logbook internship

5/25/2018 logbook internship

1/91

TanggalKode

Kegiatan

Topik Kegiatan Catatan

Pendamping

Tanda

Tangan

Pendamping

Keterangan

TambahanNo

Diagnosis Penatalaksanaan

(1) (2) (3) (4) (5) (6) (7) (8)

07/09/2013 A

Ny. S, 33 tahun, G2P1A0

uk 38 minggu, JTHIU

prekep puki in partu kala I

fase laten

- Rawat Inap Kebidanan

- Observasi kemajuan

persalinan, awasi tanda-tanda

persalinan Kala IIdr. Layali

Musafiroh

1

07/09/2013 A

Ny. A, 22 th, G1P0A0 uk

12 minggu dengan HEG

- Rawat Inap

- IVFD D5% 20 tpm

- Inj. Ranitidin 3x1A

- Inj. Ondansetron 3x1A

- po Antacyd syr 3x2 cthdr. Layali

Musafiroh

2

07/09/2013 C

Ny. T, 40 th, Dispneu ec

susp CHF

- Rawat Inap

- O2 2-4 l/m

- IVFD D5% 15 tpm

- Inj. Furosemide 2x1 A (iv) -

pasang DC

- Plan: EKG, Ro Thorax PAdr. Layali

Musafiroh

3

07/09/2013 A

Ny. P, 20 th, G1P0A0 uk 39

minggu, JTHIU, preskep,

puka, belum in partu dengan

hipertensi gestasional suspPER dd PEB

- Rawat inap

- IVFD RL 20 tpm

- Nifedipin 2x10 mg

- Plan: Darah Lengkap, Proteinurin

dr. LayaliMusafiroh

4

09/09/2013 A

Tn. S, 51 th, susp TB paru

kasus putus obat

- Rawat Jalan

- Ambroxol 3x1 tab

- Neurodex 3x1 tabdr. Layali

Musafiroh

5


2/91

- Plan: Ro Thorax PA, sputum

BTA SPS

09/09/2013 A

Ny. M, 24 th, Artralgia susp

CTS

- Rawat jalan

- Na diclofenac 3x25 mg

- Neurodex 1x1 tab- Ranitidin 3x1 tab

- Plan: Fisioterapi

- Edukasi: hindari aktifitas

tangan berlebihdr. Layali

Musafiroh

6

09/09/2013 A

An. S, perempuan, 2 th, 15

kg, DATD+ISPA

- Rawat jalan

- Lacto-B 2x1 sach

- Zinc tab 1x1 tab

- Coparcetin syr 3x1 cthdr. Layali

Musafiroh

7

09/09/2013 B

Tn. S, 55 th, kontrol postClosed Fraktur os Clavicula

Dextra + VL digiti IV

manus dextra

- Rawat jalan- Clindamycin 300 mg 3x1 cap

- Asam mefenamat 3x500 mg

- Ranitidin 3x150 mg

- Edukasi : jaga luka tetap

kering, diet tinggi protein

karena luka lama keringdr. Layali

Musafiroh

8

09/09/2013 A

Tn. S, 40 th, Hipertensi

Stage I, ISPA. TD: 150/90

mmHg

- Rawat Jalan

- Captopril tab 2x12,5 mg

- Ambroxol 3x1 tab

- Bufantacyd 3x2 cth

- Edukasi: diet rendah garamdr. Layali

Musafiroh

9

09/09/2013 B

Tn. S, 40 th, kontrol VL

plantar pedis sinistra

- Rawat Jalan

- Ciprofloxacin 2x500 mg

- Dexamethason 3x0,5mgdr. Layali

Musafiroh

10


3/91

- Asam Mefenamat 3500 mg


- Edukasi : kontrol 3 hari, jaga

luka tetap kering, diet tinggi

protein

09/09/2013 B

Tn. D, 32 th, kontrol VL

cruris dextra

- Rawat jalan

- Amoxicillin 3x500 mg



-Edukasi : antibiotik

dihabiskan, jaga luka tetap

keringdr. Layali

Musafiroh

11

09/09/2013 B

Ny. K, 41 th, LBP post

trauma susp. Fraktur

Kompresi Vertebra Lumbal

- Rawat Jalan



- Plan: Ro Vertebra

Lumbosacral AP, Konsultasi

Dokter Spesialis Bedahdr. Layali

Musafiroh

12

09/09/2013 B

Tn. M, 34 th, Appendiksitis

kronik

- Rawat Jalan


- Spasminal 3x1 tab

- Konsultasi Sp.Bdr. Layali

Musafiroh

13

09/09/2013 B

Tn. I, 31 th, kontrol VL

palpebra superior sinistra

- Rawat jalan

- Aff hecting 2

- Neurodex 1x1 tab

- Vitalong C 1x1 tabdr. Layali

Musafiroh

14

09/09/2013 ANy. R, 40 th, Hipertensi

Urgensi, TD: 200/100 mHg

- Rawat jalan (pasien menolak

rawat inap)dr. Layali

Musafiroh15


4/91

- Amlodipin 1x10 mg

- Captopril 3x25 mg

- Neurodex 1x1 tab

09/09/2013 A

Ny. M, 45 th, Mialgia - Rawat jalan

- Meloxicam 3x1 tab- Neurodex 1x1 tab

- Ranitidin 3x150 mgdr. Layali

Musafiroh

16

09/09/2013 A

Ny. M, 31 th, Obs febris

susp Chikungunya BBPV

- Rawat jalan (menolak rawat

inap)

- Betahistine mesylate 2x1ab

- Paracetamol 4x500 mg kp

- Stimuno 2x1 tabdr. Layali

Musafiroh

17

10/09/2013 A

An.P, Perempuan, 9 bl, 7,2

kg. DADRS danRhinofaringitis akut

- Rawat inap

- IVFD RL 36 tpm (mikro)- Inj. Ranitidin 3x1/3A

- Inj. Ondansetron 3x1/3a

- Lacto-B 2x1 sachet

- Zinc 20 mg 1x1/2 tab

- Erlamol syr 3x1 cthdr. Layali

Musafiroh

18

10/09/2013 B

Ny. K, 55 th, kontrol post

Close fraktur humerus

sinistra 1/3 proximal

- Rawat Jalan

- Asam mefenamat 3x500 mg dr. LayaliMusafiroh

19

10/09/2013 A

Ny. P, 25 th, G3P0A2 uk 13

minggu dengan HEG derajat

II

- Rawat inap

- IVFD RL loading 500 cc -->

30 tpm

- RL:D5%:NaCl 0,9% 1:1:1 30

tpm

- Inj. Ranitidin 3x1Adr. Layali

Musafiroh

20


5/91


- Neurosanbe drip 1A/24 jam

10/09/2013 A

An. R, 7 th, 20 kg, DADRS,

obs febris susp Thyfoid

fever

- Rawat Inap - IVFD RL

loading 200 cc--> 30 tpm -->15

tpm- Inj. Chlorampheniol 4x250

mg (iv)

- Inj. Ranitidin 3x1/2A

- Inj Ondansetron 3x1/2A

- Sanmol syr 3x2 cth

- L-Bio 3x1 sachet

- Plan: DL, widaldr. Layali

Musafiroh

21

10/09/2013 A

An. E, 7 th, 23 kg, Ob

Vomitus suspek intoksikasi

makanan

Rawat Jalan

- Antasida doen syr 3x1 cth

- Ranitidin III, Papverin III,

Vit BC III, Vit C II ,mf No.X

3x1dr. Layali

Musafiroh

22

11/09/2013 A

Perempuan, 25 th, P1A0

post partum fisiologis Hari

ke-2 dengan PEB. TD:

