RINGKASAN PULANG

(Discharge Summary) No RM : 0002083430

Nama : TRISNA SUNTARA
Tgl lahir : 17 Februari 1988 / L

Tanggal Masuk : 19 Juni 2023

(Admission Date) Tanggal Keluar : 14 Juli 2023
Ruang Rawat Terakhir : KEMUNING V (Discharge Date)
(Last Ward)
INDIKASI RAWAT INAP :
(Indication Hospitalization)

Perbaikan KU
RINGKASAN RIWAYAT PENYAKIT :
(History of Disease Summary)

Pasien datang dengan demam hebat yang tak kunjung turun. Pada stoma pasien terdapat nanah dan bekas luka yang dikeluhkan tidak kunjung
menghilang. Pasien sempat kejang dan kehilangan kesadaran beberapa jam sebelum dibawa ke RSHS untuk ditindak lanjut kembali. Pasien juga
mengeluhkan sesak sebelumnya.
PEMERIKSAAN FISIK :
(Physical Findings)

PEMERIKSAAN PENUNJANG :
(Supporting Examination)

ABO\/Rh Typing@=O Rh Positif;Asam Laktat @=1.0;Nilai Gas Darah@=;pCO2 @=26.9;pH @=7.450;pO2 @=84.3;Status Asam
Basa@=;HCO3 @=18.9;Saturasi O2 @=97.2;Standar BE-b @=-3.2;Standard BE (ecf) @=-5.3;tCO2 @=19.7;IG% @=17.2;PDW
@=.;Eritrosit=3.69;Leukosit=10.74;Trombosit=121;MCH=25.2;PCT @=.;Index Eritrosit=;MCH=25.2;MCHC=30.6;MCV=82.4;RDW-SD
@=68.7;Hematokrit=30.4;Hemoglobin=9.3;MCV=82.4;Hitung Jenis Lekosit=;Basofil=0;Blast @=;Eosinofil=0;Limfosit=12;Metamielosit
@=7;Mielosit @=5;Monosit=5;Neutrofil Batang=2;Neutrofil Limfosit Ratio=5.91;Neutrofil Segmen=69;Promielosit @=Anak : 0-1Dewasa : 0-
1;Total Basofil @=0.00;Total Blast @=;Total Eosinofil @=0.00;Total Limfosit @=1.29;Total Metamielosit @=0.75;Total Mielosit @=0.54;Total
Monosit @=0.54;Total Neutrofil @=7.63;Total Promielosit=;MCHC=30.6;IG# @=1.85;MPV @=.;RDW-CV @=23.0;Albumin=1.76;Natrium
(Na)=140;Klorida (Cl)=102;Kalium (K)=4.2;Status Asam Basa@=;HCO3 @=22.3;Saturasi O2 @=99.9;Standar BE-b @=-1.0;Standard BE (ecf)
@=-2.3;tCO2 @=23.4;Nilai Gas Darah@=;pCO2 @=33.8;pH @=7.420;pO2 @=185.8;RDW-CV @=22.9;MCH=25.1;IG%
@=10.1;Eritrosit=3.94;PCT @=0.17;Hitung Jenis Lekosit=;Basofil=0;Blast @=;Eosinofil=0;Limfosit=8;Metamielosit @=4;Mielosit
@=2;Monosit=3;Neutrofil Batang=4;Neutrofil Limfosit Ratio=10.35;Neutrofil Segmen=79;Promielosit @=Anak : 0-1Dewasa : 0-1;Total Basofil
@=0.00;Total Blast @=;Total Eosinofil @=0.00;Total Limfosit @=1.33;Total Metamielosit @=0.66;Total Mielosit @=0.33;Total Monosit
@=0.50;Total Neutrofil @=13.77;Total Promielosit=;IG# @=1.67;Hematokrit=31.5;MCV=79.9;PDW @=12.8;MCHC=31.4;MPV @=9.2;Index
