Irina A Bawah

Lendeng Ellen/ P/ 53 thn/ 00766909

dr. Yuansun Khosama Sp.B (K) V
Raber Interna

S: Luka post op terawat

O:
KU sedang, kesadaran CM
Kepala CA (-), SI (-)
Thoraks
Gerak dada simetris
BJ I dan II normal, regular
BND vesikuler
Abdomen
Datar, supel, BU (+)
Ekstremitas akral hangat, CRT <2”
Status lokalis :
Regio pedis (s): luka terawat (+), pus (-)

Lab 07/08/2022
Leu 29.1 Hb 8.9 Tro 614 GDS 152 OT/PT 7/8 Ur/Cr 75/2.5 Na/K/Cl 130/3.4/98

Lab 08/06/2022
Leu 38.4 Hb 9.5 Tro 554

A: Post Re-Debridement ec. Ulkus pedis sinistra

DM Tipe 2
AKI dd CKD
Elektrolit Imbalance

P: IVFD Nacl 0.9 %

Ranitidin IV/12 jam
Ketorolac IV/8 jam
Ceftriaxone 1 gr IV/12 jam
Metronidazole drips/8 jam
Aspilet 1x1 tab
Silostazol 2x100 mg tab
Rawat luka