130/90 mmHg

- BLPL

- Clindamicyn 3x300 mg

- Nifedipn 1x10mg

- Asam Mefenamat 3x500 mgdr. LayaliMusafiroh

23

11/09/2013 A

Perempuan, 35 th, P2A0

post partum SC atas indikasi

riwayat SC

- IVFD RL 20 tpm

- Inj. Cefriaxon 2x1 gr (iv)

- Inj. Ketorolac 3x1A

- po. Gastrul tab 2x1dr. Layali

Musafiroh

24

11/09/2013 A

Perempuan, 28 tahun,

G2P1A0 uk 37 minggu

JTHIU peskep puka in partu

- Rawat Inap obervasi vk

- IVFD RL 20 tpm

- Nifedipin 2x10 mg sldr. Layali

Musafiroh

25


6/91

kala I fase aktif dengan PER

12/09/2013 A

Tn. T, 31 th, Ob Febris susp

Thyfoid Fever

- Rawat Inap

- IVFD RL 2 tpm

- Chloramphenicol 4x500 mg

- Paracetamol 4x500 mg- Rantidin 3x150 mg

- Plan : DL, Widaldr. Layali

Musafiroh

26

12/09/2013 A

Tn. S, 30 th, DADRS - Rawat inap

- IVFD RL 20 tpm

- Loperamid 2-1-1

- L-Bio x1 sach

- Omeprazol 2x1 tabdr. Layali

Musafiroh

27

13/09/2013 A

Ny . E, 29 th, G1P0A0 uk

13 minggu dengn heg

derajat II

- Rawat inap


30 tpm - RL:D5%:NaCl ,9%

1:1:1 30 tpm



- Neosanbe drip 1A/24 jamdr. Layali

Musafiroh

28

13/09/2013 A

An. M, 10 th, 27 kg,

DADRS

- Rawat Inap

- IVFD RL 16 tpm

- Inj. Ranitidin 3x1/2 A

- L-Bio 3x1 sachet

- Zinc 1x1 tabdr. Layali

Musafiroh

29

14/09/2013 B

Tn.T, 60 th, Kontrol multpel

VL

- Rawat Jalan

- Asam mefnama 3x500 mg



Musafiroh

30


7/91

14/09/2013 A

An. B, 7 th, 18 kg, GEA

tanpa dehidrasi

- Rawat jalan

- Ranitidin 2x75 mg

- Antacida doen syr 3x1/2 cth

- L-Bio sach 2x1

- Zinc tab 1x1

dr. Layali

Musafiroh

31

14/09/2013 A

An. K, 4 th, 15 kg, GEADS

susp intoksikasi makanan

- Rawat inap

- IVFD RL 14 tpm (ma)


- Inj Metoclopramid 2x1/2A

- po Norit tab 3x5 tab

- Plan: DLdr. Layali

Musafiroh

32

14/09/20134 A

Tn. S, 54 th, Obs febris susp

Chikungunya dd DHF

- Rawat inap

- IVFD RL 20 tpm

- Paracetamol 4x500 mg

- Neurobion 1x1

- Stimuno 1x1 tabdr. Layali

Musafiroh

33

14/09/2013 B

Tn. S, 54 th , Abdominaal

pain ec GERD, dd gastritis

Rawat inap

- IVFD RL 20 tpm + Ketorolac

1A drip (extra)

- Inj Ranitidin 2x1 A

- po Ciprofloxacin 2x500 mg

- Buscopan 3x1 tab

- Plan: DL, EKGdr. Layali

Musafiroh

34

14/09/2013 A

An. G, 3 th, 8,5 kg, DADRS - Rawat inap

- IVFD RL 36 tpm (mikro)

- Inj. Ondansetron 3x1/3 A

- L-Bio 3x1 sachet

- Zinc 1x1/2 tabdr. Layali

Musafiroh

35


8/91

- Plan: DL

15/09/2013 A

Tn. W, 45 th, GEADS - Rawat inap

- IVFD RL LOADNG 500 CC

20 tpm

- Inj. Ranitidin 2x1A- Mecodiar 2 tab tiap kali BAB

- L-Bio 2x1 sach

- Zinc 1x1 tab - Plan: DLdr. Layali

Musafiroh

36

15/09/2013 A

Ny. U, 21 th, G2P1A0 uk 8

minggu dengan HEG

- Rawat inap


30 tpm

- Rl:D5%:NaCl 0,9% 1:1:1 30

tpm

- Neurosanbe drip 1A/24 jam

- Inj Ranitidin 3x1A

- Inj. Metocloperamid 3x1A

- Plan: DL, GDSdr. Layali

Musafiroh

37

15/09/2013 B

Tn. S, 56 th, susp Closed

fraktur antbrachii dextra,

hematom palpebra sinistra,

multipel VE

-Rawat inap-Wound toilet- Immobilisasi spalk+elasticband antebrachii sinistra

- IVFD RL 20 tpm- Inj. Ceftriaxon 2x1 gr (iv,

skintest)

- Inj. Ketorolac 2x1A kp- Inj. Ranitidin 3x1A-Plan: Ro antebrachi sinistra

AP&lateral, Konsultasi dr

sp.OT

dr. Layali

Musafiroh

38


9/91

16/09/2013 ANy. R, 22 th, G2P0A1 uk 36

minggu dengan konstipasi

- Rawat jalan - Microlac supp

1 tubedr. Layali

Musafiroh39

16/09/203 A

An. P, perempuan, 3, th, 18

kg, GEADS

- Rawat inap

- IVFD RL 56 tpm (mi)

- Inj Ranitidin2x1/2 A- Inj. Ondansetron 2x12A

- Myrasic syr 3x 1 1/2 cth


Musafiroh

40

16/09/203 A

Nn. I, 19 th, GEADR Rawat jalan

- Cotrimoxazol forte 2x1

- Loperamid 2-1-1 tab

- Paracetamol 3x1 tab

- Vitazym 3x1 tabdr. Layali

Musafiroh

41

16/09/2013 A

Ny. K, 25 th, G1P0A0 uk

39 minggu JTHIU presbo in

partu kala I fase aktif

Rawat inap

- IVFD RL 16 tpm


persalinandr. Layali

Musafiroh

42

17/9/2013 C

Ny. D, 60 tahun, Hipertensi

Emergensi. TD: 200/110

mmHg

Rawat inap

- IVFD RL 20 tpm

- Inj. rantidin 3x1A

- Amlodipin 2x10 mg

- Captopril 3x25 mg


- Plan: DL, GDS, Ureum,

Kreatinin, Ro thorax PA, EKGdr. Layali

Musafiroh

43

21/09/2013 A

Ny. A, 56 th, GEADS - Rawat inap

- IVFD RL 20 tpm


Musafiroh

44


10/91


- Scopma 3x1 tab

21/09/2013 A

Ny. R, 55 th, Hipertensi

stage II, Gastritis. TD:

170/100 mmHg.

