I.

Patient Database
Tanggal Review : 30 Januari 2012 Pukul : 10.00
Nama Pasien : Tn. AD
No. Registrasi : 6678910
No. Bed : -
MRS : 24 Januari 2012 Pukul : 11.13
Alamat : -
Usia : 59 tahun
Jenis Kelamin : Laki – laki
Tinggi Badan : N/A
Berat badan : N/A

Past Medical History : DM, PJK (stabil)

Family History : N/A

Social History : N/A

Allergic History : -

Medication History : Glibenclamide 1x1

II. SOAP Notes

Subjective
Bila berbaring dada terasa penuh, sulit tidur, bila duduk sesak nafas.
Objective
- Physical examination
Exam Unit 24/1 25/1 26/1 27/1 28/1 29/1 30/1
BP mmHg 130/80 120/90 120/70 130/80 130/80 110/70 110/70
HR /min 90 88 80 80 100 96 92
o
Temp C 36,2 36,8 36,6 36,5 36,6 36,1 36,7
RR /min 20 22
Foto Thorax : Kardiomegali dan kongestif paru, efusi pleura bilateral.

- Laboratory and Diagnostic Test Result

Exam Nilai normal Hasil Laboratorium
HDL ≥ 40 mg/dL2 31,4
LDL < 70 mg/dL2 87,1
Gula Puasa < 130 mg/dL2 141 mg/dL
2 jam PP < 180 mg/dL2 25/1  182 mg/dL
27/1  200 mg/dL
HbA1C < 7 %2 9,2 %

Further Information Required

Assessment

1. Problem Medis :
Terapi :
Target :
DRP :
Rekomendasi :
Monitoring :
 2. Problem Medis :
Terapi :
Target :
2. Problem Medis :
DRP :
Terapi :
Rekomendasi :
Target :
Monitoring :
DRP :
Rekomendasi :
Monitoring :
3. Problem Medis :
Terapi :
Target :
DRP :
Rekomendasi :
Monitoring :
4. Problem Medis :
Terapi :
Target :
DRP :
Rekomendasi :
Monitoring :
5. Problem Medis :
Terapi :
Target :
DRP :
Rekomendasi :

Monitoring :

Rekomendasi obat yang dibawa pulang :

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