Eritrosit=;MCH=25.1;MCHC=31.4;MCV=79.9;Trombosit=185;Leukosit=16.59;Hemoglobin=9.9;RDW-SD @=64.6;Albumin=1.87;Asam Laktat
@=1.6;Bilirubin Total =1.088;Glukosa Sewaktu=105;Kreatinin =0.54;Natrium (Na)=141;Ureum =36.6;Klorida (Cl)=102;Kalium (K)=4.6;Status
Asam Basa@=;HCO3 @=17.9;Saturasi O2 @=99.4;Standar BE-b @=-4.4;Standard BE (ecf) @=-6.5;tCO2 @=18.7;Nilai Gas Darah@=;pCO2
@=26.2;pH @=7.440;pO2 @=153.4;RDW-SD @=62.8;PDW @=11.4;RDW-CV @=21.8;MPV @=10.3;Leukosit=13.47;MCHC=32.3;Hitung
Jenis Lekosit=;Basofil=0;Blast @=;Eosinofil=0;Limfosit=6;Metamielosit @=2;Mielosit @=;Monosit=8;Neutrofil Batang=3;Neutrofil Limfosit
Ratio=13.96;Neutrofil Segmen=81;Promielosit @=Anak : 0-1Dewasa : 0-1;Total Basofil @=0.00;Total Blast @=;Total Eosinofil @=0.00;Total
Limfosit @=0.81;Total Metamielosit @=0.27;Total Mielosit @=;Total Monosit @=1.08;Total Neutrofil @=11.31;Total
Promielosit=;Trombosit=234;Hemoglobin=10.2;Index
Eritrosit=;MCH=25.8;MCHC=32.3;MCV=79.8;MCH=25.8;MCV=79.8;Eritrosit=3.96;Hematokrit=31.6;IG# @=0.84;IG% @=6.2;PCT
@=0.24;INR @=1.16;PT=16.7;Klorida (Cl)=102;Magnesium=1.8;Ureum =23.1;Glukosa Sewaktu=115;Kalium (K)=4.3;Kreatinin =0.46;Natrium
(Na)=138;Kalsium Ion =4.25;Asam Laktat @=4.3;Status Asam Basa@=;HCO3 @=18.8;Saturasi O2 @=99.2;Standar BE-b @=-4.6;Standard BE
(ecf) @=-6.3;tCO2 @=19.8;Nilai Gas Darah@=;pCO2 @=30.9;pH @=7.390;pO2 @=147.0;RDW-SD @=67.1;RDW-CV
@=23.6;Leukosit=8.56;Index
Eritrosit=;MCH=24.7;MCHC=30.6;MCV=80.7;Trombosit=225;Hemoglobin=8.6;Hematokrit=28.1;Eritrosit=3.48;INR @=1.33;PT=19.0;SGOT
(AST)=24;Kalium (K)=4.0;Natrium (Na)=139;Ureum =22.5;SGPT (ALT)=17;Bilirubin Total =1.040;Klorida (Cl)=104;Albumin=1.67;Kreatinin
=0.40;Nilai Gas Darah@=;pCO2 @=37.9;pH @=7.340;pO2 @=196.9;Status Asam Basa@=;HCO3 @=20.4;Saturasi O2 @=99.3;Standar BE-b
@=-4.3;Standard BE (ecf) @=-5.6;tCO2 @=21.6;Eritrosit=3.87;RDW-CV @=25.6;Index Eritrosit=;MCH=23.8;MCHC=30.6;MCV=77.8;RDW-
SD @=69.0;Hemoglobin=9.2;Trombosit=363;Leukosit=18.07;Hematokrit=30.1;Asam Laktat @=6.0;Status Asam Basa@=;HCO3
@=16.6;Saturasi O2 @=94.1;Standar BE-b @=-5.5;Standard BE (ecf) @=-7.3;tCO2 @=17.3;Nilai Gas Darah@=;pCO2 @=22.9;pH
@=7.470;pO2 @=69.3;Eritrosit=4.08;Leukosit=7.21;Hemoglobin=9.8;RDW-CV @=25.5;Hematokrit=32.2;Index
Eritrosit=;MCH=24.0;MCHC=30.4;MCV=78.9;RDW-SD @=69.3;Trombosit=340;Kalsium Ion =4.12;Kalium (K)=3.5;Natrium
(Na)=135;Magnesium=1.8;Eritrosit=4.10;RDW-SD @=66.8;

