vit C II ,mf No.X 3x1

22

11/09/2013 A

Perempuan, 25 th, P1A0 post partum fisiologis Hari ke-2 dengan PEB. TD:

130/90 mmHg

- BLPL

- Clindamicyn 3x300 mg - Nifedipn 1x10mg

- Asam Mefenamat 3x500 mg

23

11/09/2013 A

Perempuan, 35 th, P2A0 post partum SC atas indikasi riwayat SC

- IVFD RL 20 tpm

- Inj. Cefriaxon 2x1 gr (iv) - Inj. Ketorolac 3x1A - po. Gastrul tab 2x1

24

11/09/2013 A

Perempuan, 28 tahun, G2P1A0 uk 37 minggu JTHIU peskep puka in partu

- Rawat Inap obervasi vk - IVFD RL 20 tpm - Nifedipin 2x10 mg sl

25

(6)

kala I fase aktif dengan PER

12/09/2013 A

Tn. T, 31 th, Ob Febris susp Thyfoid Fever

- Rawat Inap - IVFD RL 2 tpm

- Chloramphenicol 4x500 mg - Paracetamol 4x500 mg - Rantidin 3x150 mg - Plan : DL, Widal

26

12/09/2013 A

Tn. S, 30 th, DADRS - Rawat inap

- IVFD RL 20 tpm - Loperamid 2-1-1 - L-Bio x1 sach - Omeprazol 2x1 tab

27

13/09/2013 A

Ny . E, 29 th, G1P0A0 uk 13 minggu dengn heg derajat II

- Rawat inap

30 tpm - RL:D5%:NaCl ,9%

1:1:1 30 tpm

- Inj. Ranitidin 3x1A - Inj. Ondansetron 3x1A - Neosanbe drip 1A/24 jam

28

13/09/2013 A

An. M, 10 th, 27 kg, DADRS

- Rawat Inap - IVFD RL 16 tpm - Inj. Ranitidin 3x1/2 A - L-Bio 3x1 sachet - Zinc 1x1 tab

29

14/09/2013 B

Tn.T, 60 th, Kontrol multpel VL

- Rawat Jalan

- Asam mefnama 3x500 mg - Ranitidin 3x150 mg - Neurodex 1x1 tab

30

(7)

14/09/2013 A

An. B, 7 th, 18 kg, GEA tanpa dehidrasi

- Rawat jalan

- Ranitidin 2x75 mg

- Antacida doen syr 3x1/2 cth - L-Bio sach 2x1

- Zinc tab 1x1

31

14/09/2013 A

An. K, 4 th, 15 kg, GEADS susp intoksikasi makanan

- Rawat inap

- IVFD RL 14 tpm (ma) - Inj. Ranitidin 2x1/2A - Inj Metoclopramid 2x1/2A - po Norit tab 3x5 tab

- Plan: DL

32

14/09/20134 A

Tn. S, 54 th, Obs febris susp Chikungunya dd DHF

- Rawat inap - IVFD RL 20 tpm - Paracetamol 4x500 mg - Neurobion 1x1

- Stimuno 1x1 tab

33

14/09/2013 B

Tn. S, 54 th , Abdominaal pain ec GERD, dd gastritis

Rawat inap

- IVFD RL 20 tpm + Ketorolac 1A drip (extra)

- Inj Ranitidin 2x1 A - po Ciprofloxacin 2x500 mg - Buscopan 3x1 tab

- Plan: DL, EKG

34

14/09/2013 A

An. G, 3 th, 8,5 kg, DADRS - Rawat inap

- IVFD RL 36 tpm (mikro) - Inj. Ondansetron 3x1/3 A - L-Bio 3x1 sachet

- Zinc 1x1/2 tab

35

(8)

- Plan: DL

15/09/2013 A

Tn. W, 45 th, GEADS - Rawat inap

- IVFD RL LOADNG 500 CC

 20 tpm

- Mecodiar 2 tab tiap kali BAB - L-Bio 2x1 sach

- Zinc 1x1 tab - Plan: DL

36

15/09/2013 A

Ny. U, 21 th, G2P1A0 uk 8 minggu dengan HEG

- Rawat inap

30 tpm

- Rl:D5%:NaCl 0,9% 1:1:1 30 tpm

- Neurosanbe drip 1A/24 jam - Inj Ranitidin 3x1A

- Inj. Metocloperamid 3x1A - Plan: DL, GDS

37

15/09/2013 B

Tn. S, 56 th, susp Closed fraktur antbrachii dextra, hematom palpebra sinistra, multipel VE

- Rawat inap - Wound toilet

- Immobilisasi spalk+elastic band antebrachii sinistra - IVFD RL 20 tpm

- Inj. Ceftriaxon 2x1 gr (iv, skintest)

- Inj. Ketorolac 2x1A kp - Inj. Ranitidin 3x1A - Plan: Ro antebrachi sinistra

AP&lateral, Konsultasi dr sp.OT

38

(9)

16/09/2013 A Ny. R, 22 th, G2P0A1 uk 36 minggu dengan konstipasi

- Rawat jalan - Microlac supp 1 tube

dr. Layali

Musafiroh 39

16/09/203 A

An. P, perempuan, 3, th, 18 kg, GEADS

- Rawat inap

- IVFD RL 56 tpm (mi) - Inj Ranitidin2x1/2 A - Inj. Ondansetron 2x12A - Myrasic syr 3x 1 1/2 cth - Plan: DL

40

16/09/203 A

Nn. I, 19 th, GEADR Rawat jalan

- Cotrimoxazol forte 2x1 - Loperamid 2-1-1 tab - Paracetamol 3x1 tab - Vitazym 3x1 tab

41

16/09/2013 A

Ny. K, 25 th, G1P0A0 uk 39 minggu JTHIU presbo in partu kala I fase aktif

Rawat inap - IVFD RL 16 tpm - Observasi kemajuan persalinan

42

17/9/2013 C

Ny. D, 60 tahun, Hipertensi Emergensi. TD: 200/110 mmHg

Rawat inap

- IVFD RL 20 tpm - Inj. rantidin 3x1A - Amlodipin 2x10 mg - Captopril 3x25 mg - Paracetamol 2x50 mg - Plan: DL, GDS, Ureum, Kreatinin, Ro thorax PA, EKG

43

21/09/2013 A

Ny. A, 56 th, GEADS - Rawat inap

- IVFD RL 20 tpm - Inj. Ranitidin 3x1A

44

(10)

- Inj. Ondansetron 3x1A - Scopma 3x1 tab

21/09/2013 A

Ny. R, 55 th, Hipertensi stage II, Gastritis. TD:

170/100 mmHg.

- Rawat inap - IVFD D5% 20 tpm - Inj. Ranitidn 3x1A

- Inj. Ondansetron 3x1 A - Catopril 3x 25 mg - Nifedipin 2x5 mg

45

21/09/2013 A

Tn. S, 58 th Obs febris susp thyfoid fever

- Rawat inap - IVFD RL 20 tpm - Paracetamol 4x500 mg - Antacida 3x1 tab - Plan : DL, Widal

46

21/09/2013 A

Ny. S, 38 th, Hipertensi stage I, GEADS

- Rawat inap

- IVFD RL 20 tpm - Inj. Ranitidin 3x1 A - Inj. Ondansetron 3x1A - Captopril 3x12,5 mg

47

21/09/2013 B

Tn. P, 30 th, Muliple VL - Rawat Jalan

- Wound toilet, hecting luar 3 - Inj. ATS 1.500 IU (im, skin test)

- Clindamycin 3x300 mg - Asam mefenamat 350 mg - Dexamethason 3x0,5 mg - Ranitidin 3x1tab

- Edukasi: jaga luka tetap kering, kontrol poliklinik

48

(11)

21/09/2013 A

Tn. E, 23 th, GEADS - Rawat inap - IVFD RL 30 tpm - Inj. Ranitidin 3x1 A - Inj. Ondansetron 3x1A - L-Bio 3x1 sach - Zinc 1x1 tab - Plan: DL

49

22/09/20103 A

Ny. T, 35 th,

BPPV+Gastritis akut

- Rawat inap

- IVFD D5%:RL 2:1 20 tpm - Inj. Ranitidn 3x1 A

- Inj. Difenhidamin 3x1A - Neurobion drip 1A (extra) - Omeprazlol 2x1 tab - Antacida Doen syr 3x2cth

