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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
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
Compliance/Dosing Issue
Infus Pz / 14 tpm
Setiap hari
Compliance
Setiap hari
Compliance
Setiap hari
Compliance
Setiap hari
Compliance
Setiap hari
Compliance
Actaprid/ 3x8UI/ SC
Setiap hari
Compliance
Actrapid/ 3x12UI/ SC
Setiap hari
Compliance
Actrapid/ 3x10UI/ SC
Setiap hari
Compliance
Humulin/ 1x8UI/ SC
Setiap hari
Compliance
Humulin/ 1x10UI/ SC
Setiap hari
Compliance
Dipiridamol/ 3x75mg/ PO
Setiap hari
Compliance
Tramadol/ 2x100mg/ IV
Setiap hari
Compliance
Setiap hari
Compliance
Setiap hari
Compliance
Setiap hari
Compliance
Ca Glukonas 10 cc
1 kali
3 Maret 2015
Compliance
Albumin 20%/100 cc
1 kali
4 Maret 2015
Compliance
1 kal
Compliance
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
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
Dipiridamol po
Tramadol po
Time Line
Date
Dipiridamol po
Actrapid sc
Metronidazole iv
Dipiridamol po
10
11
12
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
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
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
10
11
12
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
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
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
Dipiridamol po
Venosmil po