ORCHID

2 Februari 2019
NO MRS Pasien Dokter Diagnosis Masalah Terapi/Rencana Ket H
602 1/2 An. Shafira Yustinah Rhinofaringitis, RL 80cc/jam Lab 01/02: Hb 14 1
Azkia Firdaus, Demam dengue sanmol 250mg kp Leu 2310 Ht 40.7
9th, 223861 (H5) Omeprazole 2x20mg Tro 86000
Praxion 5 ml kp,
Puyer batuk (meptin 20mcg,
vestein ½, rhinofed ½) 3x1

R/ Cek DPL 2/2

603 1/2 An. Zahira Yasmi Anemia pada Periproc 3x1 Lab 01/02: Hb 9 1
Ramadhaningru thalassemia mayor Leu 5320 Ht 25.2
m, 13th, 127904 R/ Tr Prc 2 kantong dengan Tro 124000
premed lasix 20mg IV dan
dexamethason 5mg IV 1/2
605 31/1 An. Rayyanka Yustinah Rhinofaringitis RL 12 tpm Lab 31/1: Hb 13,1 Ht 38,4 2
mauza, 1 thn . DCA puyer bapil 3x1 di ot Leu 4710
400761 praxion 5 ml Tro 240000
sanmol drip 150 mg/30 menit B/E/N/L/M
jika suhu diatas 38,5 0,4/0,0/49,3/43,1/7,2
cefotaxim 3x300mg
ranitidin 2x15 mg
lacto-B 2x1 p.o
Zink 1x5 cc p.o
606 28/1 An. Qistan Alif Yustinah DHF grade 2 (7) RL 30cc/jam Lab 28/1: Hb: 15,2 5
Santana An. 10 Faringitis Nebu combivent : Ns 2 leu:5,300 ht:45
thn 10 bln, cc/8jam trom:119.000
275899 sanmol 300 mg/ 30 menit jika B/E/N/L/M 0,2
suhu 38,5 atau sakit kepala
Omeprazole 2x30 mg iv Lab 29/1 : Hb 14.5
Tempra F 7,5 ml, Leu 4970 Ht 42
orezink 1x 5 ml, Tro 67000
liprolac 2x1 sac (HOS)
(ketrin 3 mg, vestein 1/2 kaps, Lab 30/1 : Hb 16.2
meptin 20 ugr) 3x1 kaps Leu 7840 Ht 48.4
Tro 28000
R/ Cek DPL (2/2) IgG dan IgM anti Dengue
positif

Lab 31/1: Hb 13,3 Ht 38,9

Leu 8530 Tro 30000

Lab 01/02 : HB 13.1

Leu 7760 Ht 38.3
Tro 53000
609 1/2 An. Farras Aufa Yustinah Febris hr ke 5 ec RL 12 tpm Makro Lab 1/2/19: Hb 10.2 Leu 1
Permana. 5 Th . Parotitis dextra, Cefixime 2x3,5 ml 13610 Ht 29.0 Trom
299118 Dengan dehidrasi Sanmol 3x 5 ml PO, 409.000 B/E/N/L/M
ringan sedang Jika Suhu > 38,5 Propyretic 0.2/0.7/88.3/6.5/4.3
160 mg Supp
610 1/2 An. Ayyub Cece Anemia ec susp R/ Tr PRC 3x (2x40ml, Lab 01/02: Hb 5.5 1
Adnan Esya Leukimia akut dd/ 1x100ml) 1/2 Leu 7760 Ht 24.3
Ardiansyah, Thalassemia Tro 296000
9bln, 434530 B/E/N/L/M
0.3/5.2/2/77.2/15.3
611 30/1 An. M Gading Yustinah Rhinofaringitis Rl 15 tpm Lab 28/1: Hb 14.3 2
8 Th 2 Bln akut Cefotaxime 3x 600mg Leu 4030 Ht 41.3
283730 Sanmol drip 300mg Trom 338000
selama 30 menit bila suhu B/E/N/L/M
>38.5 0.5/0/47.1/39.1/13.2
 Praxion forte 5 ml bila T > 38
Puyer bartuk pilek 3x1 pulv
Orezink 1x 5 ml
Liprolac 2x 1 Sachet,
combivent:NS/8jam
Puyer 3x1 (ketricin 3mg,
meptin 20 ugr, vestein ½ kaps,
rhinofed ½ tab)
615 30/1 An. Raffasya Yustin, Rhinobronkitis IV Plug Lab 30/1: Hb 10 Leu 5980 3
Akbar, 5 bln 11 Kobal Puyer batuk ( Triamcinolon Ht 31 Tro 268000
hari, 441738 0.5mg, Salbutamol 0.7mg,
Vestein ¼, rhinofed 1/3) 3x1
Cefotaxim 3x250mg
Combivent1/2:NS/6jam
Paracetamol 100 mg kp
suhu>38,5
Sanmol drop 0,8cc kp demam