- Rawat inap

- IVFD D5% 20 tpm

- Inj. Ranitidn 3x1A- Inj. Ondansetron 3x1 A

- Catopril 3x 25 mg

- Nifedipin 2x5 mgdr. Layali

Musafiroh

45

21/09/2013 A

Tn. S, 58 th Obs febris susp

thyfoid fever

- Rawat inap

- IVFD RL 20 tpm


- Antacida 3x1 tab

- Plan : DL, Widaldr. Layali

Musafiroh

46

21/09/2013 A

Ny. S, 38 th, Hipertensi

stage I, GEADS

- Rawat inap

- IVFD RL 20 tpm

- Inj. Ranitidin 3x1 A


- Captopril 3x12,5 mgdr. Layali

Musafiroh

47

21/09/2013 B

Tn. P, 30 th, Muliple VL - Rawat Jalan

- Wound toilet, hecting luar 3

- Inj. ATS 1.500 IU (im, skin

test)

- Clindamycin 3x300 mg

- Asam mefenamat 350 mg

- Dexamethason 3x0,5 mg

- Ranitidin 3x1tab

- Edukasi: jaga luka tetap

kering, kontrol poliklinikdr. Layali

Musafiroh

48


11/91

21/09/2013 A

Tn. E, 23 th, GEADS - Rawat inap

- IVFD RL 30 tpm



- L-Bio 3x1 sach- Zinc 1x1 tab


Musafiroh

49

22/09/20103 A

Ny. T, 35 th,

BPPV+Gastritis akut

- Rawat inap

- IVFD D5%:RL 2:1 20 tpm

- Inj. Ranitidn 3x1 A

- Inj. Difenhidamin 3x1A

- Neurobion drip 1A (extra)

- Omeprazlol 2x1 tab

- Antacida Doen syr 3x2cthdr. Layali

Musafiroh

50

22/09/2013 A

Nn. I, 13 th, 24 kg, Obs

febris 5 hari susp Thyfoid

fever dd DHF

- Rawat inap

- IVFD RL 20 tpm


- Inj. Ondansetron 3x1 A

- Paracetamol tab 3x500 mg


Musafiroh

51

22/09/2013 C

Ny. T, 60 th, Asma attack

pada asma persistten sedang,

hipertensi stage II, susp TB

paru kasus putus obat. TD:

160/90 mmHg

Rawat inap

- O2 2-4 l/m

- Nebulisasi Ventolin 2,5 mcg

- IVFD RL 20 tpm


- Ambroxol 3x1 tab

- Captopril 3x25 mg

- Paracetamol 3x500 mgdr. Layali

Musafiroh

52


12/91

- Plan: Ro thorax PA, GDS,

DL, sputum BTA SPS, EKG

22/09/2013 A

An. R, perempuan, 7 bln,

6,5kg, GEADS,

Rinobronkhitis akut

Rawat inap


30 tpm (mi)- L-Bio 3x1 sach

- Zinc x1/2 tab

- GG II, CTM II, PCT II, vit C

II mf X 3x1


Musafiroh

53

22/09/2013 A

Tn. E, 33 th, Gasroenteritis

kronik, Candidiais oral,

suspek AIDS

- Rawat inap

- IVFD D5% 30 tpm


- Antacida Doen syr 3x2 cth

- L-Bio 3x1 sachet

- Zinc 1x1 tab

- Kandstatin drop 4x100.000

IU

- Plan: DL, GDSdr. Layali

Musafiroh

54

23/09/2013 A

Tn. S., 39 th, obs. Febris

susp TF

Rawat jalan




- Neurodex 1x1 tab - Plan:

DL, widaldr. Layali

Musafiroh

55

23/09/2013 C

Ny. M, 61 th,Obs dyspnea

ec anemia gravis

- Rawat inap

- O2 3 l/m

- IVFD NaCl 0,9% 20 tpmdr. Layali

Musafiroh

56


13/91

(ma)

- Inj. Ranitidin 3x1A(iv)

Plan: DL, golongan darah,

EKG, Ro thorax

23/09/2013 B

Tn. P, 30 th, VEdorsumpedis dextra et

sinistra

Rawat jalan- Amoxicillin 3x 500 mg


-Neurodex1x1tabdr. Layali

Musafiroh

57

23/09/2013 B

Tn.W, 75 th,Obs dyspnea

susp PPOK dd TB paru

Rawat inap

- O2 3l/m

- IVFD RL 20 tpm


Musafiroh

58

24/09/2013 A

Ny. R, 50 th, GEADS Rawat inap

- IVFD RL loading 300cc

30 tpm

- Inj.Ranitidin 2x1A


- Cotrimoxazol 2x1tab

- Scopamin plis 2x1 tab

- Zinc tab 1x2

- New diatab 3x1dr. LayaliMusafiroh

59

24/09/2013 C

Ny.M, 45 th,Multple VE,

VL capitis

- Rawat inap

- O2 2l/m

- IVFD RL 30 tpm


- Inj.Ondansetron 3x1A

- Ketorolac drip 3x 1 A

- Inj.Neurotam 3x1Adr. Layali

Musafiroh

60


14/91

- Inj.Citicholin 3x 1 A

- Inj. Ceftriaxon 2x1 gr (iv,

skin test)

24/09/2013 C

Ny. R,23 th, VE cruris

dextra

Rawat jalan

- Amoxicillin 3x500 mg- Asam mefenamat 3x500 mg

dr. LayaliMusafiroh

61

24/09/2013 A

An.Aditya,6

th,15kg,Tonsilitiskronik

eksaserbasi akut

Rawat inap

- IVFD RL15 tpm

- Inj.Ceftriaxon 2x250 mg

- Inj.Gentamicin 2x20 mg

- Inj.MP 2x1/2cc

- Luminal II, PCT III,

Domperidon II, Vit. C III mf

X,3x1dr. Layali

Musafiroh

62

24/09/2013 A

Ny.S,28 th, obs.febris susp

DHF dd TF

rawat jalan



- Neurodex 1x1 tab

- Vitalong C1x1 tabdr. Layali

Musafiroh

63

24/09/2013 A

Tn. A, 25 th, TTH Rawat jalan


- Neurodex 1x1 tab

- Vitalong c 1x1 tabdr. Layali

Musafiroh

64

24/09/2013 A

Tn.S, 75 th,Obs febris susp

Chikungunya

rawat inap

- IVFD RL loading 1000 cc

20 tpm

- Inj. Cefotaxim 2x1 gr

- Inj.Dexamethason 3x1Adr. Layali

Musafiroh

65


15/91



- Luminal 2x1 tab

24/09/2013 A

An.S, 7 th,Obs febris susp

DHF grade II

Rawat inap

- IVFD RL 40 tpm 4jam

20tpm


- Paracetamol syr 3x1 cth

- DEHAF 2x1

- Curcuma 2x1cthdr. Layali

Musafiroh

66

24/09/2013 A

Tn.S, 38 th,GEADS Rawat inap

- IVFD RL loading 300 tpm

30 tpm

- Inj.Ranitidin3x1A

- New diatab 3x1

- Cotrimoxazol 2x1

- Scopamin plus 2x1

- L-Bio 3x1sach


Musafiroh

67

24/09/2013 A

Ny.D,20 th, G1P0A0 uk

39+4 minggu

JTHIU,preskep,inpartu kala

II lama

rawat inap

-Vakum ekstraksi

dr. Layali

Musafiroh

68

25/09/2013 A

Ny.K,60th, gastritis rawat inap

- IVFD RL 16 tpm

- Inj.Ranitidin 3x1 A



Musafiroh

69


16/91

- Curcuma 3x1 tab

25/09/2013 A

An.E,5th,15 kg, Kejang

Demam Sederhana

rawat inap

- IVFD D5%15 tpm

- Inj.Dexamethason 3x2cc

- Luminal 5 mg II, Vit. C 25mgII,PCT 70mg III, mf X,3x1

dr. LayaliMusafiroh

70

25/09/2013 A

An.H,2 th,9 kg,GEA

dehidrasi sedang,

rawat inap

- IVFD RL 300 cc loading-->

36 tpm

- Fuzide syr 3x1 cth

- Sanmol syr 3x3/4 cth

- L-bio 3x1/2sach

- Zinc 1x1/2tabdr. Layali

Musafiroh

71

25/09/2013 B

An.I, 1 th,8,5 kg,

KDS,Rhinofaringitis akut

rawat inap

- IVFD RL loading 200cc -->

30tpm (mi)