50

22/09/2013 A

Nn. I, 13 th, 24 kg, Obs febris 5 hari susp Thyfoid fever dd DHF

- Rawat inap - IVFD RL 20 tpm - Inj. Ranitidin 3x1A - Inj. Ondansetron 3x1 A

- Paracetamol tab 3x500 mg - Plan: DL, widal

51

22/09/2013 C

Ny. T, 60 th, Asma attack pada asma persistten sedang, hipertensi stage II, susp TB paru kasus putus obat. TD:

160/90 mmHg

Rawat inap - O2 2-4 l/m

- Nebulisasi Ventolin 2,5 mcg - IVFD RL 20 tpm

- Inj. Ranitidin 2x1 A - Ambroxol 3x1 tab - Captopril 3x25 mg - Paracetamol 3x500 mg

52

(12)

- Plan: Ro thorax PA, GDS, DL, sputum BTA SPS, EKG

22/09/2013 A

An. R, perempuan, 7 bln,

6,5kg, GEADS,

Rinobronkhitis akut

Rawat inap

30 tpm (mi)

- L-Bio 3x1 sach - Zinc x1/2 tab

- GG II, CTM II, PCT II, vit C II mf X 3x1

- Plan: DL

53

22/09/2013 A

Tn. E, 33 th, Gasroenteritis kronik, Candidiais oral, suspek AIDS

- Rawat inap

- IVFD D5% 30 tpm - Inj. Ranitidin 3x1A - Antacida Doen syr 3x2 cth - L-Bio 3x1 sachet

- Zinc 1x1 tab

- Kandstatin drop 4x100.000 IU

- Plan: DL, GDS

54

23/09/2013 A

Tn. S., 39 th, obs. Febris susp TF

Rawat jalan

- Chloramphenicol 4x500 mg - Ranitidin 3x150 mg

- Paracetamol 3x500 mg - Neurodex 1x1 tab - Plan:

DL, widal

55

23/09/2013 C

Ny. M, 61 th,Obs dyspnea ec anemia gravis

- Rawat inap - O2 3 l/m

- IVFD NaCl 0,9% 20 tpm

56

(13)

(ma)

- Inj. Ranitidin 3x1A(iv) Plan: DL, golongan darah, EKG, Ro thorax

23/09/2013 B

Tn. P, 30 th, VE dorsumpedis dextra et sinistra

Rawat jalan

- Amoxicillin 3x 500 mg - Asam mefenamat 3x500 mg -Neurodex1x1tab

57

23/09/2013 B

Tn.W, 75 th,Obs dyspnea susp PPOK dd TB paru

Rawat inap - O2 3l/m

- IVFD RL 20 tpm - Paracetamol 4x500 mg

58

24/09/2013 A

Ny. R, 50 th, GEADS Rawat inap

- IVFD RL loading 300cc  30 tpm

- Inj.Ranitidin 2x1A - Inj. Ondansetron 2x1A - Cotrimoxazol 2x1tab - Scopamin plis 2x1 tab - Zinc tab 1x2

- New diatab 3x1

59

24/09/2013 C

Ny.M, 45 th,Multple VE, VL capitis

- Rawat inap - O2 2l/m

- IVFD RL 30 tpm - Inj.Ranitidin 3x1A - Inj.Ondansetron 3x1A - Ketorolac drip 3x 1 A - Inj.Neurotam 3x1A

60

(14)

- Inj.Citicholin 3x 1 A - Inj. Ceftriaxon 2x1 gr (iv, skin test)

24/09/2013 C

Ny. R,23 th, VE cruris dextra

Rawat jalan

- Amoxicillin 3x500 mg - Asam mefenamat 3x500 mg

61

24/09/2013 A

An.Aditya,6

th,15kg,Tonsilitiskronik eksaserbasi akut

Rawat inap

- IVFD RL15 tpm

- Inj.Ceftriaxon 2x250 mg - Inj.Gentamicin 2x20 mg - Inj.MP 2x1/2cc

- Luminal II, PCT III,

Domperidon II, Vit. C III mf X,3x1

62

24/09/2013 A

Ny.S,28 th, obs.febris susp DHF dd TF

rawat jalan

- Amoxicillin 3x500 mg - Ranitidin 3x150 mg - Neurodex 1x1 tab - Vitalong C1x1 tab

63

24/09/2013 A

Tn. A, 25 th, TTH Rawat jalan

- Paracetamol 3x500 mg - Neurodex 1x1 tab - Vitalong c 1x1 tab

64

24/09/2013 A

Tn.S, 75 th,Obs febris susp Chikungunya

rawat inap

- IVFD RL loading 1000 cc  20 tpm

- Inj. Cefotaxim 2x1 gr - Inj.Dexamethason 3x1A

65

(15)

- Inj. Ranitidin 2x1A - Paracetamol 4x500 mg - Luminal 2x1 tab

24/09/2013 A

An.S, 7 th,Obs febris susp DHF grade II

Rawat inap

- IVFD RL 40 tpm 4jam  20 tpm

- Inj. Ranitidin 2x1/2A - Paracetamol syr 3x1 cth - DEHAF 2x1

- Curcuma 2x1cth

66

24/09/2013 A

Tn.S, 38 th,GEADS Rawat inap

- IVFD RL loading 300 tpm  30 tpm

- Inj.Ranitidin3x1A - New diatab 3x1 - Cotrimoxazol 2x1 - Scopamin plus 2x1 - L-Bio 3x1sach - Paracetamol 4x500 mg

67

24/09/2013 A

Ny.D,20 th, G1P0A0 uk

39+4 minggu

JTHIU,preskep,inpartu kala II lama

rawat inap -Vakum ekstraksi

68

25/09/2013 A

Ny.K,60th, gastritis rawat inap

- IVFD RL 16 tpm - Inj.Ranitidin 3x1 A - Antasida doen syr 3x2 cth - Omeprazol 2x1 tab

69

(16)

- Curcuma 3x1 tab

25/09/2013 A

An.E,5th,15 kg, Kejang Demam Sederhana

rawat inap

- IVFD D5%15 tpm - Inj.Dexamethason 3x2cc - Luminal 5 mg II, Vit. C 25mg II,PCT 70mg III, mf X,3x1

70

25/09/2013 A

An.H,2 th,9 kg,GEA dehidrasi sedang,

rawat inap

- IVFD RL 300 cc loading-->

36 tpm

- Fuzide syr 3x1 cth - Sanmol syr 3x3/4 cth - L-bio 3x1/2sach - Zinc 1x1/2tab

71

25/09/2013 B

An.I, 1 th,8,5 kg, KDS,Rhinofaringitis akut

rawat inap

- IVFD RL loading 200cc -->

30tpm (mi)

- Sanmol syr 3x 3/4cth - CTM II, GG II,Luminal II, VitCII,m.f X,3x1

72

25/09/2013 A

ny. R,50 th,DM tipe 2 degan GEADS

rawat inap

- IVFD RL loading 500cc --

>24tpm

-Inj.Ranitidin 3x1A

- Inj. Ondansetron1 A (extra) - Glibenclamide1x5mg (1-0-0) - New diatab 3x1 tab

- Scopamin plus3x1tab - PCT 3x500mg

73

(17)

25/09/2013 A

An.M,2 th, 9 kg,GEADS rawat inap

-IVFD RL loading 150 cc --

>36tpm (mi) -L-Bio 3x 1/2sach - Zinc 1x1/2tab

74

25/09/2013 B

An. M,12 th, 20 kg,Obs febris susp DHFderajat II dd TF

rawat inap

- IVFD RL loading 400 cc-->

30 tpm

- Inj.Ranitidin 3x1/2A - sanmol syr4x2 cth - Stimuno tab 1x1 - DEHAF2x 1/2sach - Plan: DL, widal

75

25/09/2013 A

An.M, 9 bln,8,5

kg,GEADS,Rhinofaringitis akut

rawat inap

- IVFD D5% loading 100 cc-->

40 tpm(mi)

- Sanmol syr 4x1 cth - Lacto B 3x1/2sach - Zinc 1x1/2tab

- GG II,CTM II,Vit C III,mf X 3x1

76

25/09/2013 A

Tn. S,40 th,Vl dorsum pedis dextra,VE olecranon sinistra

rawat jalan

- wound toilet,hecting luar - Inj ATS1.500 IU

(im,skintest)

- Amoxicillin 3x500 mg - Asam mefenamat 3x500 mg - Ranitidin 3x150 mg

77

(18)

