MORNING REPORT

5/8/2019 14.00 – 6/8/2019 08.00 WIT

dr. Jofetrlin Lewerissa

1) Tn. Haji Umar Tuni (60 thn;Liang;BPJS)

 Rawat : R. Jantung
 DPJP : dr. Iman Sp.JP

A : Unstable angina pectoris + Hipertensi stage 2

P:
infus Nacl 0.9% 16 tpm
Inj Ranitidin 1 amp/12 jam/iv
ISDN 5 mg (sl) kemudian lanjut 3x5 mg/po
Amlodipin 1x10 mg/po
Micardis 1x160 mg/po
Aspilet 1x 160 mg/po besok lanjut 1x80 mg/po
CPG 1x75 mg/po
Simvastatin 1x 20 mg
Observasi TD sistol per 6 jam
2) By Raffa Zaini Voth
(4 bln; 7kg; Tulehu; Umum)
 Rawat : R. Anak O2 2 lpm
 DPJP : dr. Dwi Murti, Sp.A Observasi tiap 2 jam
 A : Pneumonia + Susp PJB BC tiap 4 jam
Sianotik Foto thorax AP/Lat
 P: Rencana Echo dengan dr.Iman Sp.JP
Inf RL 8 tpm besok
Inj Cefotaxime 250 mg/8jam/iv
Inj Gentamicin 35 mg/24jam/iv
Inj Dexamethasone 1mg/8jam/iv
Inj Recodril 0.7 cc/ extra di IGD
Paracetamol 7cc/6jam/po
3) Nn. Rosiawati L Lestaluhu
(23thn;Tulehu;BPJS)
 Rawat : R. Bedah
 DPJP : dr. Mo Tualeka Sp.B

 A : Susp Tumor intraabdomen + post laparatomi

2 minggu
 P :

Infus RL 20 tpm
Inj Ketorolac 1 amp/8jam/iv
Inj Ranitidin 1 amp/12jam/iv
Paracetamol 3x500mg/po