Anda di halaman 1dari 9

PATIENT DATABASE

Demographic and Administration Information


Name
Age
Height
Admission date
Discharge

:
:
:
:
:
:

Tn. S
Oro-oro
49 tahun
2 Maret 2015
19 Maret 2015

Weight

Patient ID
Room
MD
Pharmacist
Race
Religion
Occupation

: 11.04.80.xx
: Pandan II
:
: ADR
: Jawa
: Islam
: Pekerja Pabrik

No.

: 11

Gender : Laki-laki

History of Present Illness:


Past Medical History/Surgery:
2 minggu yang lalu menginjak kerikil, luka memberat sejak 3
Sejak 3 minggu yang lalu didiagnosa DM, kemudian
hari SMRS, kaki bengkak.
menggunakan glibenclamid
Pasien baru mengetahui bahwa menderita DM 3 minggu yang
lalu (control di puskesmas). Mengaku banyak minum (1 L)
sejak 9 bulan yang lalu, sering BAK (9x/hari) sejak 2 tahun
yang lalu
Lifestyle:
Family and Social History:
Tidak ada data
Tidak ada data
Acute and Chronic Medical Problem:
DM ND II + Gangren Pedis D + Hiperkalemia + Sepsis

Allergies/Intolerances:
Social Drug Use
Cost Meds/month
Allergen
Reaction
Alcohol
: Insurance
: JPS
Notes:
Caffein
: Copay
:
Tindakan yang dilakukan :
Tobacco : Medicaid
:
Kultur Aerob (6 Mei 2010 8 Mei 2010)
Annual income
:
Bahan : Pus
Hasil : biakan Staphyllococcus coagulase negatif
Sensitif : Amikacin
Resisten : Gentamycin, Ampi-Sulbactam, Penisillin G, Piperacylin tazobactam, Cotrimoxazole,
Tetracycline,Chloramphenicol, Erythromycin, Clindamycin, Azitromycin, Levofloxacin
Kultur Aerob (7 Mei 2010 10 Mei 2010)
Bahan: Urine
Hasil: tidak ada pertumbuhan kuman aerob
Kultur Aerob dan anaerob
(6 Mei 2010 11 Mei 2010)
Bahan: darah
Hasil: tidak ada pertumbuhan kuman

Vital Sign
Parameter

Normal Range

3/5

4/5

5/5

6/5

7/5

8/5

9/5

Suhu (C)

36-37,8

37

37

37

36,5

36

10/5
37

TD (mmHg)

120/80

130/70

130/80

130/80

Nadi (x/menit)

80-100

108

92

88

76

80

72

RR (x/menit)

15-25

22

20

20

18

Baik

Cukup

Cukup

cukup

Cukup

Cukup

KU
Parameter

Normal Range
Suhu (C)

11/5

12/5

13/5

14/5

15/5

140/80

16/5

36-37,8

37

37

36,7

37

17/5
36,7

18/5

36,5

37

37

TD (mmHg)

120/80

170/80

170/80

130/85

130/80

140/90

Nadi (x/menit)

80-100

80

84

84

73

80

88

80

RR (x/menit)

15-25

18

18

18

18

16

Lemah

Lemah

Lemah

Cukup

cukup

KU

Laboratory Data
Parameter

Normal Range

2/5

3/5

6/5

10/5

11/5

14/5

17/5

18/5

WBC
RBC
HGB
HCT
PLT
MCV
MCH
MCHC

4,5-10,5 (x103/L)
4,5-5,5 (x103/L)
11-18 (g/dL)
35-60(%)
150-450 (x103/L)
80-99 (fL)
27-31(pg)
33-37 (g/dL)

24,1
3,25
8,9
27,2
776
83,6
27,5
32,9

23,82
3,11
8,4
27,1
685
-

22,90
2,63
7,1
23,2
776
88,2
27
30,6

20,0
3,35
9,0
27,7
557
82,7
26,9
32,5

16,3
3,56
9,52
28,3
583
79,4
26,7
33,6

13,8
3,72
9,91
30,6
513
82,4
26,7
32,4

14,7
3,41
9,66
29,3
497
-

GLU
CREA

<200 (mg/dl)
0,5-1,4(mg/dl)