28/09/2013 A An. F,14 th, susp Miopia ODS,

Rujuk Sp.M dr. Layali

Musafiroh 78

28/09/2013 C

Tn.M, 23th,VE genu dan olecranon sinistra

rawat jalan

- Amoxicillin 3x 500 mg - Asam Mefenamat 3x 500mg - ranitidin 3x 150mg

- Amlodipin 1x5 mg

79

28/09/2013 B

Ny. T,30 th, G3P2A0 uk 38 minggu JTHIU preskep in partudgn febris hari ketiga dan Hipertensi gestasional susp PER

Rawat inap - IVFD RL 16tpm - Nifedipin1x 10 mg - Paracetamol 3x500 mg - Plan: DL,protein urin

80

28/09/2013 C

An.S,12th, 36kg, Combustio derajat II-III luas 18%

rawat inap

-IVFD RL16 loading 300 cc-->

30tpm

- Inj.Ranitidin 3x1/2A - Bioplasenton saelp 3dd ue -kompres luka/8 jam dengan NaCl

81

28/09/2013 B

Tn.Y,58 th,Asma attack rawat inap - O2 4-5 lpm

- Nebulisasi Ventolin 1A -IVFD D5% 16tpm

- Methylprednisolon tab 2x4mg

- Salbutamol 3x2 mg - Ambroxol3x30 mg

82

29/09/2013 A tn. M,59 th, Dm tipe 2 rawat jalan dr. Layali 83

(19)

dengan motion sickness - Dimenhidrinat 3x1 tab - Domperidon 2x1 tab - Ranitidin 3x150mg - PCT 3x500 mg - Glibenclamid 1x5 mg - Metformin 3x500 mg

Musafiroh

29/09/2013 B

Ny. S, 60th,obs dyspnea ec susp CPC decompensata dd Bronkopneumonia

rawat inap - O2 4-5lpm

- Inj.Ceftriaxon 2x 1gr (iv) - Inj.Furosemid 2x1A - Nifedipin1x10 mg - Digoxin 1x0,125mg - Plan: DL, Ur, Cr, GDS, ro thorax PA, EKG

84

29/09/2013 B Ny.S, 25th, G1P0A0 uk 39 minggu dengan inersia uteri

rawat inap -Konsul Sp.OG

dr. Layali

Musafiroh 85

01/10/2013 A

An.L, 13 bulan, 7,5kg, GEADS, Rhinofaringitis akut

Rawat inap

30 tpm (mi)

- Inj.Ranitidin 2x1/3A - Lacto b 3x1/2sach - Zinc 1x1/2tab

- GG II,CTM II,sacharin adlib mf X 3x1

86

01/10/2013 B

Ny.N, 65 th,VL capitis rawat jalan

- wound toilet,hecting luar7 - Clindamycin 3x300 mg - Asam mefenamat 3x500mg

87

(20)

- Ranitidin 3x150 mg

01/10/2013 B

Nn.A,25th,Vulnus punctum plantar pedis sinistra

rawat jalan

– Inj. ATS1500 IU - Clindamycin3x300 mg - Asam mefenamat 3x500mg - Ranitidin 3x150 mg

88

01/10/2013 B

Ny.T, 21 1th, Vulnus Punctum plantar pedis sinistra

Rawat jalan

- Inj. ATS 1.500 IU - Amoxicillin 3x500 mg - Asam mefenamat 3x500 mg - Rantidin 3x150 mg

89

02/10/2013 A

Ny. T, 50 th, GEADS Rawat inap

30 tpm

- Inj. Ranitidin 3x1 A - Inj. Ondansetron 3x1 A - Loperamid 2-1-1 tab - Paracetamol 4x500 mg - Scopamin plus 3x1 tab Plan: DL

90

02/10/2013 A

An. J, 10 th, 25 kg, GEADS rawat inap

16 tpm

- Inj. Rantidin 3x1/2 A - Lacto B 3x1 sach - Zinc tab 1x20 mg

91

05/10/2013 C Tn. D, 60 th, Obs. dyspnea susp TB paru kasus baru,

- Rawat inap

- O2 3-4 l/m, nasal canul

dr. Layali

Musafiroh 92

(21)

hipertensi stage I , TD:

140/90 mmHg

- IVFD D5% 20 tpm - Inj. Ranitidin 3x1 A - Amboxol tab 3x30mg - Amlodipin 1x10mg - Curcuma 3x1 tab - Plan: DL, EKG, Ur, Cr, GDS, Ro thorax PA, BTA SPS

05/10/2013 A

Ny. S, 34 th, Gastritis kronik - Rawat inap

- IVFD D5% 20 tpm --> D5%:

RL 1:1

- Inj. Ranitidin 3x1 A - Inj Ondansetron 3x1 A - Omeprazol 2x1 tab - Antasida doen syr 3x2 cth

93

05/10/2013 A

Nn. S, 19 th, Obs febris susp TF dd DHF, Gastritis akut

- Rawat inap

- IVFD D5% 20 tpm 2 flab --

> RL 20 tpm

- Inj. Ranitidin 2x1 A

- Inj. Ondansetron 1A (extra) - PCT 4x500 mg

- Curcuma 1x1 tab - Plan: Dl, Widal, GDS: 77 mg/dl

94

05/10/2013 A

Ny. S, 55 th, Obs febris susp TF dd DHF

- Rawat inap

maintenance 20 tpm - Inj. Ranitidin 3x1 A - Inj Ondanasetron x1 A

95

(22)

- Paracetamol 4x500 mg - Neurodex 1x1 tab - Plan: DL, widal

05/10/2013 A

Ny. N, 44 th, BPPV - Rawat inap - IVFD RL 20 tpm - Inj. Ranitidin 3x1A - Inj. Ondansetron 3x1A - Betahstin mesylate 3x1 tab - Paracetamol 3x500 mg - Antasida Doen 3x2 cth

96

05/10/2013 A

Ny. K., 50 th, GEADS, Hipertensi stage II, susp DM tipe II. TD: 170/100, GDS:

359 mg/dl

- Rawat inap

maintenance 20 tpm - Inj. Ranitidin 3x1A - Inj. Ondansetron 3x1 A - Cotrimoxaol 3x1 tab - Scopamin plus 3x1 tab - Captopril 3x25 mg - Metformin 3x500 mg - Plan: DL, GDP. G2PP, Ro thorax PA

97

05/10/2013 B

An. G, 6 th, 20 kg, VE reg capitis

- Rawat jalan

- Amoxicillin yr 3x1 cth - Erlamol syr 2x cth

98

05/10/2013 A

Ny. K, 57 th, GERD - Rawat inap (APS) - IVFD RL16 tpm - Ranitidin 3x 150mg - Omeprazol 2x1 tab

99

(23)

- Antasida doen syr 3x 2 cth - Neurodex 1x1 tab

05/10/2013 A

Ny. E, 6 th, DM tipe II, Hipertensi stage II. TD:

180/100 mmHg, GDS: 143 mg/dl

- Rawat jalan - Glimepirid 1x1 mg - Captopril 3x 25 mg - Amlodipin 1x10 mg - Neurodex 1x1 tab

100

05/10/2013 A

An. E, 9 bln, 9,2 kg, GEADS

- Rawat inap

- IVFD D5%-1/4 NS loading 100 cc--> maintenance 36 tpm (mi)

- Lacto-B 2x1/2 sach - Zinc 1x10 mg

- Paracetamol drop 3x0.9 cc - Plan: DL

101

07/10/2013 C

Ny. A, 20 th, obs. vomitus ec intoksikasi larutan pemutih pakaian; Tentament suicide

Rawat inap Bilas lambung 500 cc NaCl --> jernih--

>puasakan 6 jam

30 tpm --> 20 tpm - Inj. Ranitidin 3x1 A - Norit 3x6 tab

- Alprazolam 1x0,5 mg (0-0-1) - Plan: DL

102

07/10/2013 B

Tn. A, 27 th, Multiple VE - Rawat jalan - Wound toilet

- Amoxicillin 3x 500 mg - Paracetamol 3x500 mg

103

(24)

- Ranitidin 2x10 mg - Neurodex 1x1 tab

07/10/2013 B

An. B, 80 th, 20 kg,VL reg Fontal dextra

- Rawat jalan - Hecting luar 2

- Amoxicillin syr 3x1 cth - Paracetamol syr 3x1 cth

104

07/10/2013 C

An. L, 5 th, 8,5 kg, KDS, obs febris h1. t: 42 C

- Rawat inap

- IVFD RL 12 tpm (ma) - Paracetamol syr 4x1 cth - Diazepam 5mg III, Vit C III, Vit BC III --> No. X, 3x1 - Plan: DL