- Sanmol syr 3x 3/4cth

- CTM II, GG II,Luminal II,

VitCII,m.f X,3x1dr. Layali

Musafiroh

72

25/09/2013 A

ny. R,50 th,DM tipe 2 degan

GEADS

rawat inap

- IVFD RL loading 500cc --

>24tpm

-Inj.Ranitidin 3x1A

- Inj. Ondansetron1 A (extra)

- Glibenclamide1x5mg (1-0-0)

- New diatab 3x1 tab

- Scopamin plus3x1tab

- PCT 3x500mgdr. Layali

Musafiroh

73


17/91

25/09/2013 A

An.M,2 th, 9 kg,GEADS rawat inap

-IVFD RL loading 150 cc --

>36tpm (mi)

-L-Bio 3x 1/2sach

- Zinc 1x1/2tab

dr. Layali

Musafiroh

74

25/09/2013 B

An. M,12 th, 20 kg,Obs

febris susp DHFderajat II dd

TF

rawat inap

- IVFD RL loading 400 cc-->

30 tpm

- Inj.Ranitidin 3x1/2A

- sanmol syr4x2 cth

- Stimuno tab 1x1

- DEHAF2x 1/2sach


Musafiroh

75

25/09/2013 A

An.M, 9 bln,8,5

kg,GEADS,Rhinofaringitis

akut

rawat inap

- IVFD D5% loading 100 cc-->

40 tpm(mi)

- Sanmol syr 4x1 cth

- Lacto B 3x1/2sach

- Zinc 1x1/2tab

- GG II,CTM II,Vit C III,mf X

3x1dr. Layali

Musafiroh

76

25/09/2013 A

Tn. S,40 th,Vl dorsum pedis

dextra,VE olecranon sinistra

rawat jalan

- wound toilet,hecting luar

- Inj ATS1.500 IU(im,skintest)

- Amoxicillin 3x500 mg -

Asam mefenamat 3x500 mg -

Ranitidin 3x150 mgdr. Layali

Musafiroh

77


18/91

28/09/2013 AAn. F,14 th, susp Miopia

ODS,

Rujuk Sp.M dr. Layali

Musafiroh78

28/09/2013 C

Tn.M, 23th,VE genu dan

olecranon sinistra

rawat jalan

- Amoxicillin 3x 500 mg

- Asam Mefenamat 3x 500mg- ranitidin 3x 150mg

- Amlodipin 1x5 mgdr. Layali

Musafiroh

79

28/09/2013 B

Ny. T,30 th, G3P2A0 uk 38

minggu JTHIU preskep in

partudgn febris hari ketiga

dan Hipertensi gestasional

susp PER

Rawat inap

- IVFD RL 16tpm

- Nifedipin1x 10 mg


- Plan: DL,protein urindr. Layali

Musafiroh

80

28/09/2013 C

An.S,12th, 36kg, Combustio

derajat II-III luas 18%

rawat inap

-IVFD RL16 loading 300 cc-->

30tpm


- Bioplasenton saelp 3dd ue

-kompres luka/8 jam dengan

NaCldr. Layali

Musafiroh

81

28/09/2013 B

Tn.Y,58 th,Asma attack rawat inap

- O2 4-5 lpm

- Nebulisasi Ventolin 1A

-IVFD D5% 16tpm

- Methylprednisolon tab

2x4mg

- Salbutamol 3x2 mg

- Ambroxol3x30 mgdr. Layali

Musafiroh

82

29/09/2013 A tn. M,59 th, Dm tipe 2 rawat jalan dr. Layali 83


19/91

dengan motion sickness - Dimenhidrinat 3x1 tab

- Domperidon 2x1 tab

- Ranitidin 3x150mg

- PCT 3x500 mg

- Glibenclamid 1x5 mg- Metformin 3x500 mg

Musafiroh

29/09/2013 B

Ny. S, 60th,obs dyspnea ec

susp CPC decompensata dd

Bronkopneumonia

rawat inap

- O2 4-5lpm

- Inj.Ceftriaxon 2x 1gr (iv)

- Inj.Furosemid 2x1A

- Nifedipin1x10 mg

- Digoxin 1x0,125mg

- Plan: DL, Ur, Cr, GDS, ro

thorax PA, EKGdr. Layali

Musafiroh

84

29/09/2013 BNy.S, 25th, G1P0A0 uk 39

minggu dengan inersia uteri

rawat inap

-Konsul Sp.OGdr. Layali

Musafiroh85

01/10/2013 A

An.L, 13 bulan, 7,5kg,

GEADS, Rhinofaringitis

akut

Rawat inap


30 tpm (mi)


- Lacto b 3x1/2sach

- Zinc 1x1/2tab

- GG II,CTM II,sacharin adlib

mf X 3x1

dr. Layali

Musafiroh

86

01/10/2013 B

Ny.N, 65 th,VL capitis rawat jalan

- wound toilet,hecting luar7


- Asam mefenamat 3x500mgdr. Layali

Musafiroh

87


20/91


01/10/2013 B

Nn.A,25th,Vulnus punctum


rawat jalan

Inj. ATS1500 IU

- Clindamycin3x300 mg

- Asam mefenamat 3x500mg- Ranitidin 3x150 mg

dr. LayaliMusafiroh

88

01/10/2013 B

Ny.T, 21 1th, Vulnus

Punctum plantar pedis

sinistra

Rawat jalan

- Inj. ATS 1.500 IU



- Rantidin 3x150 mgdr. Layali

Musafiroh

89

02/10/2013 A

Ny. T, 50 th, GEADS Rawat inap


30 tpm





- Scopamin plus 3x1 tab

Plan: DLdr. Layali

Musafiroh

90

02/10/2013 A

An. J, 10 th, 25 kg, GEADS rawat inap


16 tpm

- Inj. Rantidin 3x1/2 A- Lacto B 3x1 sach

- Zinc tab 1x20 mgdr. Layali

Musafiroh

91

05/10/2013 CTn. D, 60 th, Obs. dyspnea

susp TB paru kasus baru,

- Rawat inap

- O2 3-4 l/m, nasal canuldr. Layali

Musafiroh92


21/91

hipertensi stage I , TD:

140/90 mmHg

- IVFD D5% 20 tpm


- Amboxol tab 3x30mg

- Amlodipin 1x10mg

- Curcuma 3x1 tab- Plan: DL, EKG, Ur, Cr, GDS,

Ro thorax PA, BTA SPS

05/10/2013 A

Ny. S, 34 th, Gastritis kronik - Rawat inap

- IVFD D5% 20 tpm --> D5%:

RL 1:1


- Inj Ondansetron 3x1 A

- Omeprazol 2x1 tab

- Antasida doen syr 3x2 cthdr. Layali

Musafiroh

93

05/10/2013 A

Nn. S, 19 th, Obs febris susp

TF dd DHF, Gastritis akut

- Rawat inap

- IVFD D5% 20 tpm 2 flab --

> RL 20 tpm


- Inj. Ondansetron 1A (extra)

- PCT 4x500 mg

- Curcuma 1x1 tab

- Plan: Dl, Widal, GDS: 77

mg/dldr. Layali

Musafiroh

94

05/10/2013 A

Ny. S, 55 th, Obs febris suspTF dd DHF

- Rawat inap- IVFD RL loading 500 cc -->

maintenance 20 tpm


- Inj Ondanasetron x1 Adr. Layali

Musafiroh

95


22/91


- Neurodex 1x1 tab

- Plan: DL, widal

05/10/2013 A

Ny. N, 44 th, BPPV - Rawat inap

- IVFD RL 20 tpm- Inj. Ranitidin 3x1A


- Betahstin mesylate 3x1 tab


- Antasida Doen 3x2 cthdr. Layali

Musafiroh

96

05/10/2013 A

Ny. K., 50 th, GEADS,

Hipertensi stage II, susp DM

tipe II. TD: 170/100, GDS:

359 mg/dl

- Rawat inap


maintenance 20 tpm



- Cotrimoxaol 3x1 tab


- Captopril 3x25 mg

- Metformin 3x500 mg

- Plan: DL, GDP. G2PP, Ro

thorax PAdr. Layali

Musafiroh

97

05/10/2013 B

An. G, 6 th, 20 kg, VE reg

capitis

- Rawat jalan

- Amoxicillin yr 3x1 cth

- Erlamol syr 2x cth

dr. Layali

Musafiroh

98

05/10/2013 A

Ny. K, 57 th, GERD - Rawat inap (APS)

- IVFD RL16 tpm

- Ranitidin 3x 150mg


Musafiroh

99


23/91

- Antasida doen syr 3x 2 cth

- Neurodex 1x1 tab

05/10/2013 A

Ny. E, 6 th, DM tipe II,

Hipertensi stage II. TD:

180/100 mmHg, GDS: 143mg/dl

- Rawat jalan

- Glimepirid 1x1 mg

- Captopril 3x 25 mg- Amlodipin 1x10 mg


Musafiroh

100

05/10/2013 A

An. E, 9 bln, 9,2 kg,

GEADS

- Rawat inap

- IVFD D5%-1/4 NS loading

100 cc--> maintenance 36 tpm

(mi)

- Lacto-B 2x1/2 sach

- Zinc 1x10 mg

- Paracetamol drop 3x0.9 cc

- Plan: DL dr. LayaliMusafiroh

101

07/10/2013 C

Ny. A, 20 th, obs. vomitus

ec intoksikasi larutan

pemutih pakaian; Tentament

suicide

Rawat inap Bilas lambung

500 cc NaCl --> jernih--

>puasakan 6 jam


30 tpm --> 20 tpm


- Norit 3x6 tab

- Alprazolam 1x0,5 mg (0-0-1)

- Plan: DL

dr. Layali

Musafiroh

102

07/10/2013 B

Tn. A, 27 th, Multiple VE - Rawat jalan

- Wound toilet

- Amoxicillin 3x 500 mg


Musafiroh

103


24/91

- Ranitidin 2x10 mg

- Neurodex 1x1 tab

07/10/2013 B

An. B, 80 th, 20 kg,VL reg

Fontal dextra

- Rawat jalan

- Hecting luar 2

- Amoxicillin syr 3x1 cth- Paracetamol syr 3x1 cth dr. LayaliMusafiroh

104

07/10/2013 C

An. L, 5 th, 8,5 kg, KDS,

obs febris h1. t: 42 C

- Rawat inap

- IVFD RL 12 tpm (ma)


- Diazepam 5mg III, Vit C III,

Vit BC III --> No. X, 3x1


Musafiroh

105

07/10/2013 A

Tn. S, 80 th, Hipertensi

stage I, Retensio urine susp

BPH. TD: 150/90 mmHg

- Rawat jalan

- Ganti kateter urin


- Ranitidin 2x150 mg -

Captopril 1x12,5 mgdr. Layali

Musafiroh

106

07/10/2013 A

Ny. T,2 th, Gastritis akut - Rawat jalan

- Ranitidin 3150 mg


- Omepraol 2x1 tabdr. Layali

Musafiroh

107

07/10/2013 A

An. S, 12 th, 27 kg , Obs

febris susp TF, gastritis

Rawat inap

- IVFD RL 20 tpm

- Inj Ranitidin 2x50 mg- Inj. Ondansettron 2x4 mg


- Antasida syr 3x2 cth

- Plan: DL, Widaldr. Layali

Musafiroh

108


25/91

07/10/2013 A

Tn. N, 28 th, Vomitus ec

intoksikasi obat kuat

- Rawat jalan

- Domperidon 3x1 tab

- Ranitidin 2x1 tab

- Diazepam 1x2mgdr. Layali

Musafiroh

109

07/10/2013 C

Tn. S, 18 th, CKR, VLlabium superior, Multiple

VE . GCS: E4M6V3.

- Rujuk- IVFD RL loading 500 cc -->

20 tpm

- Inj. cefotaxim 2x 1 gr (iv),

skin test

- Inj. Ranitidin 250 mgdr. Layali

Musafiroh

110

07/10/2013 B

Ny. S, 40 th, Multiple VE - Rawat jalan

- Wound toilet





Musafiroh

111

07/10/2013 B

An. A, 4 th, 12kg, VE reg

facial

- Rawat jalan

- Amoxicillin syr 3x1cth

- PCT syr 3x1 cthdr. Layali

Musafiroh

112

08/10/2013 A

An. L, 5 thh, 8,5 kg, KDS,

obs febris H3 susp thypoid

fever. t: 39,3 C

-Rawat inap - IVFD D5%-

1/4NS loading 100 cc --> 36

tpm (mi)


- PCT syr 4x1 cth- Diazepam 5 mg III, Vit C III,

Vit BC III --> No. X, 3x1 -

Plan: Widaldr. Layali

Musafiroh

113

08/10/2013 A An. E, 1 th, 9 kg, GEADS, Rawat inap dr. Layali 114


26/91

Rhinofaringitis akut - IVFD RL Loading 100 cc-->

36tpm (mi)


- Paracetamol drop 4x0,9 cc

- L-bio 2x1/2 sach

- Zinc syr 1x1/2 cth

- GG II, CTM III,

Dexamethason 0,5 mg II

sacharin lib --> No.X, 3x1

- Plan: DL

Musafiroh

10/10/2013 A

Ny. V, G1P0A0 usia 19

tahun uk 40 minggu JTHIU

preskep puki belum in partu

dengan ketuban pecah awal.