Chest fisioterapi
615 1/2 An. Syakira Ismet Febris ec viral D5% ½ ns + Kcl 25meq Lab 01/02: Hb 10.2 1
Ramdhani, 8bl, infection, 10cc/jamPhental 35 mg dalam Leu 4990 Ht 30
453601 Obs seizure ec NS 25cc/12jam, Tro 432000
epilepsi? Sanmol 60mg kp Na/K/Cl 139/4.2/107
Ceftriaxone 1x60mg
Dexamethason 3x1
616 29/1 An. Farel, 11 Yustinah Viral infection RL 15 tpm Lab 29/1: Hb 12,6 Ht 35,1 4
thn . 414634 bila demam -> PCT tablet Leu 9630 Tro 274000
3x500mg B/E/N/L/M
bila 38,5 C berikan PCT infus 0,1/0,0/87,5/5,4/7,0
500mg iv selama 30 menit
cefotaxime 2x1gr Lab 01/02 : Hb 13.5
Dexamethason 2x1 Leu 2900 Ht 38.1
Erdostein 3x1 Tro 144000
Omeprazole 2x1

R/ cek DPL 2/2

617 1/2 An. Raesa Yustinah Hiperpireksia RL 12 tpm makro Lab 01/02: Hb 11.4 1
Lutfah Kamila, pada febris H-2 ec Cefotaxim 3x300mg Leu 24760 Ht 33.1
1th, 415369 Rhinofaringitis Paracetamol 5 ml kp Tro 395000
akut Proris 125mg kp

R/ Cek UL 1/2
618 31/1 An Muhammad Ismet Hiperpireksia e.c RL 6 tpm makro Lab 31/1 : Hb 10.8 2
Fatih Marzuki, farngitis Cefotaxim 3x300 mg, Leu 9190 Ht 32
2 th 10 bln, tapp off terapi paracetamol 3x100mg, Tro 335000
394317 epilepsi kepra 1x90mg
puyer 2x1 (salbutamol0,5 mg,Lab 01/02 : Hb 11.4
cetirizin 0,5 mg, methyl Leu 6059 Ht 34.3
prednisolon) Tro 267000
malaria mikroskopik tidak
ditemukan
618 10/1 An. Daffa Cece co Infeksi CMV Operasi Kaen 1 B 4 cc/jam Lab 10/1: reticulosit 2. 23
ramadhan, 7bln, Ismet co kongenital, katarak Ceftriaxon 2x250mg (iv) Hb 11,1 leuko 16880
0452010 Hessy Katarak (cece tdk Cymevene 2x25mg (2minggu, HT 32 Tro 360000
Asmawa kongenital, acc) 28 kali pemberian) → 26/28) Alb 3,5 Bil tot 0,09,
ti co penyakit jantung bil direk 0,05 bil ind 0,05
Ramzi kongenital, R/ Tes ASSR dan OAE → ot/pt 34/13 gamma GT 58
co GDD, mikrosefali jadwal tunda tgu Cimeven Ur/Cr 8/0,25.
Chandra selesai anti rubela IgG non
→ Vebi reaktive.
Sherly Anti rubella IgM negatif.
R/Echo 28/1 jam 19.00 → Anti Toxo IgG/IgM
 Tunda sampai cymevene non reactive.
selesai GDT: anemia normositik
normokrom, (hasil lab
prodia by Phone anti
CMV IgG + 59,2)

CT head 11/1:
Toxoplasmosis

Tes BERA 14/1 : 70/80

Vena Seksi 16/1

vena sectie 28/1 jam

18.30

Lab 31/1: Alb 3,5

Ur/Cr 7/0,25 Egfr 238,7
619 31/1 An. Khalis, Yasmi DD dd/ DBD IVFD RL gtt 10 makro Lab 31/1: Hb 10,7 Ht 32,6 2
1 thn . 420001 parasetamol drop 4 x 0,9 cc Leu 5620 Tro 130000
Ranitidin 2 x 10 mg B/E/N/L/M
0,2/1,1/30,8/61,7/6,2
R/ Cek serial DPL
Lab 01/02 : Hb 11.1
Leu 7110 Ht 32.7
Tro 146000
619 31/1 An. Ainiya Fakhrul, palatoschizis IVFD RL/24 jam Lab 31/1: 2
Faida Azmi Co Bilateral Cefotaxime 2x200mg PT/APTT/INR
1 th 5 buln, Yasmi PCT 3x3/4 cth 9,9/0,93/39,9
422841, co (K 9,1/0,85/30)
rahmat OT/PT 39/13
Ur/Cre 22/0,25 eGFR 200