20/07/2023 e-RM.RI.02/20 Rev 05

Page 1
 RINGKASAN PULANG
(Discharge Summary) No RM : 0002083430
Nama : TRISNA SUNTARA
Tgl lahir : 17 Februari 1988 / L

TERAPI/PENGOBATAN SELAMA DI RUMAH SAKIT :

(Therapi/Treatment in Hospital)

Riwayat Pemberian Obat Selama di Rumah Sakit :

1. ACETAR MJB INF 500ML 11. EFEDRIN INJ 50MG/ML NOVELL 21. HIDROKORTISON INJ 100MG PRATAPA
2. AIR UNTUK INJEKSI 25ML (SATORIA) 12. EPINEFRIN INJ 0,1% LASA PHAPROS 22. KALSIUM GLUKONAT INJ 100MG/ML DEXA
3. ASAM TRANEKSAMAT INJ 500MG HEXPHARM 13. FARPRESIN INJ 20MG/ML 23. KETOROLAK INJ 30MG/ML MERSI
4. ASAM TRANEKSAMAT TAB 500MG HEXP 14. FENTANYL INJ 0,05MG/ML 2ML 24. LIDOKAIN INJ 2% 2ML PHAPROS
5. ATRAKURIUM INJ 25MG/2.5ML ETHICA 15. FITOMENADION INJ 2MG/ML PHAPROS 25. LOPERAMID TAB 2MG NOVAPH
6. ATROPIN INJ 0,25MG/ML ETHICA 16. FORTANEST INJ 15MG/3ML 26. LUBRAGEL 2% 12.5G
7. B FLUID INF 500ML 17. FORTANEST INJ 5 MG/5ML 27. MEROPENEM INJ 1G INTERBAT
8. DEKSAMETASON INJ 5MG/ML PHAPROS 18. FRESOFOL 1% MCT/LCT 20ML 28. METILPREDNISOLON INJ 125MG/2ML PHAPROS
9. DEKSTROS INF 10% 500ML SATORIA 19. GABARITH PMSET 1DT-XX-150CM 29. METOKLOPRAMID INJ 10MG/2ML INTERBAT
10. EFAVIRENZ TAB 600MG 20. GELAFUSAL INF 4% 500ML 30. METOKLOPRAMID INJ 10MG/2ML IPHA

31. METRONIDAZOL FM INF 500MG/100ML KAL LASA 41. OTSU MGSO4 INJ 20% 51. RANITIDIN INJ 50MG/2ML PHAPROS
32. NACL INF 0,9% 100 ML SATORIA 42. OTSU NS 0,9% INF 100ML 52. RINGER ASETAT INF 500ML(MJB)
33. NACL INF 0,9% 500ML BRAUN 43. OTSU NS 0,9% INF 100ML KEMENKES 53. RINGER LACTAT INF 500ML BRAUN
34. NACL INF 0,9% 500ML SATORIA 44. OTSU RL INF 500ML 54. RINGER LAKTAT INF 500ML SATORIA
35. NEOSTIGMIN INJ 0,5MG/ML PRATAPA 45. PARASETAMOL INF 10MG/ML DARYA 55. ROKURONIUM INJ 50MG/5ML DEXA
36. NOREPINEFRIN INJ 4 MG/4ML DEXA 46. PARASETAMOL INF 10MG/ML HEXP 56. SEFTRIAKSON INJ 1G LASA HEXPHARM
37. OLIMEL INF N9E 1000ML 47. PARASETAMOL INF 1GR/100ML BERNO 57. SEVOFLURANE IH PER ML MERSI
38. OMEPRAZOL INJ 40MG PHAPROS 48. PETIDIN INJ 50MG/ML 58. SEVOFLURANE IH PER ML YARINDO
39. ONDANSETRON INJ 4MG/2ML DEXA 49. POTASSIUM KLORIDA INJ 7,46% SATORIA 59. SMOFKABIVEN PERIPHERAL INF 1206 ML
30. OTSU D 40% INF 25ML 40. RANITIDIN INJ 50MG/2ML MERSI 50. TUTOSOL INF 500ML

