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    Ny. Rumiati

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    gita
    This medical report summarizes the care of a 63-year-old female patient being treated for several conditions including dyspnea, hypertension, electrolyte imbalance, and kidney cysts. The patient was lethargic and short of breath. Vital signs and physical exam are documented. Intravenous treatments including antibiotics and diuretics are noted. Monitoring and follow up tests are planned.

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    Ny. Rumiati

    Uploaded by

    gita
    15 views4 pages
    This medical report summarizes the care of a 63-year-old female patient being treated for several conditions including dyspnea, hypertension, electrolyte imbalance, and kidney cysts. The patient was lethargic and short of breath. Vital signs and physical exam are documented. Intravenous treatments including antibiotics and diuretics are noted. Monitoring and follow up tests are planned.

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    This medical report summarizes the care of a 63-year-old female patient being treated for several conditions including dyspnea, hypertension, electrolyte imbalance, and kidney cysts. The patient was lethargic and short of breath. Vital signs and physical exam are documented. Intravenous treatments including antibiotics and diuretics are noted. Monitoring and follow up tests are planned.

    Copyright:

    © All Rights Reserved
    Download as RTF, PDF, TXT or read online from Scribd
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    15 views4 pages

    Ny. Rumiati

    Uploaded by

    gita
    This medical report summarizes the care of a 63-year-old female patient being treated for several conditions including dyspnea, hypertension, electrolyte imbalance, and kidney cysts. The patient was lethargic and short of breath. Vital signs and physical exam are documented. Intravenous treatments including antibiotics and diuretics are noted. Monitoring and follow up tests are planned.

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    of 4

    Selamat pagi

    Laporan dinas siang

    Perawatan H2

    Tgl 6/7/23

    Ny, RUMIATI/ 63thn/ 80kg/ 061141

    DX: Dyspneu Obs. Penkes ec susp. vaskular Kolesistitis Policystic kidney disease Kista hepar Spondilosis
    lumbalis HT terkontrol BP

    Elektolit imbalans

    Dpjp dr. laily spPD

    co/ dr asy spP

    co/ dr martua spJp

    co/ dr roy sp an (team)

    S/ kontak (+)

    RPD :-

    RPO :-

    O/

    Ku tsb, kes somnolen GCS E2M4V2, os tampak sesak nafas

    Td : 90/60(67)mmhg

    hr : 137x/mnt
    S : 38c

    Rr : 26x/mnt

    SpO2: 100 % hfnc

    Kepala: normocephal, KA -/-, SI -/-, RCL +/+, pupil isokor +/+

    Leher : KGB tak teraba

    Thorax: bentuk dan gerak simetris

    Pulmo : snv +/+, rh +/- halus, wh -/-

    Cor : BJ I-II reg, murmur (-), gallop (-)

    Abd : supel, datar, BU (+) N, NTE (-)

    Ekst : akral hangat +/+, CRT <2", edem pitting pedis +/-

    Motorik (penilaian secara pasif):

    1111|1111

    1111|1111

    kesan lateralisasi: tidak ada

    Refleks fisiologis: (+)

    Refleks patologis: (-)

    P/

    os terpasang hfnc flow 50 fraksi 70 ivfd no 20 taka ne 0,3mcg/kgbb/mt (4amp), taki no 22 asering
    500cc/8jam ngt (+) residu (-) dcath prod (+), heparin 10rb/24jam

    gds :

    jam 06 : 184 mg/dl


    jam 12 : 162 Mg/ dl

    jam 18 : 183mg/dl

    Th/ injeksi

    nac 1x8cc (h2)

    dexa 2x5mg (h1)

    omz 2x40mg

    furosemid 2x1amp

    odr 3x8mg

    pct 3x1gr iv

    meropenem 3x 1g (h2)

    Moxifloxacin 1x400mg

    Th/ oral

    nystatin drop 4x1

    sucralfat 3x1cth

    curcuma 3x1

    isdn 3x5mg

    vip albumin 3x2caps

    rebamipid 3x1tab

    ksr 3x1200mg STOP

    codein 2x10mg

    hp pro 2x1 caps

    meptin 2x1
    simvastatin 1x20mg(m)

    cpg 1x75mg

    digoxin 1x1tab

    kendaron 3x200 mg

    Bicnat 3x500mg

    CaCO3 3x1

    Asam folat 2x1

    intake :

    output :

    bc/ 15jam :

    Program

    - obs hemodinamik, bc, pola nafas, tingkat kesadaran, skala nyeri, perdarahan, tanda tanda peningkatan
    tik

    - berikan posisi nyaman

    - fu ro thorax tgl 5/7/23

    - r/ctcsan kepala nk jika transortable

    - r/ Cek ur cr per 3 hari tgl 09/07/23

    - kgdh

    terima kasih
    gita, rahma susi

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