Ro Tho 31/1: Normal

Post palatoplasty 01/02

jam 08.00)
621 13/1 An Dhavin Ismet, Penurunan Binasal 3lpmRA 20cc/jam, Lab 13/1: Hb 12 20
Rezky Aulia, Anthar kesadaran ec Meropenem 3x500mg Leu 16120 Ht 34,8
7th 5bln, co meningo- Omeprazole 1x30mg, Trom 564000 ur 30
452247 Rahmat ensefalitis TB Piracetam 3x500mg, cr 0.42 eGFR 183,6
co perbaikan , Paracetamol 250mg/6jam kp Na 131
PICU 16* Sulung Hidrocephalus Prednison 3x5mg , K 3,9 cl 96
co Post VP shunt, INH 1x300mg, Kultur darah steril
Kobal Stress ulcer Rifampicin 1x350mg,
perbaikan, Pirazinamide 1x500mg, ro thorax 14/1 :
HT stg II Ethambutol 1x500mg, Pneumonia (Spesifik?
Vit B6 1x10mg,
Valepsy 3x5ml Nacl 50ml+phental
bila TD > 97/54 Captopril 250mg 13/1
3x25mg, bila TD < 97/54
Captopril 2x25mg CT Scan kepala dengan
kontras 14/1:
MC 6x100ml Meningo-encephalitis dg
hydrocephalus derajaT
Sedang

Lab 15/1: HBsAg negatif

Anti HIV non reaktif
PT 9,9(10,3)
INR 0,93(0,96)
APTT 28,1(29,7)
 analisa cairan otak bekuan
negatif, agak keruh,
Pandy negatif,
Nonne negatif, sel MN 84
sel PMN 16 sel
abnormal negatif klorida
LCS 112
glukosa cairan 55
VP Shunt 15/1

Lab 16/1: Hb 10,3

Leu 11810 Ht 19,8
Tro 375000

Ro Thorax 16/1 : Normal

Lab 17/1: Hb 10.8

Leu 9240 Ht 31.4
Tro 378000 PT 9.4(10.5)
INR 0.88(0.98)
APTT 31.7(33.2)

GDS 19/1: 88

Ekstubasi + Kultur ujung

ett (23/1)

Lab 24/1:
AGD pH 7.394 PO2 48
PCO2 63.5 SaO2 81
HCO3 39.1 BE 14
(darah Vena?)
kultur ujung ETT:
Klebsiella pneumonia,
sensitif ( Ertapenem,
Amikasin, Piperacillin
tazobactam, ciprofloxacin,
Tygecillin, nitrofurantoin,
meropenem)

Aff hecting selang-seling

(24/1)

Lab 25/1:
Na/ K/ Cl 128/ 4/ 83
621 2/2 An. Fadhlan Ismet CKR GCS 15 RL 8 tpm makro Lab 2/2/2019: Hb 13.9 0
Ahmad dengan amnesia Ceftriaxone 2x1 gr Leu 11.040 Ht 37.5 Trom
Imanulhaq . 9 retrogade Piracetam 3x 500 mg 511.000
Th . 453615

622 1/2 An. Abiyyu Yustinah Rhinofaringitis RL 12 tpm makro Lab 1/2 : Hb: 11,6 2
Rifid Chelitis angularis Cefotaxime 3x400mg iv Leu: 891 HT: 34,4
Rafardhan, 3 Paracetamol 5cc kp S>38, Trom: 223.000
thn 7 bln, Proris 125 kp S>38,5 b/e/n/l/m
361353 Kenalog oral (sama ortu) 0,4/0,1/78,7/7,3/13,5
Puyer batuk (Salbutamol
1,4mg , vestein 1/3, rhinofed Lab 01/02 : Normal
1/3) 3x1
622 2/2 An. Muhammad Desi DCA dehidrasi RL 10 tpm makro Lab 2/2/2019: Hb 12.8 0
Ar Rayyan . 4 ringan-sedang, Acran 2x15 mg Leu 7730 Ht 35.5 Trom
Th . 434596 Observasi vomitus Orezink 1x1cth, 293.000 B/E/N/L/M
dengan dehidrasi Lasidofil 1x1 sachet, 0.3/0.1/77.1/14.1 Na/K/Cl
ringan Vometa 3x3/4cth kp muntah, 134/3.3/100
Praxion 4x1cth

R/ Cek Darah samar , Sampel -