105

07/10/2013 A

Tn. S, 80 th, Hipertensi stage I, Retensio urine susp BPH. TD: 150/90 mmHg

- Rawat jalan - Ganti kateter urin - Ciprofloxacin 2x500 mg - Ranitidin 2x150 mg - Captopril 1x12,5 mg

106

07/10/2013 A

Ny. T,2 th, Gastritis akut - Rawat jalan - Ranitidin 3150 mg

- Antasida doen syr 3x2 cth - Omepraol 2x1 tab

107

07/10/2013 A

An. S, 12 th, 27 kg , Obs febris susp TF, gastritis

Rawat inap

- IVFD RL 20 tpm - Inj Ranitidin 2x50 mg - Inj. Ondansettron 2x4 mg - Paracetamol 4x250 mg - Antasida syr 3x2 cth - Plan: DL, Widal

108

(25)

07/10/2013 A

Tn. N, 28 th, Vomitus ec intoksikasi obat kuat

- Rawat jalan

- Domperidon 3x1 tab - Ranitidin 2x1 tab - Diazepam 1x2mg

109

07/10/2013 C

Tn. S, 18 th, CKR, VL labium superior, Multiple VE . GCS: E4M6V3.

- Rujuk

20 tpm

- Inj. cefotaxim 2x 1 gr (iv), skin test

- Inj. Ranitidin 250 mg

110

07/10/2013 B

Ny. S, 40 th, Multiple VE - Rawat jalan - Wound toilet

- Amoxicillin 3x500 mg - Ranitidin 2x150 mg - Paracetamol 3x500 mg - Neurodex 1x1 tab

111

07/10/2013 B

An. A, 4 th, 12kg, VE reg facial

- Rawat jalan

- Amoxicillin syr 3x1cth - PCT syr 3x1 cth

112

08/10/2013 A

An. L, 5 thh, 8,5 kg, KDS, obs febris H3 susp thypoid fever. t: 39,3 C

-Rawat inap - IVFD D5%- 1/4NS loading 100 cc --> 36 tpm (mi)

- Inj. Ranitidin 3x1/2 A - PCT syr 4x1 cth

- Diazepam 5 mg III, Vit C III, Vit BC III --> No. X, 3x1 - Plan: Widal

113

08/10/2013 A An. E, 1 th, 9 kg, GEADS, Rawat inap dr. Layali 114

(26)

Rhinofaringitis akut - IVFD RL Loading 100 cc-->

36tpm (mi)

- Inj. Ranitidin 2x1/2A - Paracetamol drop 4x0,9 cc - L-bio 2x1/2 sach

- Zinc syr 1x1/2 cth - GG II, CTM III,

Dexamethason 0,5 mg II

sacharin lib --> No.X, 3x1 - Plan: DL

Musafiroh

10/10/2013 A

Ny. V, G1P0A0 usia 19 tahun uk 40 minggu JTHIU preskep puki belum in partu dengan ketuban pecah awal.

- Rawat inap kebidanan - IVFD RL 16 tpm

115

10/10/2013 A

An. L, 8 bln, 8,5 kg, Obs febris suspek DHF dd TF

- Rawat inap

- IVFD RL Loading 100 cc-->

32 tpm (mi)

- Inj. Ranitidin 2x1/2A - Paracetamol drop 4x0,8 cc - Plan: DL (trombosit

36.000/mm3, Widal S.thypii O:1/80

116

10/10/2013 A

An. Q, 9 bln, 6,8 kg, GEADS, Rhinofaringitis akut

Rawat inap

28 tpm (mi)

- Paracetamol drop 4x0,7 cc - Lacto B 3x1/2 sach

- Zinc 1x1/2 tab

117

(27)

- GG II, CTM II,

Dexamethason II, mf No. X, 3x1

10/10/2013 B

Tn. S, 37 th, Open fraktur tibia et fibula dextra 1/3 medial displaced neglected

- Rawat jalan

- Ro Cruris dextra AP&lateral - Clindamycin 3x300 mg - Ranitidin 3x150 mg - pro Konsultasi Sp.OT, pasien menolak.

118

10/10/2013 A

Tn. K., 60 th, Obs febris susp Thyfoid fever dd DHF

- Rawat inap - IVFD RL 20 tpm - Paracetamol 3x500mg - Curcuma 3x1 tab - Antasida 3x2 cth

119

10/10/2013 C

Tn. M, 3 th, Obs heematemesis-melena up hepatiis, dd cholelithiasis, gastritis erosive, ulkus peptikum

- Rawat inap - IVFD D5% 20 tpm - Inj.Ranitidin 3x1A - Inj. Metoclopramid 3x1A

- Inj. Asam tranamat 3x500 mg - Curcuma 3x1 tab

- Plan: DL, GDS (87 mg/dl), HBsAg, Bilirubin

120

10/10/2013 A

An. P, 14 bln, 8 kg, KDK.

s: 38C, kejang 2x

- Rawat inap

- IVFD RL loaoding 100 cc--

>aintenance 32 tpm (mi) - Paracetamol drop 4x0,8 cc - Luminal 30 mg IV, VIt C III, Vit BC III, No. X, 3x1 -

121

(28)

Plan: DL

10/10/2013 B

Tn. H, 18 th, Vulnus laseratum digiti II manus sinistra

- Rawat jalan

- Wound toilet, Hecting luar 1 - Amoxicillin 3x500 mg

- Asam mefenamat 3x500 mg - Ranitidin 2x150 mg - Neurodex 1x1 tab

122

10/10/2013 A

Ny. K, 50 th, Hipertensi grade II, gastritis.

TD:152/120 mmHg

- Rawat inap

- IVFD RL 20 tpm - Ranitidin 3x150 mg - Captopril 3x25 mg - Amlodipin 1x10 mg - Neuroex 2x1 tab - Plan: DL, GDS, Ur, Cr, Ro thorax PA

123

10/10/2013 A

Nn. R, 16 th urtikartia Rawat jalan

- Dexamethason 3x1 tab - Loratadin 1x1 tab - Paracetamol 3x500 mg

124

10/10/2013 A

Ny. S, 19 th, G1P0A0 40 minggu JTHIU,prekep, in partu dengan kala II lama

- Rawat inap - IVFD RL 20 tpm - Pimpin persalinan - Konsultasi dr. Arif, Sp.OG

125

12/10/2013 A

An. K, 14 bln, 13 kg kontrol post diare dan faringitis akut

- Rawat jalan - Cefadroxil 2x1 cth - Cetirizine II, Dexamethason II, Vit C III, mf No.X, 3x1

126

12/10/2013 A, B Tn. W, 80 th, kontrol VL - Rawat jalan dr. Layali 127

(29)

palmar sinistra, hipertensi stage I. TD: 140/90 mmHg

- Aff hecting - Captopril 1x12,5 mg - Neurodex 1x1 tab

Musafiroh

12/10/2013 A

An. M, 2,5 th, 11 kg, GEADS

- Rawat inap

10tm (ma)

- Inj Ranitidin 2x1/2A

- Inj Metoclopramid 2x1/2A - Lacto-B 2x1 sach

- Zinc 1x20 mg - Plan: DL

128

12/10/2013 A

Ny. A, 20 th, kontrol post intoksikasi bayclin, gastritis

- Rawat jalan

- Ranitidin 3x150 mg - Omeprazol 2x1 tab - Vitazym 2x1

- Curcuma 3x1

129

12/10/2013 A

An. S, 2 th, 12 kg, Febris usp TF, Rhinofaringitis akut.

- Rawat jalan - Cefadroxil 2x1 cth

- Paracetamol syrup 4x1 cth - Dexamethason II, GG II, Vit C III, mf no.X, 3x1

130

12/10/2013 A

Ny. T, 33 th, Hipertensi stage II. TD: 180/90 mmHg.

