R. Kenanga.docx

1. NASMI, 81 THN, 1212PJ14637 (21/04/18) S: Muntah-muntah sdh 8x, mual (+), BAB(+), BAK(+), nafsu makan menurun (+). Riw DM (+), HT(+), Riw. Obat Insulin 1x14IU (malam) O: NT epigastrium (+), Edema pretibial (+/+) TD 140/70mmhg, Nadi 120, RR 26, T 369 Laboratorium: Hb 12,1/ leu 30780/ Net 92/ Lim 5/ Eri 4,8/ Plt 211000/ Ht 36/ Ur 83/ Cr 2,8/ As Urat 3,2 A: Gastropathy diabetikum + HT Stage I + DM Tipe 2 P: - IVFD RL 20 gtt/I makro (IV) - Inj. Ranitidine 1 amp/12 jam - Inj Ondansetrone 1 amp/ 8 jam - Insulin 1 x 14 IU - Nucral syr 4xCII 22/04/18 S: gelisah (+), mual (+) O: Nyeri tekan epigastrium (+) A: Sepsis ec ? Hiponatremia Hipokalemia AKI Riffle I P: - Inj. Cefoporazone 1 gr/12 jam - Levofloxacin drip 500mg/ 24 jam - Inj esozid 1 vial/ 24 jam - Inj Ranitidine di stop - Ganti IVFD NACl 0,45 30 gtt/I makro - Cek ulang WBC 23/04/18 S: Lemas (+) O: TD 130/90 mmhg A: Sepsis ec ISK dd/Pneumonia DM tipe 2 uncontrolled Hiponatremia Hipokalemia P: cek BSN, BSPP, HbA1C, LDL-TG Terapi lanjutkan