259
2,78

2,6

1,3

1,31

1,1

150
1,2

87
-

Parameter
ALB

Nilai Normal
3,2-5 (g/dL)

2/5
2,82

3/5
2,9

6/5
-

10/5
2,6

11/5
2,8

14/5
2,5

17/5
2,9

18/5
-

UREUM
SGOT
SGPT

< 25 (U/I)
< 29 (U/I)

137,1
-

20
37

13
15

17
13

21
15

BUN
ASAM URAT

10-20 (mg/dl)
3,4-5,7 (mg/dl)

60
8,4

35,5
5,7

25,4
-

27,3
-

29,8
4,4

PHOSPHAT
T-BIL

0,1-1,2 (mg/dl)

3,1
0,96

4,2
-

2,6
1,16

3,4
0,67

D-BIL
Na
K
Cl
Ca
CRP Kuantitatif

0-0,3 (mg/dl)
137-145 (mEq/L)
3,6-5,0 (mEq/L)
97-103 (mEq/L)
4,3-5,16 (mEq/L)
< 6mg/L

126,3
5,41
9,0
-

101,3
-

0,54
136,6
3,89
10,8
51

7,1
-

0,14
7,5
-

0,17
-

Drug Name/Dose/Strength/Route

Prescribed
Schedule

Duration Start Stop Dates

Compliance/Dosing Issue

Infus Pz / 14 tpm

Setiap hari

3 Maret 19 Maret 2015

Compliance

Ceftazidime/ 2x1g/ infuse

Setiap hari

3 Maret 6 Maret 2015

Compliance

Omeprazole/ 2x40mg/ injeksi

Setiap hari

3 Maret 9 Maret 2015

Compliance

Omeprazole/ 1x40mg/ injeksi

Setiap hari

10 Maret 19 Maret 2015

Compliance

Metronidazole/ 3x500mg/ iv drip

Setiap hari

3 Maret 19 Maret 2015

Compliance

Actaprid/ 3x8UI/ SC

Setiap hari

4 Maret 9 Maret 2015

Compliance

Actrapid/ 3x12UI/ SC

Setiap hari

10 Maret 17 Maret 2015

Compliance

Actrapid/ 3x10UI/ SC

Setiap hari

18 Maret 19 maret 2015

Compliance

Humulin/ 1x8UI/ SC

Setiap hari

7 Maret 9 Maret 2015

Compliance

Humulin/ 1x10UI/ SC

Setiap hari

17 Maret 18 Maret 2015

Compliance

Dipiridamol/ 3x75mg/ PO

Setiap hari

5 Maret 19 Maret 2015

Compliance

Tramadol/ 2x100mg/ IV

Setiap hari

6 Maret 9 Maret 2015

Compliance

Ciprofloxacin/ 2x400mg/ drip

Setiap hari

7 Maret 12 Maret 2015

Compliance

18 Maret - 19 Maret 2015


Amikacin/ 2x 250 mg/ injeksi

Setiap hari

12 Maret 17 Maret 2015

Compliance

Venosmil/ 3x200 mg/ PO

Setiap hari

9 Maret 19 Maret 2015

Compliance

Ca Glukonas 10 cc

1 kali

3 Maret 2015

Compliance

Albumin 20%/100 cc

1 kali

4 Maret 2015

Compliance

Transfusi PRC/1 kalf

1 kal

8 Maret dan 12 Maret 2010

Compliance

Current Drug Therapy


Medication PTA
Time Line
: Circle actual administration times and record appropriate medications and meals below.
Date Glibenclamid
: 3 Mei 2010
6

Time Line
Date

8 9 10 11
Metronidazole iv
Ceftazidime iv
Omeprazole iv

4 5 6
7
Metronidazole iv

9 10 11
Ceftazidime iv
Omeprazole iv

12 1 2 3 4
Metronidazole iv

: Circle actual administration times and record appropriate medications and meals below.
: 4 Mei 2010
6

Acrapid sc

Time Line
Date

12

10

11

Metronidazole iv
Ceftazidime iv
Omeprazole iv

12

Actrapid sc

10

11

12

Metronidazole iv

Ceftazidime iv
Omeprazole iv
Actrapid sc
Albumin infus

Metronidazole iv

: Circle actual administration times and record appropriate medications and meals below.
: 5 Mei 2010
6

