Hari perawatan bangsal 4 Tanggal 23 September 2018 S Lemas batuk O TD 12050

Hari perawatan bangsal 4 tanggal 23 september 2018 s

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Hari perawatan bangsal 4 (Tanggal 23 September 2018) S : Lemas, batuk (+) O : TD: 120/50 mmHg N: 88x/m RR: 16x/m S: 36,1 Kepala, mata, telinga, hidung, mulut : dbn Pulmo : SD ves +/+ RBH +/+ RBK +/+ Wh -/- Cor : dbn Abd : dbn Eks : dbn Rontgen Thorax: Cor tak membesar Bronkopneumonia (22 Februari 2016 pukul 10.30) GDP : 485, GD2PP: 490 A : DM, Hipertensi, Bronkopneumonia P : IVFD RL:NaCl 0.9% 20 tpm Diet DM 1500 kkal Inj Novorapid 10-10-10 Inj Lantus 0-0-20 U PO Ambroxol 3x1cth Inj Ranitidin 1 Amp/12 jam PO Amlodipin 1x10 mg PO PCT 3x1 Besok BLPL PROGNOSIS Ad vitam : dubia ad bonam Ad fungsionam : dubia ad malam Ad sanationam : dubia ad malam
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PORTOFOLIO INTERNSIP DM dengan Hiperglikemia Suspek KAD, Hipertensi Grade II Pendamping: dr. Nur Cahyono Anggorojati Disusun oleh: dr. Fikrianisa Safrina PROGRAM INTERNSIP DOKTER INDONESIA RUMAH SAKIT UMUM DAERAH MAJENANG KABUPATEN CILACAP 2017-2018
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