- Rawat inap kebidanan -

IVFD RL 16 tpm

dr. Layali

Musafiroh

115

10/10/2013 A

An. L, 8 bln, 8,5 kg, Obs

febris suspek DHF dd TF

- Rawat inap

- IVFD RL Loading 100 cc-->

32 tpm (mi)



- Plan: DL (trombosit

36.000/mm3, Widal S.thypii

O:1/80dr. Layali

Musafiroh

116

10/10/2013 A

An. Q, 9 bln, 6,8 kg,

GEADS, Rhinofaringitisakut

Rawat inap

- IVFD RL loading 100 cc -->28 tpm (mi)


- Lacto B 3x1/2 sach

- Zinc 1x1/2 tabdr. Layali

Musafiroh

117


27/91

- GG II, CTM II,

Dexamethason II, mf No. X,

3x1

10/10/2013 B

Tn. S, 37 th, Open fraktur

tibia et fibula dextra 1/3

medial displaced neglected

- Rawat jalan

- Ro Cruris dextra AP&lateral



- pro Konsultasi Sp.OT, pasien

menolak.dr. Layali

Musafiroh

118

10/10/2013 A

Tn. K., 60 th, Obs febris

susp Thyfoid fever dd DHF

- Rawat inap

- IVFD RL 20 tpm

- Paracetamol 3x500mg

- Curcuma 3x1 tab

- Antasida 3x2 cthdr. Layali

Musafiroh

119

10/10/2013 C

Tn. M, 3 th, Obs

heematemesis-melena up

hepatiis, dd cholelithiasis,

gastritis erosive, ulkus

peptikum

- Rawat inap

- IVFD D5% 20 tpm


- Inj. Metoclopramid 3x1A

- Inj. Asam tranamat 3x500 mg

- Curcuma 3x1 tab

- Plan: DL, GDS (87 mg/dl),

HBsAg, Bilirubindr. Layali

Musafiroh

120

10/10/2013 A

An. P, 14 bln, 8 kg, KDK.

s: 38C, kejang 2x

- Rawat inap

- IVFD RL loaoding 100 cc-->aintenance 32 tpm (mi)


- Luminal 30 mg IV, VIt C III,

Vit BC III, No. X, 3x1 -dr. Layali

Musafiroh

121


28/91

Plan: DL

10/10/2013 B

Tn. H, 18 th, Vulnus

laseratum digiti II manus

sinistra

- Rawat jalan

- Wound toilet, Hecting luar 1





Musafiroh

122

10/10/2013 A

Ny. K, 50 th, Hipertensi

grade II, gastritis.

TD:152/120 mmHg

- Rawat inap

- IVFD RL 20 tpm


- Captopril 3x25 mg

- Amlodipin 1x10 mg

- Neuroex 2x1 tab

- Plan: DL, GDS, Ur, Cr, Ro

thorax PAdr. Layali

Musafiroh

123

10/10/2013 A

Nn. R, 16 th urtikartia Rawat jalan

- Dexamethason 3x1 tab

- Loratadin 1x1 tab


Musafiroh

124

10/10/2013 A

Ny. S, 19 th, G1P0A0 40

minggu JTHIU,prekep, in

partu dengan kala II lama

- Rawat inap

- IVFD RL 20 tpm

- Pimpin persalinan

- Konsultasi dr. Arif, Sp.OGdr. Layali

Musafiroh

125

12/10/2013 A

An. K, 14 bln, 13 kg kontrolpost diare dan faringitis akut

- Rawat jalan- Cefadroxil 2x1 cth

- Cetirizine II, Dexamethason

II, Vit C III, mf No.X, 3x1dr. Layali

Musafiroh

126

12/10/2013 A, B Tn. W, 80 th, kontrol VL - Rawat jalan dr. Layali 127


29/91

palmar sinistra, hipertensi

stage I. TD: 140/90 mmHg

- Aff hecting

- Captopril 1x12,5 mg

- Neurodex 1x1 tab

Musafiroh

12/10/2013 A

An. M, 2,5 th, 11 kg,

GEADS

- Rawat inap


10tm (ma)

- Inj Ranitidin 2x1/2A

- Inj Metoclopramid 2x1/2A

- Lacto-B 2x1 sach

- Zinc 1x20 mg


Musafiroh

128

12/10/2013 A

Ny. A, 20 th, kontrol post

intoksikasi bayclin, gastritis

- Rawat jalan


- Omeprazol 2x1 tab

- Vitazym 2x1

- Curcuma 3x1dr. Layali

Musafiroh

129

12/10/2013 A

An. S, 2 th, 12 kg, Febris

usp TF, Rhinofaringitis

akut.

- Rawat jalan

- Cefadroxil 2x1 cth

- Paracetamol syrup 4x1 cth

- Dexamethason II, GG II, Vit

C III, mf no.X, 3x1dr. LayaliMusafiroh

130

12/10/2013 A

Ny. T, 33 th, Hipertensi

stage II. TD: 180/90 mmHg.

- Rawat jalan

- Captopril 3x 25 mg

- Neurox 1x1 tab- SF 1x1 tab

dr. Layali

Musafiroh

131

12/10/2013 BTn. W, 16 th, kontrol VE

reg capitis

- Rawat jalan


Musafiroh132

12/10/2013 A Tn. A, 62 th, gastritis - Rawat jalan dr. Layali 133


30/91

- Lagesyl syr 3x1 cth

- Laproton 2x30 mg

- Neurobion 1x1 tab

Musafiroh

12/10/2013 A

Ny. S, 25 th, intoksikasi

alkohol, gastritis

- Rawat inap

- IVFD D5% 16 tpm


- Omeprazol 1x1 tab

- Antasida syr 3x2 cthdr. Layali

Musafiroh

134

12/10/2013 C

Tn. R, 65 th, obs dyspnea

susp PPOK, dd TB paru,

pneumothorax.

- Rawat inap

- IVFD RL 16 tpm


- Aminofilin 3x1 tab

- Dexamethason 3x1 tab

- Captopril 1x25 mg

- Plan: EKG, Ro thorax PAdr. Layali

Musafiroh

135

12/10/2013 A

An.A, 3 th, 16 kg, observasi

febris susp Thyfoid fever dd

DHF

- Rawat inap

- Plan: DL, widal

- IVFD RL 12 tpm

- Paracetmol syr 3x 1 1/2 cth

- GG III, CTM II, Vit C IIIdr. Layali

Musafiroh

136

15/10/2013 A

Tn. M, 53 th, hipertensi

stage II, susp DM tipe II.

TD: 190/100 mmHg, gds;

258 mg/dl.

- Rawat inap

- IFVD RL 20 tpm

- Captopril 3x25 mg

- HCT 1x1 tab (1-0-0)- Metformin 3x500 mg

- Plan: DL, GDP, GD2PP,

EKG: LVHdr. Layali

Musafiroh

137

15/10/2013 A, B Tn. T, 80 th, multiple VE, - Rawat jalan dr. Layali 138


31/91

hipertensi stage II. TD:

160/100mmHg




- Neurodex 2x1 tab

- Vitalong C 1x1 tab

Musafiroh

15/10/2013 A

Ny. N, G1P0A0 usia 31

tahun uk 37 minggu preskep

dengan hipertensi dalam

kehamilan sup PER dd PEB,

susp panggul sempit. TB:

138 cm, TD: 136/90 mmHg

- Rawat inap

- IVFD RL 16 tpm

- Plan: DL, proten urin

dr. Layali

Musafiroh

139

15/10/2013 A

Ny. N, 55 th,Hipertensi

stage II dengan epistaksis.

TD: 180/100 mmHg.

