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DPJP JANTUNG No. 1.

Identitas Pasien M. Taufiqur/25 tahun/246330/NPBI

Keluhan Utama dan Vital Sign KU : Kejang TD : 180/120 mmHg HR : 123 x/menit RR : 32 x/menit SpO2 : 69%

Diagnosis Masuk CKD + Konvulsi + Anemia + Dyspnea e.c ALO

Terapi Konsul Sp.JP : Inj. ................. 1mg/jam (5 cc/jam) Inj. Lasix 20 mg/jam (10 cc/jam) p/o Candesartan 16 mg 0-0-1 Raber Interna Pro ICCU Konsul Sp.P : Dx : .......................... + Efusi Pleura Bilateral Pro pumgs, tunggu USG Thorax Marker Inj. Cefoperazone 2 x 1 gram Nebul Combivent ½ ampul/8 jam Nebul Pulmicort ½ ampul/12 jam p/o Codein 3x10 mg

2.

Ruangan ICCU

Keterangan DPJP Jantung Raber Paru dan Interna

DPJP INTERNA No. 1.

Identitas Pasien Slamet/51 tahun/120012/NPBI

Keluhan Utama dan Vital Sign KU : Lemas TD : 115/67 mmHg HR : 69 x/menit RR : 29 x/menit SpO2 : 96%

Diagnosis Masuk Anemia + CKD HD Reguler + TB On Therapy

Terapi Konsul Sp.PD : Batasi minum Transfusi PRC 1kolf/hari hingga Hb > 9 gr/dL Terapi simptomatis Konsul Sp.P : Dx : .......................... + Efusi Pleura Bilateral Pro pumgs, tunggu USG Thorax Marker Inj. Cefoperazone 2 x 1 gram Nebul Combivent ½ ampul/8 jam Nebul Pulmicort ½ ampul/12 jam p/o Codein 3x10 mg

2.

Slamet/56 tahun/247430/NPBI

KU : Tidak bisa BAB TD : 168/99 mmHg HR : 68

Ruangan ICCU

Keterangan DPJP Jantung Raber Paru dan Interna

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