- Rawat jalan

- Captopril 3x 25 mg - Neurox 1x1 tab

- SF 1x1 tab

131

12/10/2013 B Tn. W, 16 th, kontrol VE reg capitis

- Rawat jalan - Vitalong C 1x1 tab

dr. Layali

Musafiroh 132

12/10/2013 A Tn. A, 62 th, gastritis - Rawat jalan dr. Layali 133

(30)

- Lagesyl syr 3x1 cth - Laproton 2x30 mg - Neurobion 1x1 tab

Musafiroh

12/10/2013 A

Ny. S, 25 th, intoksikasi alkohol, gastritis

- Rawat inap - IVFD D5% 16 tpm - Inj. Ranitidin 3x1 A - Omeprazol 1x1 tab - Antasida syr 3x2 cth

134

12/10/2013 C

Tn. R, 65 th, obs dyspnea susp PPOK, dd TB paru, pneumothorax.

- Rawat inap - IVFD RL 16 tpm - Inj. Ranitidin 2x1A - Aminofilin 3x1 tab - Dexamethason 3x1 tab - Captopril 1x25 mg - Plan: EKG, Ro thorax PA

135

12/10/2013 A

An.A, 3 th, 16 kg, observasi febris susp Thyfoid fever dd DHF

- Rawat inap

- Plan: DL, widal - IVFD RL 12 tpm

- Paracetmol syr 3x 1 1/2 cth - GG III, CTM II, Vit C III

136

15/10/2013 A

Tn. M, 53 th, hipertensi stage II, susp DM tipe II.

TD: 190/100 mmHg, gds;

258 mg/dl.

- Rawat inap - IFVD RL 20 tpm - Captopril 3x25 mg - HCT 1x1 tab (1-0-0) - Metformin 3x500 mg - Plan: DL, GDP, GD2PP, EKG: LVH

137

15/10/2013 A, B Tn. T, 80 th, multiple VE, - Rawat jalan dr. Layali 138

(31)

hipertensi stage II. TD:

160/100mmHg

- Amoxicillin 3x500 mg - Captopril 3x12,5 mg - Paracetamol 3x500 mg - Neurodex 2x1 tab

- Vitalong C 1x1 tab

Musafiroh

15/10/2013 A

Ny. N, G1P0A0 usia 31 tahun uk 37 minggu preskep dengan hipertensi dalam kehamilan sup PER dd PEB, susp panggul sempit. TB:

138 cm, TD: 136/90 mmHg

- Rawat inap

- IVFD RL 16 tpm - Plan: DL, proten urin

139

15/10/2013 A

Ny. N, 55 th,Hipertensi stage II dengan epistaksis.

TD: 180/100 mmHg.

- Rawat jalan

- Captopril 3x25 mg - Propanolol 1x40 mg - Kalnex tb 2x500 mg - Ranitidin 2x150 mg

140

15/10/2013 B

Tn. R, 60 th, VL dorsum pedis sinistra

- Rawat jalan

- Wound toilet, hecting - Inj. ATS 1500 IU, im, skin test

- Amoxicillin 3x500 mg - Paracetamol 3x500 mg - Ranitidin 2x150 mg

141

15/10/2013 A

Nn. A 29 th, gastritis akut, susp ISK

- Rawat jalan

- Amoxicillin 3x500 mg - Scopamin plus 3x1 tab - Ranitidin 2x150mg - Antasida doen syr 3x2cth

142

(32)

15/10/2013 A

Ny. K, 65 th, GEADS Rawat inap

- IVFD RL loading 500 cc--

>20 tpm - Inj.Ranitidin 2x1A - Miratrim 3x1 tab - Mecodiar 3x1 tab - Omegdiar 3x1 tab -Vosea 3x1 tab

143

15/10/2013 A

Ny. A, 29 th, G2P1A0 uk 39 minggu dengan hipertensi dalam kehamilan suspek PEB. TD: 169/114 mmHg.

- Rawat inap - IVFD RL 16 tpm - Nifedipin 4x10 mg - Plan: DL, protein urin

144

17/10/2013 A

Ny. R, 39 th, G3P2A0 uk 41 minggu JTHIU preskep dengan hipertensi dalam kehamilan susp PER dd PEB. TD: 140/90 mmHg

- Rawat inap observasi kemajuan persalinan - Plan: DL, protein urin - IVFD RL 16 tpm - Nifedipin 2x10 mg - Gastrul per vag 1/8 tab tiap 6 jam

145

17/10/2013 A

An. A, 8 bln, 8 kg, GEADS, obs febris susp demam tifoid.

- Rawat inap - Plan: DL, widal

12 tpm

- Inj. Ranitidin 2x1/2 A - Inj. Ondansetron 2x1/2A - Lacto B 2x1 sach

- Zinc syr 1x1/2 cth - Paracetamol syr 3x1 cth

146

(33)

17/10/2013 B

Tn, D, 53 th, vulnus laseratum plantar pedis dextra.

Rawat jalan

- Wound toilet, hecting - Inj. ATS 1500 IU, im - Clindamycin 3x300 mg - Amoxicillin 3x500 mg

- Asam mefenamat 3x500 mg - Dexamethason 3x0,5 mg - Ranitidin 3x150 mg - Neurodex 2x1 tab

147

17/10/2013 B

Ny. I, 4 th, VE digiti I pedis dextra

Rawat jalan

- Amoxicilin 3x500 mg - Asam mefenamat 3x500 mg - Dexamethason 3x0,5 mg - Ranitidin 3x150 mg - Vitalog C 1x1 tab

148

17/10/2013 B

Tn. D, 55 th, VE reg cruris dextra

Rawat jalan

- Amoxicilin 3x500mg - Paracetamol 3x500 mg - Ranitidin 2x150 mg - Vitalong C 1x1 tab

149

18/10/2013 A

Ny. K, 60 th, hipetensi stage II, gastritis. TD: 180/100 mmHg

- Rawat inap - IVFD RL 20 tpm - Inj. Ranitidin 2x1A - Inj. Metoclopramid 2x1A - Captopril 3x25 mg - HCT 1x25 mg (1-0-0) - Curcuma 3x1 tab - Plan: DL

150

(34)

18/10/2013 A

An. K, 1,5 th, 8 kg.

Vomitus, TB paru dalam pengobatan fase intensif

- Rawat inap

- IVFD RL 30 tpm (mi) - Domperidon syr 3x1 cth - Terapi TB dilanjutkan

151

18/10/2013 A

Ny. M, 22 th, G2P1A0 uk 38 minggu JTHIU preskep puka in partu dengan hipertensi gestasional suspek PER. TD 150/90 mmHg.

Rawat inap

- IVFD RL 20 tpm - Nifedipin 3x10 mg - Plan: DL, Protein urin - Observasi kemajuan persalinan

152

18/10/2013 A

Nn. L, 22 th, GERD dd gastritis

Rawat jalan

- Ranitidin 3x150 mg - Lansoprazol 2x1 tab - Antasid 3x2 cth - Neurodex 1x1 tab

153

18/10/2013 A

An. R, 7 bln, Diare Cair Akut tanpa Dehidrasi, 8,5 kg

Rawat jalan

- L-Bio 3x1/2 sach - Zinc 1x1/2 tab

- Paracetamol drop 3x0,9 cc

154

20/10/2013 B

Tn. D, 53 th, kontrol VL plantar pedis dextra

Rawat jalan - Ganti balut

- Amoxicillin 3x500 mg - Asam mefenamat 3x500 mg - Ranitidin 3x150 mg - Vitalong C 1x1 tab

155

20/10/2013 B

Ny. K, 45 th, VE manus sinistra

Rawat jalan

- Amoxicillin 3x500 mg - Ranitidin 3x150 mg

156

(35)

- Neurodex 1x1 tab - Vitalong C1x1 tab

20/10/2013 B

Tn. R, 59 th, VE genu sinistra

Rawat jalan

- Amoxicillin 3x500 mg - Ibuprofen 2x400 mg - Ranitidin 2x150 mg - Neurodex 1x1 tab

157

20/10/2013 A

Ny. Y, 25 th, Vomitus ec susp hepatitis akut dd Cholesistitis, Thyfoid fever

Rawat jalan (menolak rawat inap)

- Ibuprofen 3x400 mg - Curcuma 3x1 tab - Metoclopramid 3x1 tab - Ranitidin 2x150mg - Livron B plex 2x1 tab

158

20/10/2013 A

An. R, perempuan, 5 bln, 5,5 kg, GEADS, febris susp Thyfoid fever

Rawat inap

- IVFD D5%-1/4NS loading 100 cc --> 22 tpm (mi) - Lacto-B 2x1/2 sach - Zinc syr 1x1/2 cth - PCT drop 3x0,6 cc - Plan: DL, Widal

159

23/10/2013 B

Tn. D, 53 th, kontrol VL plantar pedis dextra

- Ciprofloxacin 2x500 mg - Metronidazol 3x500 mg - Asam mefenamat 3x500 mg - Ranitidin 3x150 mg

160

(36)

23/10/2013 A

Ny. S, 50 th,

Laringitis+gastritis akut

Rawat jalan

- Dexamethason 3x0,5 mg - Paracetamol 3x500 mg - Ranitidin 3x1 tab - Lansoprazol 1x1 tab

161

23/10/2013 A

Ny. K, 53 th, DM tipe II.

