51
Batuk +/-
Keringat +/-
dingin +/-
Sesak Nafas +/- -
Nyeri dada +/- -
Nyeri Perut +/- + + -
Sakit Kepala +/- +
GCS 456 456
Profil Data Laboratorium
Data Laboratorium Nilai Normal Tanggal / Bulan
13/8 14/8 15/8 16/8 17/8 18/8
Hematologi
Hemoglobin/HB 12,0-16,0 gr/dL 13,2 12,3
Leukosit/WBC (4,3-10,8)x103/L 15,5 5,0
LED L<15 : Pr<20 mm/jam 44 40
Trombosit/PLT (142-424) x 103/mm3 171 160
Hematokrit/Hct 35-48 % 38,0 35,2
Eritrosit/RBC (L.4,0-5,5 : P.4,0-5,0)x106/μL
Keseimbangan Elektrolit
Na+ 136-145 mmol/L
K+ 3,5-5,0 mmol/L
Cl- 98-106 mmol/L
Ca2+ 7,6-11,0 mg/Dl
Profi Lemak
Kolesterol total < 200 mg/dL
Trigliserida < 200 mg/dL 154
Kolesterol HDL >40 mg/dL
52
Kolesterol LDL < 150 mg/dL 218
Metabolisme Kimia Darah
GDS < 200 mg/dL 64,9
GDP 60-100 mg/dL
Ureum 20-40 mg/dL 74,0 35,8
Kreatinin <1,3 mg/dL 1,40 0,99
Asam Urat L. 3,4-7,5 : P. 2,3-6,0 mg/dL
Profil Pengobatan
No Nama Obat Regimen dosis Rute Tanggal / Bulan
13/8 14/8 15/8 16/8 17/ 8
O2
Inf. Asering 20 tpm IV drip
Inf. NaCl 0,9% 20 tpm IV drip
Inf. Aminofluid 14 tpm IV drip
Dobutamin 2-20 µg/kgBB/mnt IV drip 5,4 µg/kgBB/mnt 3,0 µg/kgBB/mnt 2,5 µg/kgBB/mnt
Vascon 0,05 µg/kgBB/mnt IV drip
Paracetamol 3x500 mg PO
Cefoperazon 2x1 g IV bolus
Metoklopramid 3x10 mg IM bolus
Omeprazole 1x40 mg PO IV bolus IV bolus
As. Tranexamat 3x500 mg IV
Vit K 3x1 mg IV bolus
Meropanem 2x1 g IV bolus
Ramipril 0-2,5 mg PO
Lactulose 3x5 ml (5g/ml) PO
5,4 µg/kgBB/mnt 3,0 µg/kgBB/mnt 2,5 µg/kgBB/mnt
53