- Rawat jalan

- Captopril 3x25 mg

- Propanolol 1x40 mg

- Kalnex tb 2x500 mg


Musafiroh

140

15/10/2013 B

Tn. R, 60 th, VL dorsum

pedis sinistra

- Rawat jalan

- Wound toilet, hecting

- Inj. ATS 1500 IU, im, skin

test




Musafiroh

141

15/10/2013 A

Nn. A 29 th, gastritis akut,susp ISK

- Rawat jalan- Amoxicillin 3x500 mg


- Ranitidin 2x150mg

- Antasida doen syr 3x2cthdr. Layali

Musafiroh

142


32/91

15/10/2013 A

Ny. K, 65 th, GEADS Rawat inap

- IVFD RL loading 500 cc--

>20 tpm


- Miratrim 3x1 tab

- Mecodiar 3x1 tab

- Omegdiar 3x1 tab

-Vosea 3x1 tabdr. Layali

Musafiroh

143

15/10/2013 A

Ny. A, 29 th, G2P1A0 uk 39

minggu dengan hipertensi

dalam kehamilan suspek

PEB. TD: 169/114 mmHg.

- Rawat inap

- IVFD RL 16 tpm

- Nifedipin 4x10 mg

- Plan: DL, protein urindr. Layali

Musafiroh

144

17/10/2013 A

Ny. R, 39 th, G3P2A0 uk 41

minggu JTHIU preskep


kehamilan susp PER dd

PEB. TD: 140/90 mmHg

- Rawat inap observasi

kemajuan persalinan

- Plan: DL, protein urin

- IVFD RL 16 tpm

- Nifedipin 2x10 mg

- Gastrul per vag 1/8 tab tiap 6

jamdr. Layali

Musafiroh

145

17/10/2013 A

An. A, 8 bln, 8 kg, GEADS,

obs febris susp demam

tifoid.

- Rawat inap

- Plan: DL, widal


12 tpm

- Inj. Ranitidin 2x1/2 A- Inj. Ondansetron 2x1/2A

- Lacto B 2x1 sach


- Paracetamol syr 3x1 cthdr. Layali

Musafiroh

146


33/91

17/10/2013 B

Tn, D, 53 th, vulnus

laseratum plantar pedis

dextra.

Rawat jalan

- Wound toilet, hecting

- Inj. ATS 1500 IU, im






- Neurodex 2x1 tabdr. LayaliMusafiroh

147

17/10/2013 B

Ny. I, 4 th, VE digiti I pedis

dextra

Rawat jalan

- Amoxicilin 3x500 mg




- Vitalog C 1x1 tabdr. LayaliMusafiroh

148

17/10/2013 B

Tn. D, 55 th, VE reg cruris

dextra

Rawat jalan

- Amoxicilin 3x500mg




Musafiroh

149

18/10/2013 A

Ny. K, 60 th, hipetensi stage

II, gastritis. TD: 180/100

mmHg

- Rawat inap

- IVFD RL 20 tpm


- Inj. Metoclopramid 2x1A- Captopril 3x25 mg

- HCT 1x25 mg (1-0-0)

- Curcuma 3x1 tab


Musafiroh

150


34/91

18/10/2013 A

An. K, 1,5 th, 8 kg.

Vomitus, TB paru dalam

pengobatan fase intensif

- Rawat inap

- IVFD RL 30 tpm (mi)

- Domperidon syr 3x1 cth

- Terapi TB dilanjutkandr. Layali

Musafiroh

151

18/10/2013 A

Ny. M, 22 th, G2P1A0 uk

38 minggu JTHIU preskep

puka in partu dengan

hipertensi gestasional

suspek PER. TD 150/90

mmHg.

Rawat inap

- IVFD RL 20 tpm

- Nifedipin 3x10 mg

- Plan: DL, Protein urin



Musafiroh

152

18/10/2013 A

Nn. L, 22 th, GERD dd

gastritis

Rawat jalan


- Lansoprazol 2x1 tab

- Antasid 3x2 cth


Musafiroh

153

18/10/2013 A

An. R, 7 bln, Diare Cair

Akut tanpa Dehidrasi, 8,5

kg

Rawat jalan

- L-Bio 3x1/2 sach

- Zinc 1x1/2 tab

- Paracetamol drop 3x0,9 ccdr. Layali

Musafiroh

154

20/10/2013 B


plantar pedis dextra

Rawat jalan

- Ganti balut



- Ranitidin 3x150 mg- Vitalong C 1x1 tab

dr. LayaliMusafiroh

155

20/10/2013 B

Ny. K, 45 th, VE manus

sinistra

Rawat jalan



Musafiroh

156


35/91

- Neurodex 1x1 tab

- Vitalong C1x1 tab

20/10/2013 B

Tn. R, 59 th, VE genu

sinistra

Rawat jalan


- Ibuprofen 2x400 mg



Musafiroh

157

20/10/2013 A

Ny. Y, 25 th, Vomitus ec

susp hepatitis akut dd

Cholesistitis, Thyfoid fever

Rawat jalan (menolak rawat

inap)

- Ibuprofen 3x400 mg

- Curcuma 3x1 tab

- Metoclopramid 3x1 tab

- Ranitidin 2x150mg

- Livron B plex 2x1 tabdr. Layali

Musafiroh

158

20/10/2013 A

An. R, perempuan, 5 bln,

5,5 kg, GEADS, febris susp

Thyfoid fever

Rawat inap

- IVFD D5%-1/4NS loading

100 cc --> 22 tpm (mi)

- Lacto-B 2x1/2 sach


- PCT drop 3x0,6 cc

- Plan: DL, Widaldr. LayaliMusafiroh

159

23/10/2013 B



Rawat jalan

- Ganti balut

- Ciprofloxacin 2x500 mg- Metronidazol 3x500 mg




Musafiroh

160


36/91

23/10/2013 A

Ny. S, 50 th,

Laringitis+gastritis akut

Rawat jalan



- Ranitidin 3x1 tab

- Lansoprazol 1x1 tabdr. Layali

Musafiroh

161

23/10/2013 A

Ny. K, 53 th, DM tipe II.

GDS: 285 mg/dl

Rawat jalan

- Glimepirid 1x1 mg



Musafiroh

162

23/10/2013 A

Ny. E, 26 th, Febris susp

Thyfoid fever. S:38,5C

Plan: DL, Widal. Hasil:

Leukosit 6.300/mm3, Widal S.

Typhii O dan H: +1/320

-Rawat jalan




- Neurodex 1x1 tab

- Edukasi: tirah baring, diet

lunak.dr. Layali

Musafiroh

163

23/10/2013 A

Ny. S, 61 th, Osteoarthritis

Genu sinistra

Rawat jalan



- Livron B plex 1x1 tab

-Fisioterapi

dr. Layali

Musafiroh

164

23/10/2013 A

Nn. F, 18 th, BPPV Rawat jalan

- Betahistin mesylate 2x1 tab

- Ranitidin 2x1 tab


Musafiroh

165


37/91

- Saran konsultasi dr. Sp.S

23/10/2013 A

Tn. T, 43 th, Gasritis,

kontrol post GEADS

Rawat jalan

- Ranitidin 2x1 tab



Musafiroh

166

23/10/2013 B

Tn. N, kontrol post op

Tumor supraorbita dextra

Rawat jalan

- Aff hecting 2

- Neurodex 1x1 tab


Musafiroh

167

23/10/2013 A

Ny. D, 60 th, DM tipe II,

dispepsia. GDS: ##high.