GDS: 285 mg/dl

Rawat jalan

- Glimepirid 1x1 mg - Metformin 2x500 mg - Neurodex 2x1 tab

162

23/10/2013 A

Ny. E, 26 th, Febris susp Thyfoid fever. S:38,5⁰C

Plan: DL, Widal. Hasil:

Leukosit 6.300/mm3, Widal S.

Typhii O dan H: +1/320 -Rawat jalan

- Ciprofloxacin 2x500 mg - Paracetamol 3x500 mg - Ranitidin 3x150 mg - Neurodex 1x1 tab - Edukasi: tirah baring, diet lunak.

163

23/10/2013 A

Ny. S, 61 th, Osteoarthritis Genu sinistra

Rawat jalan

- Na diclofenac 2x25 mg - Ranitidin 2x150 mg - Livron B plex 1x1 tab -Fisioterapi

164

23/10/2013 A

Nn. F, 18 th, BPPV Rawat jalan

- Betahistin mesylate 2x1 tab - Ranitidin 2x1 tab

- Neurodex 1x1 tab

165

(37)

- Saran konsultasi dr. Sp.S

23/10/2013 A

Tn. T, 43 th, Gasritis, kontrol post GEADS

Rawat jalan

- Ranitidin 2x1 tab

- Antasida doen syr 3x2 cth - Neurodex 1x1 tab

166

23/10/2013 B

Tn. N, kontrol post op Tumor supraorbita dextra

Rawat jalan - Aff hecting 2 - Neurodex 1x1 tab - Vitalong C 1x1 tab

167

23/10/2013 A

Ny. D, 60 th, DM tipe II, dispepsia. GDS: ##high.

TD: 130/90 mmHg

rawat jalan (menolak rawat inap)

- Glibenclamid 2x5 mg - Metformin 3x500 mg - Lansoprazol 1x30 mg - Neurodex 1x1 tab

168

23/10/2013 A

An. B, 5 th, Febris suspek thyfoid fever. S:39C, BB 20 kg.

rawat jalan

- Amoxicillin syr 3x1 cth - PCT syr 3x1 1/2 cth - Curcuma 3x1 cth - Plan: DL, widal

169

24/10/2013 A

Ny. S, 44 th, ODS Konjungtivitis kronik

Rawat jalan

- Gentamisin tetes mata 3x3 tetes ODS

170

24/10/2013 A

An. D, perempuan, 5 th, 15 kg, Observasi febris hari ke- 4 susp Thyfoid fever dd DHF

Plan: DL (Trombosit 178.00.mm3, leukosit

4300/mm3), Widal S. Thyphii O dan H: +1/320 - Rawat inap

171

(38)

15 tpm (ma)

- Inj. Ranitidin 2x1/2A - Thiamphenicol syr 3x1 cth - PCT syr 3x1 1/2 cth - Curcuma syr 3x1 cth

24/10/2013 A

Ny. C, 30 th, G3P2A0 uk 39+6 minggu JTHIU preskep puka dengan hipertensi gestasional susp PEB. TD: 160/100 mmHg

Plan: DL, protein urin - Rawat inap

- IVFD RL 16 tpm - Nifedipin 4x10 mg - Observasi kemajuan persalinan

172

24/10/2013 A

Tn. S, 25 th, Observasi febris suspek malaria dd thyfoid fever. S:39C

Plan: DL, Widal, Apusan darah tepi Plasmodium

- Rawat inap - IVFD RL 20 tpm - Inj. Ranitidin 2x1A - Pct 3x500 mg - Neurodex 2x1 tab

173

24/10/2013 A

Tn. H, 72 tahun, hipertensi stage II, Diare akut tanpa dehidrasi. TD: 165/100 mmHg.

Rawat jalan

- Captopril 3x25 mg - HCT 1x5 mg (1-0-0) - Ranitidin 2x150 mg - Antasida 3x2cth - Lacto-B 3x2 sach

174

25/10/2013 B

Tn. T, 37 th, Multple VE Rawat jalan - Wound toilet

- Amoxicillin 3x500 mg

175

(39)

- Ranitidin 2x150 mg - Vit. C 1x1 tab

25/10/2013 B

Ny. K, 36 th, VL dorsum pedis dextra, VE pedis sinistra

Rawat jalan

- Wound toilet, hecting luar 2 - Amoxicillin 3x500 mg - Paracetamol 3x500 mg - Ranitidin 2x150 mg - Vit. C 1x1 tab

176

25/10/2013 A

Tn. A, 27 th, myalgia post trauma

Rawat jalan - Neurodex 2x1 tab - Vitalong C 1x1 tab

177

25/10/2013 A

Ny. T, 50 th, Observasi febris susp Thyfoid fever dd DHF. S: 39⁰C

Plan: DL (Leukosit 14.000/mm3, trombosit 258.000/mm3), Widal - (S.typhii O dan H: +1/160), GDS: 97mg/dl. EKG: sinus takikardi

- Rawat inap

30 tpm --> RL:D5% 1:1 30 tpm

- Inj. Ranitidin 2x1A - Ciprofloxacin 2x500 mg - Paracetamol 4x500 mg

178

25/10/2013 A

An. J, 5 th, 15 kg, GEADS Rawat inap

- IVFD RL loading 150 cc --

>12 tpm

- Inj. Ranitidin 2x1/2A

179

(40)

- Amoxicillin syr 3x1 cth - L.Bio 2x1 sach

- Zinc syr 1x1 cth - Plan: DL

25/10/2013 A, B

Tn. M, 45 th, Hernia scrotalis dextra+dispepsia

Rawat jalan (pro konsultasi Sp.B, menolak)

- Scopma plus 3x1 tab - Paracetamol 2x500 mg - Ranitidin 2x150 mg - Antasida doen 3x2cth - Curcuma 3x1 cth

180

26/10/2013 A

Tn.S, 80 th, Bronkhitis akut, hipertensi terkontrol. TD:

130/90 mmHg

Rawat jalan

- Ambroxol 3x30 mg - Erlamol 3x1 cth - Bufantasid 3x1 tab - Neurodex 1x1 tab

181

26/10/2013 B

Tn.D, 53 th, kontrol VL plantar pedis dextra

Rawat jalan - Aff hecting 3

- po. Metronidazol 3x500 mg - Ciprofloxacin 2x500 g

- Dexamethason 3x0,5 mg - Ranitidin 3x150 mg - Vitalong C 1x1 tab

182

26/10/2013 A

An. R, 12 th, 23 kg, Obs.

Febris susp thyfoid fever dd DHF

Rawat inap

- IVFD D5%-1/4NS loading 200 cc--> 16 tpm

- Inj. Ranitidin 2x1/2A - Paracetamol 3x1/2tab

183

(41)

- L-Bio 2x1 sach - Curcuma 3x1 cth - Plan: DL, Widal

26/10/2013 A

Tn. M, 40 th, LBP Rawat jalan

- Na diclofenac 2x25 mg - Ranitidin 2x150 mg - Neurodex 2x1 tab

184

26/10/2013 A

Ny. P, 45 th, Gastritis akut Rawat inap

- IVFD RL 20 tpm - Inj. Ranitidin 2x1A - Bufantasid tab 2x1 - Curvit 3x1 tab

185

26/10/2013 B

Tn. K, 50 th, susp ureterolithiasis sinistra

Rawat jalan - Nefrolit 3x1 tab - Spasminal 3x1 tab - Analtram 3x1 tab

186

02/11/2013 A

Ny. D, 60 th, Gastritis, susp ISK

Rawat inap

- IVFD RL 20 tpm

- Inj. Metoclopramid 3x1 A - Inj. Ranitidin 3x1A - Omeprazol tab 1x1 - Curvit 3x1 tab - Paracetamol 3x500 mg - Plan: DL, UL

187

02/11/2013 A

An. A, 10 th, 20 kg, Obs.

