Selamat Pagi Bu Salmeha

Berikut Report pasien CPI di RS Awal Bros hari ini (30/9)

Jumlah pasien : 2 orang
1.An. Ragil, 14th,330865,ICU--> Orchid
Dokter: Kuswan,Ferdinand,Rahmat co: Ilham
S: keluhan O: KU Sedang CM N 100 R 24 S 36,2
Lab 18/7 (RS Chevron) : Hb 12,7 Leu 4700 Ht 35,4 Tro 65300 Ur/Cr 12,8/0,39 Ot/Pt 44/23 Alb
2,14 Glo 1,7 Total protein 3,8 ALP 85
Na/K/Cl139,7/3,97/104,8 Ca 1,93 GDP 126
Lab 23/7 : Alb 2,7
Lab 26/7 : Alb 4,0 Hb 9,6 Leu 8550 Tc 329000
Lab 5/8 : Hb 7,9 Leu 8560 Ht 23.3 Tc 585000
Lab 7/8 : Hb 10,3 Leu 7160 Ht 29.6 Tc: 538000
Lab 9/8: Hb 10 Leu 9730 Ht 29.4 Tc 549000 Aln 3.5
Lab 16/8 : Hb 7,6 Leu 6860 Ht 23.3 Tc 492000 Alb 2.9
Lab 1/9: Hb 11.4 Leu 9060 Ht 32.5% Tc 457000 Alb 4.1
kultur pus 16/8: selected organism:Acinetobacter baumanii; Ampicillin (R),
Ampicillin/sulbactam(R), Piperacillin/Tazobactam (R), Cefazolin (R), Cefmetazole (R),
Ceftazidime (R), Ceftriaxone(R), Cefepime(R),
Aztreonam(R), Meropenem(R), Amikacin (S), Gentamicin (R), Ciprofloxacin (R), Levofloxacin
(R), Tigecycline(S), Trimethoprim/Sulfamethoxazole(R) Lab 18/8: Hb 13.9 Leu 9770 Ht 41.4 Tc
518000 Alb 3.9 SGOT/SGPT 29/14 Ureum/kreatinin 10/0.3 Na/K/Kl 147/ 3.3/106
Lab 20/8: Hb 11.7 Leu 9190 Ht 34.1 Tc 435000
Lab 23/8: Urinalisis,Makroskopis; Warna: Merah, Kejernihan: Agak keruh, Leukosit esterase:
75/uL, Darah: 300/uL. Mikroskopis;eritrosit: 235/lpb, Leu:27,2/lpb, Bakteri: 29.57/lpb
USG 24/8: Hidronefrosis sedang,dengan dilatasi ureter proksimal dextra. Pelviectasis ren sinistra
Lab 26/7: Hb 9.6, Leu 8550 Ht 27.5 Tc 329000 Alb 4.0
A: Post Debridement+ Skin Graft ec Combustio gr II-III 30%, Hidronefrosis Dextra, ISK
P: IVFD RL/ 8jam, Tygecil 2x50mg, Mikasin 3x200mg, Mefinal 3x500mg Post Tranfusi
Plasbumin20% 100ml/3hari (19/7, 20/7) 21/7)Post Debridement dan rawat skin graft(20/7,
22/7,24/7, 29/7, 1/8, 8/8, 12/8, 15/8, 19/8,24/8, 29/8, 7/9, 11/9, 16/9, 21/9, 25/9) Post Skin graft
(3/9), Post pasang CVP (20/7), post plasmanat 5% (23/7, 20/8),Post transfusi plasbumin 20%
100cc (22-24/7), Post Transfusi PRC (6/8, 17/8), Post debridement dan rawat skin graft (29/9)
2.Tn.Hasrul bin Bahtar, 51th, 337288, Rose
Dokter: Iqbal,Nurul, Kobal, Grace, Agung
S: keluhan lemah badan sudah berkurang
O: KU sedang CM TD 134/83 N 85 R 20 S 36,2
Lab 23/9: Hb 15,6 Leu 9410 Ht 45,0 Tr 260000 GDS 132 OT/PT 13/17 Ur/Kr 20/0,7 Na/K/Cl
145/4,1/107
Ro-thoraks 23/9: normal
Lab 27/9: Kolesterol total 246, LDL 166, HDL 49, Trigliserid 185, HbA1c 7.4 CT-scan 24 sept:
Infark lakunar kecil periventricular kiri. Sinusitis maksillaris kanan berat.
Ro.Panoramik 28/9: Tampak sisa radix M2 kanan dan kiri atas
A:Hipertensi, parese n.VII, CVD iskemik DD/ Bells palsy, sisa radix M2 kanan dan kiri atas
P: IVFD NS 0,9%/8jam, Captopril 3x12,5mg, Acyclovir 5x800mg,Medixon 3x1, Methylcobal
2x500mg,Canderin 1x8mg, Crestor 1x20mg POstkonsul dokter bedah mulut, R/Pulang dengan
obat (Levemir 1x10IU malam, Amlodipin 1x10mg, Canderin 1x8mg, Captopril 3x12,5mg,

Crestor 1x20mg, Metformin 2x500mg,Mrthycobal 2x500mg, Acyclovir 5x800mg), R/Tindakan

di bidang bedah mulut (tunggu perbaikan KU, saat rawat jalan)

Regards,
dr. Puti Syania (082126010295)
Case Coordinator
RS Awal Bros Pekanbaru