61. URINE BAG STERIL SPMED

62. WIDA BES INF 500ML

REAKSI OBAT : Tidak

DIET :
(Diet)

HASIL KONSULTASI :
(The Result of Consultations):

DIAGNOSIS UTAMA :
(Primary Diagnosis)
R57.2 SEPTIC SHOCK ICD 10 :

DIAGNOSIS TAMBAHAN :
(Additional Diagnosis)
- R19.5 OTHER FAECAL ABNORMALITIES ICD 10 :
- K56. 600 PARTIAL INTESTINAL OBSTRUCTION, UNSPECIFIED ICD 10 :
- C18.2 MALIGNANT NEOPLASM OF ASCENDING COLON ICD 10 :
- E87. 8 OTHER DISORDERS OF ELECTROLYTE AND FLUID BALANCE, NOT ELSEWHERE CLASSIFIED ICD 10 :
- E46 UNSPECIFIED PROTEIN-ENERGY MALNUTRITION ICD 10 :
- D64. 9 FOR ANEMIA, UNSPECIFIED ICD 10 :
- E86 VOLUME DEPLETION ICD 10 :

TINDAKAN/PROSEDUR/OPERASI :
(Action/Procedur/Surgery)
- 99.04 TRANSFUSION OF PACKED CELLS ICD 9 :
- 99.09 TRANSFUSION OF OTHER SUBSTANCE ICD 9 :
- 54.11 EXPLORATORY LAPAROTOMY. ICD 9 :
- 45.73 OPEN AND OTHER RIGHT HEMICOLECTOMY ICD 9 :
- CVC APPLICATION ICD 9 :
- 46.2 ILEOSTOMY ICD 9 :
- 93.57 APPLICATION OF OTHER WOUND DRESSING ICD 9 :
- 99.18 INJECTION OR INFUSION OF ELECTROLYTES ICD 9 :
- 46.4 REVISION OF INTESTINAL STOMA ICD 9 :

INSTRUKSI PERAWATAN LANJUTAN/EDUKASI :

(Continued Care Instruction/Education)

20/07/2023 e-RM.RI.02/20 Rev 05

Page 2
 RINGKASAN PULANG
(Discharge Summary) No RM : 0002083430
Nama : TRISNA SUNTARA
Tgl lahir : 17 Februari 1988 / L

Cara Pulang : Dipulangkan

Kondisi Saat Pulang : Meninggal > 48 Jam

TERAPI PULANG :
(Take Home Therapy)

KONTROL KE :
Alamat Faskes :
Tanggal Kontrol :

APABILA DALAM KEADAAN DARURAT DAPAT MENGHUBUNGI:

Nama :
No. Telp :
PROGNOSIS (Prognose) :
Ad. Functional : Dubia ad Malam
Ad. Vitam : Dubia ad Malam
Bandung, 14 Juli 2023
Pasien / Keluarga Dokter Penanggung Jawab Pelayanan

(.............................) Dr.dr. Kiki Lukman, M.Sc., Sp.B-KBD

20/07/2023 e-RM.RI.02/20 Rev 05

Page 3