Febris 4 hari susp DHF dd Thyfoid fever

Rawat inap

15 tpm

- Inj. Metoclopramid 2x1/2 A

188

(42)

- Inj. Ranitidin 2x1/2 A - Paracetamol syr 3x2 cth - Curvit 3x1 tab

- DEHAF 2x1 sch

02/11/2013 A

Ny. M, 33 th, P2A1 susp abortus komplet dd abortus inkomplet

Rawat jalan (APS)

- Clindamycin 3x300 mg - Asam mefenamat 3x500 mg - Livron B plex 1x1 tab

189

02/11/2013 A

Ny. R, 29 th, G4P1A2 uk 39 minggu presbo puka in partu kala I fase aktif dengan KPD

Rawat inap

- IVFD RL 16 tpm - Inj. Amoxicillin 3x1 gr (iv) Observasi kemajuan persalinan

190

02/11/2013 A

Ny. T, 23 th, G1P0A0 uk 40 mgg presbo puka in partu kala I fase aktif

Rawat inap

- IVFD RL 20 tpm - Observasi kemajuan persalinan

191

02/11/2013 C

Ny. S, 60 th, Obs dyspnea susp BrPn dd CHF, TB paru

Rawat inap

- O2 2-3 l/m, nasal canul - IVFD RL 20 tpm

- Inj. Cefotaxim 2x1 gr (iv, skin test)

- Inj. Furosemid 1A (extra) - Inj. Ranitidin 2x1A - Ambroxol 3x30 mg Plan: DL, Ur, Cr, Ro thorax PA

192

06/11/2013 A An. Z, 3 th, 16 kg, GEADR Rawat jalan - Zinc 1x1 tab

dr. Layali

Musafiroh 193

(43)

- L-Bio 3x1 sach - Norvom syr 3x1/2 cth

06/11/2013 A

Tn. K, 31 th, DADR, hipertensi stage II. TD:

170/110 mmHg

Rawat jalan

- Captopril 3x12,5 mg - Mecodiar 3x1 tab - Dimenhidrinat 3x1 tab

194

06/11/2013 A

An. A, 2 th, 10 kg, DADRS Rawat inap

10 tpm

- Inj. Ondansetron 2x1/4A - Kaotin syr 3x1 cth - L-Bio 3x1 sach - Zinc 2x1/2 tab - Plan: DR, widal

195

06/11/2013 A

Ny. R, obs febris, post partum 2 minggu

Rawat inap - IVFD RL 20 tpm - Inj. Scopamin 2x1A - Erlamol 3x1 tab

- Plan: DR, Urin rutin, widal

196

06/11/2013 A

Tn. W, 60 th, GEADS Rawat inap - IVFD RL 30 tpm - Inj. Ranitidin 3x1A - Inj. Ondansetron 3x1A - Diastop 3x1 tab

- L-Bio 3x1 sach - Plan: DL

197

06/11/2013 A Ny. T, 27 th, G2P1A0 uk 39+5 minggu JTHIU

Rawat inap

- IVFD RL 16 tpm

dr. Layali

Musafiroh 198

(44)

presentasi kaki, puki, in partu kala I fase aktif

- Observasi kemajuan persalinan

06/11/2013 A

An. Q, 9 bln, 6,5 kg, GEADS, obs febris susp Thyfoid fever

Rawat inap

28 tpm (mi) --> RL:D5-1/4NS 1:1 28 tpm (mi) - Paracetamol drops 4x0,7 cc - Zinc 1x1/2 tab

- L-Bio 2x1/2 sach

199

06/11/2013 B

Ny. N, 24 th, susp tumor mammae dextra

Rawat jalan

- Amoxiciin 3x500 mg - Asam mefenamat 3x500 mg - Dexamethason 3x0,5 mg - Ranitidin 3x150 mg - Kontrol ke poli bedah

200

07/11/2013 B

Ny. S, 39 th, kontrol VL capitis+supraorbita sinistra

- Ciprofloxacin 2x500 mg - Asam mefenamat 3x500 mg - Neurodex 1x1 tab

201

07/11/2013 A

Tn. A, 17 th, Bronkhitis kronis

Rawat jalan

- Cefadroxil 2x500 mg - Fludane plus 3x1 tab - Ranitidin 2x1 tab - Vitalong C 1x1 tab

202

07/11/2013 B An. M, 4 th, 15 kg, kontrol vulnus amputatum digiti V

Rawat jalan - Aff hecting

dr. Layali

Musafiroh 203

(45)

pedis sinistra - Paracetamol syr 3x1 cth

07/11/2013 B

An. A, 13 th, 31 kg, kontrol VE plantar pedis dextra

Rawat jalan

- Wound toilet, ganti balut - Ciprofloxacin 2x250 mg - Paracetamol 3x250 mg - Gentamisin salep 1xoles - Bioplasenton salep 1xoles

204

07/11/2013 A

Ny. S, 59 th, Dispepsia, PV Rawat jalan - Ranitidin 3x1 tab - Omeprazol 1x1 tab - Neurodex 1x1 tab - Ketokonazol salep 2xoles

205

07/11/2013 A

Ny. R, 44 th, Dispepsia, susp anemia

Rawat jalan

- DL: pasien menolak - Ranitidin 3x150 mg - SF 2x1 tab

- Curvit 3x1 tab - Neurodex 1x1 tab

206

07/11/2013 A

Ny. I, 45 th, konrol post thyfoid fever

Rawat jalan

- Chloramphenicol 4x500 mg - Curvit 3x1 tab

- Ranitidin 3x150 mg

207

07/11/2013 A

Ny. R, 60 th, Fatigue, hipertensi terkontrol. TD:

110/90 mmHg

Rawat jalan

- Captopril 1x12,5 mg - Neurodex 2x1 tab - Curvit 3x1 tab - Paracetamol 3x500 mg

208

07/11/2013 A Ny. J, 70 th, DADRS, Rawat jalan dr. Layali 209

(46)

hipertensi stage II. TD:

161/95 mmHg

- Captopril 3x25 mg - New diatab 3x1 tab - Scopamin plus 3x1 tab - L-Bio 3x2 sach

- Ranitidin 2x1 tab

Musafiroh

08/11/2013 A

Tn.S, 53 th, hipertensi stage I, gastritis. TD: 147/80 mmHG

Rawat jalan

- Captopril 3x12,5 mg - Ranitidin 3150 mg - Neurodex 2x1 tab

210

08/11/2013 A

Ny R, 38 th, myalgia Rawat jalan

- Na diclofenac 2x25 mg - Ranitidin 2x150 mg - Neurodex 1x1 tab

211

08/11/2013 A

Ny. N, 31 th, obs dyspnea ec alergi makanan

Rawat inap - O2 2-3 l/m

- IVFD D5% 20 tpm - Inj. Dexamethason 3x1A - Loratadin 1x1 tab

212

09/11/2013 B

An. Z, 13 th, 50 kg, CKR, hematom reg. Capitis, VE reg cruris sinistra

Rawat jalan

- Amoxicillin 3x500 mg - Piracetam 3x400 mg - Ranitidin 3x150 mg - Neurodex 2x1 tab - Paracetamol 3x500 mg

213

09/11/2013 A

Tn. H, 52 th, GEADS Rawat inap

30tpm

214

(47)

- Inj. Ondansetron 3x1A - New diatabs 3x1 tab - Scopma 3x1 tab Plan: DL

09/11/2013 A

Tn. K, 41 th, GEADS Rawat inap

30 tpm

- Inj. Ranitidin 3x1A - Inj. Ondansetron 3x1A - Loperamid 2-1-1 tab - Kaotin 3x1

- Scopma 3x1 tab

215

09/11/2013 B

An. M, 4 1/2 th, 13 kg, Multipel VE

Rawat jalan - Wound toilet

- Amoxicillin syr 3x1 cth - Paracetamol syrup 3x1 cth - Bioplasenton gel 2xoles

216

09/11/2013 B

Ny. S, 45 th, Dislokasi anterior articulatio glenohumerale dextra+

fraktur caput humeri dextra

Rawat jalan (menolak konsul Sp.OT)

- Tramadol 2x50 mg - Ranitidin 2x150 mg - Neurodex 2x1 tab

- Plan: Ro shoulder joint dextra

217

09/11/2013 A

An. M, 2 th, 14 kg, GEADS Rawat inap

15 tpm

- Inj. Ondansetron 3x1/3A - L-Bio 2x1 sach

218

(48)