Actrapid sc

10

11

12

Metronidazole iv Actrapid sc Metronidazole iv Actrapid sc


Ceftazidime iv
Omeprazole iv

10

11

12

Ceftazidime iv metronidazole iv
Omeprazole iv

Dipiridamol po

Time Line
Date

Dipiridamol po

: Circle actual administration times and record appropriate medications and meals below.
: 6 Mei 2010
6

Actrapid sc

10

11

Dipiridamol po

10

11

12

3 4

Ceftazidime iv Metronidazole iv
Omeprazole iv

Dipiridamol po
Tramadol po

: Circle actual administration times and record appropriate medications and meals below.
: 7 Mei 2010
6

Actrapid sc

10

11

12

Metronidazole iv Actrapid sc
Ciprofloxacin drip
Omeprazole iv

Dipiridamol po
Tramadol po
Time Line
Date

12

Metronidazole iv Actrapid sc Metronidazole iv Actrapid sc


Ceftazidime iv
Omeprazole iv

Dipiridamol po
Tramadol po
Time Line
Date

Dipiridamol po

Actrapid sc
Metronidazole iv

Dipiridamol po

10

11

12

Ciprofloxacin drip Metronidazole iv


Omeprazole iv
Humulin sc

Dipiridamol po
Tramadol po

: Circle actual administration times and record appropriate medications and meals below.
: 8 Mei 2010

Actrapid sc

10

11

12

Metronidazole iv Actrapid sc
Ciprofloxacin drip Transfusi PRC
Omeprazole iv

Dipiridamol po
Tramadol po

10

11

12

Ciprofloxacin drip Metronidazole iv


Omeprazole iv
Humulin sc

Dipiridamol po

Dipiridamol po
Tramadol po

Metronidazole iv
Time Line
Date

Actrapid sc

: Circle actual administration times and record appropriate medications and meals below.
: 9 Mei 2010
6

10

11

12

10

11

12

Actrapid sc Metronidazole iv Actrapid sc Metronidazole iv Actrapid sc Ciprofloxacin drip Metronidazole iv


Ciprofloxacin drip
Omeprazole iv
Omeprazole iv
Humulin sc
Dipiridamol po
Tramadol po
Venosmil po
Time Line
Date

Dipiridamol po
Venosmil po

Dipiridamol po
Tramadol po
Venosmil po

: Circle actual administration times and record appropriate medications and meals below.
: 10 11 Mei 2010
6

10

11

12

Actrapid sc Metronidazole iv Actrapid sc Metronidazole iv Actrapid sc


Ciprofloxacin drip
Omeprazole iv

10

11

12

Ciprofloxacin drip Metronidazole


Omeprazole iv
iv

Dipiridamol po
Venosmil po

Time Line
Date

Dipiridamol po
Venosmil po

Dipiridamol po
Venosmil po

: Circle actual administration times and record appropriate medications and meals below.
: 12 Mei 2010
6

10

11

12

Actrapid sc Metronidazole iv Actrapid sc Metronidazole iv Actrapid sc


Ciprofloxacin drip Transfusi PRC
Omeprazole iv
Dipiridamol po
Venosmil po

Time Line
Date

Dipiridamol po
Venosmil po

10

11

12

Amikasin iv Metronidazole iv
Omeprazole iv

Dipiridamol po
Venosmil po

: Circle actual administration times and record appropriate medications and meals below.
: 13 16 Mei 2010

10

11

12

10

11

12

Actrapid sc Metronidazole iv Actrapid sc Metronidazole iv Actrapid sc Amikasin iv Metronidazole iv


Amikasin iv
Omeprazole iv
Omeprazole iv
Dipiridamol po
Venosmil po

Time Line
Date

Dipiridamol po
Venosmil po

Dipiridamol po
Venosmil po

: Circle actual administration times and record appropriate medications and meals below.
: 17 18 Mei 2010
6

10

11

Actrapid sc Metronidazole iv
Amikasin iv
Omeprazole iv
Dipiridamol po
Venosmil po

12

10

11

12

Actrapid sc Metronidazole iv Actrapid sc Ciprofloxacin drip Metronidazole iv


Omeprazole iv
Dipiridamol po
Venosmil po

Dipiridamol po
Venosmil po