- Zinc 1x1 tab - Plan: DL

09/11/2013 A

Tn. W, 30 th, Obs febris, konstipasi, candidiasis oral, susp HIV/AIDS

Rawat jalan (menolak rawat inap)

- Bisacodyl 2x1 tab - Paracetamol 4x500 mg - DMP 3x1 tab

- Curvit 3x1 tab

- Candistatin drops 4x100.000 IU

219

13/11/2013 A

Tn. S, 70 th, GERD Rawat inap

- IVFD RL 20 tpm - Inj. Ranitidin 3x1A - Inj. Ondansetron 3x1A - Lansoprazol tab 2x1 - Antasida doen syr 3x2 cth

220

13/11/2013 A

Ny. E, 41 th, serangan asma ringan pada asma intermitten

Rawat jalan

- Nebulisasi Ventolin 1amp - Ambroxol 3x30 mg

221

14/11/2013 A

Tn. S, 72 th, hipertensi stage II, obs vomitus. TD: 177/89 mmHg. GDS: 101 mg/dl

Rawat inap

- IVFD D5% 20 tpm -->

D5%:RL 1:1 20 tpm - Inj. Ranitidin 3x1A - Inj Ondansetron 3x1A - Inj. Spashi 1A

- Captopril 3x25 mg - HCT 1x25 mg (1-0-0)

222

14/11/2013 B Tn. S, 57 th, kontrol Vulnus Rawat jalan dr. Layali 223

(49)

Punctum digiti IV manus dextra

- Aff hecting 1

- Amoxicillin 3x500 mg - Ranitidin 3x150 mg - Neurodex 2x1 tab

Musafiroh

14/11/2013 C

Nn. L, 21 th, Multipel VE Rawat jalan

- Amoxicillin 3x500 mg - Ranitidin 3x150 mg - Neurodex 2x1 tab

224

14/11/2013 D

Nn. R, 17 th, anxietas Rawat jalan

- Alprazolam 1x0,25 mg - Neurobion 1x1 tab

225

14/11/2013 B

An. A, 10 th, 29 kg, VL labium superior sinistra

Rawat jalan

- Wound toilet, hecting luar 1 - Amoxicillin syr 3x1 cth - Paracetamol 3x2 cth

226

15/11/2013 A

Ny. N, 20 th, G1P0A0 uk 40 minggu JTHIU preskep in partu kala I Iama

Rawat inap - IVFD RL 16 tpm

- Konsultasi dr. Arif, Sp.OG : induksi persalinan dengan Misoprostol 1/8 tab fp tiap 8 jam.

227

15/11/2013 A

Tn. N, 48 th, DADS, hipertensi stage I. TD:

140/90 mmHg

Rawat inap

30 tpm

- Inj. Ranitidin 2x1A - Inj. Ondansetron 2x1A - Loperamid tab 2-1-1 - Scopma 3x1 tab

228

(50)

- L-Bio 3x2 sachet - Captopril 3x12,5 mg - Plan: DL

15/11/2013 A

Ny. S, 27 th, G4P2A1 uk 40 minggu JTHIU preskep in partu kala II, dengan riwayat TB

Rawat inap - Pimpin persalinan

229

15/11/2013 A

Ny. L, 40 th, Gastritis akut Rawat inap (APS) - IVFD RL 20 tpm - Inj. Ranitidin 3x1A - Bufantasid syr x2 cth - Omeprazol 2x1 tab - Curvit 3x1 tab

230

18/11/2013 B

Sdr. S, 16 th, VL dan dislokasi digiti V pedis dextra, Multiple VE

Rawat inap

- Konsultasi dr. Yuli, Sp.OT : motivasi operasi

reposisi+pasang wire - IVFD RL 16 tpm - Inj. Ranitidin 2x1A - Amoxicillin 3x500 mg - Asam mefenamat 3x500 mg - Plan : Ro pedis dextra, DL

231

18/11/2013 A

Ny. S, 72 th, suspek hepatitis akut, aritmia. EKG:

Ventricular couplet

Rawat inap

- Plan: DL. HBsAg, bilirubin total, bilirubin direk

D5% 24 tpm

232

(51)

- Curvit 3x1 tab

- Paracetamol 3x1 tab - Konsultasi dr. Luqman, Sp.PD: Dx susp

Cholangiocarcinoma, VES.

Terapi: bisoprolol 1x2,5 mg.

Cek laborat SGOT dan SGPT, pro USG abdomen di

dr.Alip,Sp.Rad.

20/11/2013 A

Ny. R, 19 th, G2P0A1 uk 42+2 minggu JTHIU preskep in partu kala I fase laten

Rawat inap

- IVFD RL 16 tpm - Observasi kemajuan persalinan

233

20/11/2013 B

Tn. R, 27 th,VL reg labium superior, VE genu dextra et sinistra

Rawat jalan

- Ciprofloxacin 2x500 mg - Asam mefenamat 3x500 mg - Vitalong C 1x1 tab

- Neurodex 1x1 tab

234

21/11/2013 C

An. N, 2,5 th, 10,5 kg, KDS.

S:38C.

Rawat inap

- O2 2l/m, nasal canul - IVFD D5%1/4 NS loading 100 cc --> 12 tpm (ma) - Stesolid supp 1 (extra) - Cefadroxil syr 2x1 cth - PCT syr 4x1 cth

- Diazepam 2mg VI, mfla pulv dtd X, 3x1

235

21/11/2013 A Tn. M, 52 th, hipertensi Rawat jalan dr. Layali 236

(52)

stage I, ISPA. TD: 140/90 mmHg

- Ciprofloxacin 2x500 mg - Captopril 3x12,5 mg - Ambroxol 3x30 mg - Neurodex 1x1 tab

Musafiroh

24/11/2013 B

An. D, laki-laki, 12 th, multiple VE.

Rawat jalan

- Amoxicillin syr 3x1 cth - PCT syr 3x1 cth - Curcuma syr 3x1 cth

237

24/11/2013 B

Nn. L, 21 th, VL capitis Rawat jalan

- Wound toilet, hecting luar 2 - Ciprofloxacin 2x500 mg - Asam mefenamat 3x500 mg - Neurodex 1x1 tab

238

24/11/2013 A

An. M, 8 bln, 4,6 kg.

GEADS, obs febris susp thyfoid fever

Rawat inap

- IVFD D5% 1/4 NS loading 100 cc --> 24 tpm (mi) - PCT drops 4x0.6 cc - L-Bio 2x1/2 sach - Zinc 1x10 mg - Plan: DL, Widal

239

24/11/2013 A

An. N, 5,5 th, 16 kg, KDS Rawat jalan (menolak rawat inap)

- Amoxicillin 3x1 cth - PCT 3x 1 1/2 cth

- Diazepam 2mg VIII, Vit C IV, sacharin ad lib mfla pulv X, 3x1

240

(53)

24/11/2013 A

Ny. K, 38 th, G5P2A2 uk 41+2 minggu JTHIU preskep belum in partu dengan hipertensi dalam kehamilan susp PER dd PEB. TD: 151/72 mmHg

Rawat inap - IVFD RL 16 tpm

- Konsultasi dr. Arif, Sp.OG:

induksi Misoprostol 1/8 tab fp tiap 8 jam

- Plan: DL, protein urin

241

24/11/2013 C

Tn. T, 70 th, Observasi dyspnea susp PPOK dd TB paru

Rawat inap

- Plan: GDS (104 mg/dl), EKG (sinus takikardi, P pulmonal pada lead II, III, aVF), DL, Ur, Cr, Ro thorax PA.

- O2 3 l/m, nasal canul - IVFD D5%+Aminofilin 1A 20 tpm

- Inj. Ranitidin 2x1A - Inj. Ondansetron 2x1A - Ambroxol 3x30 mg - PCT 3x500 mg - Curvit 3x1 tab

242

24/11/2013 B

Tn. A, 41 th, chest pain post trauma 2 hari SMRS, VE manus dextra.

Rawat jalan

- Amoxicillin 3x500 mg - Asam mefenamat 3x500 mg - Neurodex 1x1 tab

243

25/11/2013 B

Tn I, 26 th, tumor perianal Rawat jalan - pro konsul Sp.B

- Ciprofloxacin 2x500 mg - Dexamethason 3x0,5 mg

244