TD: 130/90 mmHg

rawat jalan (menolak rawat

inap)

- Glibenclamid 2x5 mg


- Lansoprazol 1x30 mg


Musafiroh

168

23/10/2013 A

An. B, 5 th, Febris suspek

thyfoid fever. S:39C, BB 20

kg.

rawat jalan

- Amoxicillin syr 3x1 cth

- PCT syr 3x1 1/2 cth

- Curcuma 3x1 cth


Musafiroh

169

24/10/2013 A

Ny. S, 44 th, ODS

Konjungtivitis kronik

Rawat jalan

- Gentamisin tetes mata 3x3

tetes ODSdr. Layali

Musafiroh

170

24/10/2013 A

An. D, perempuan, 5 th, 15kg, Observasi febris hari ke-

4 susp Thyfoid fever dd

DHF

Plan: DL (Trombosit178.00.mm3, leukosit

4300/mm3), Widal S. Thyphii

O dan H: +1/320

- Rawat inapdr. Layali

Musafiroh

171


38/91


15 tpm (ma)


- Thiamphenicol syr 3x1 cth

- PCT syr 3x1 1/2 cth

- Curcuma syr 3x1 cth

24/10/2013 A

Ny. C, 30 th, G3P2A0 uk

39+6 minggu JTHIU

preskep puka dengan

hipertensi gestasional susp


Plan: DL, protein urin

- Rawat inap

- IVFD RL 16 tpm

- Nifedipin 4x10 mg



Musafiroh

172

24/10/2013 A

Tn. S, 25 th, Observasi

febris suspek malaria dd

thyfoid fever. S:39C

Plan: DL, Widal, Apusan darah

tepi Plasmodium

- Rawat inap

- IVFD RL 20 tpm


- Pct 3x500 mg


Musafiroh

173

24/10/2013 A

Tn. H, 72 tahun, hipertensi

stage II, Diare akut tanpa

dehidrasi. TD: 165/100

mmHg.

Rawat jalan

- Captopril 3x25 mg

- HCT 1x5 mg (1-0-0)


- Antasida 3x2cth- Lacto-B 3x2 sach

dr. LayaliMusafiroh

174

25/10/2013 B

Tn. T, 37 th, Multple VE Rawat jalan

- Wound toilet

- Amoxicillin 3x500 mgdr. Layali

Musafiroh

175


39/91


- Vit. C 1x1 tab

25/10/2013 B

Ny. K, 36 th, VL dorsum

pedis dextra, VE pedis

sinistra

Rawat jalan





- Vit. C 1x1 tabdr. Layali

Musafiroh

176

25/10/2013 A

Tn. A, 27 th, myalgia post

trauma

Rawat jalan

- Neurodex 2x1 tab


Musafiroh

177

25/10/2013 A

Ny. T, 50 th, Observasi

febris susp Thyfoid fever dd

DHF. S: 39C

Plan: DL (Leukosit

14.000/mm3, trombosit

258.000/mm3), Widal -

(S.typhii O dan H: +1/160),

GDS: 97mg/dl. EKG: sinus

takikardi

- Rawat inap


30 tpm --> RL:D5% 1:1 30

tpm




dr. Layali

Musafiroh

178

25/10/2013 A

An. J, 5 th, 15 kg, GEADS Rawat inap

- IVFD RL loading 150 cc --

>12 tpm

- Inj. Ranitidin 2x1/2Adr. Layali

Musafiroh

179


40/91


- L.Bio 2x1 sach

- Zinc syr 1x1 cth

- Plan: DL

25/10/2013 A, B

Tn. M, 45 th, Hernia

scrotalis dextra+dispepsia

Rawat jalan (pro konsultasi

Sp.B, menolak)

- Scopma plus 3x1 tab



- Antasida doen 3x2cth

- Curcuma 3x1 cthdr. Layali

Musafiroh

180

26/10/2013 A

Tn.S, 80 th, Bronkhitis akut,

hipertensi terkontrol. TD:

130/90 mmHg

Rawat jalan

- Ambroxol 3x30 mg

- Erlamol 3x1 cth

- Bufantasid 3x1 tab


Musafiroh

181

26/10/2013 B

Tn.D, 53 th, kontrol VL


Rawat jalan

- Aff hecting 3

- po. Metronidazol 3x500 mg

- Ciprofloxacin 2x500 g




Musafiroh

182

26/10/2013 A

An. R, 12 th, 23 kg, Obs.Febris susp thyfoid fever dd

DHF

Rawat inap- IVFD D5%-1/4NS loading

200 cc--> 16 tpm


- Paracetamol 3x1/2tabdr. Layali

Musafiroh

183


41/91

- L-Bio 2x1 sach

- Curcuma 3x1 cth

- Plan: DL, Widal

26/10/2013 A

Tn. M, 40 th, LBP Rawat jalan




Musafiroh

184

26/10/2013 A

Ny. P, 45 th, Gastritis akut Rawat inap

- IVFD RL 20 tpm


- Bufantasid tab 2x1

- Curvit 3x1 tabdr. Layali

Musafiroh

185

26/10/2013 B

Tn. K, 50 th, susp

ureterolithiasis sinistra

Rawat jalan

- Nefrolit 3x1 tab

- Spasminal 3x1 tab

- Analtram 3x1 tabdr. Layali

Musafiroh

186

02/11/2013 A

Ny. D, 60 th, Gastritis, susp

ISK

Rawat inap

- IVFD RL 20 tpm

- Inj. Metoclopramid 3x1 A


- Omeprazol tab 1x1

- Curvit 3x1 tab


- Plan: DL, UL

dr. Layali

Musafiroh

187

02/11/2013 A

An. A, 10 th, 20 kg, Obs.

Febris 4 hari susp DHF dd

Thyfoid fever

Rawat inap


15 tpm

- Inj. Metoclopramid 2x1/2 Adr. Layali

Musafiroh

188


42/91



- Curvit 3x1 tab

- DEHAF 2x1 sch

02/11/2013 A

Ny. M, 33 th, P2A1 susp

abortus komplet dd abortus

inkomplet

Rawat jalan (APS)



- Livron B plex 1x1 tabdr. Layali

Musafiroh

189

02/11/2013 A

Ny. R, 29 th, G4P1A2 uk 39

minggu presbo puka in partu

kala I fase aktif dengan

KPD

Rawat inap

- IVFD RL 16 tpm

- Inj. Amoxicillin 3x1 gr (iv)

Observasi kemajuan persalinandr. Layali

Musafiroh

190

02/11/2013 A

Ny. T, 23 th, G1P0A0 uk 40

mgg presbo puka in partu

kala I fase aktif

Rawat inap

- IVFD RL 20 tpm



Musafiroh

191

02/11/2013 C

Ny. S, 60 th, Obs dyspnea

susp BrPn dd CHF, TB paru

Rawat inap

- O2 2-3 l/m, nasal canul

- IVFD RL 20 tpm

- Inj. Cefotaxim 2x1 gr (iv,

skin test)

- Inj. Furosemid 1A (extra)


- Ambroxol 3x30 mgPlan: DL, Ur, Cr, Ro thorax

PAdr. Layali

Musafiroh

192

06/11/2013 AAn. Z, 3 th, 16 kg, GEADR Rawat jalan

- Zinc 1x1 tabdr. Layali

Musafiroh193


43/91

- L-Bio 3x1 sach

- Norvom syr 3x1/2 cth

06/11/2013 A

Tn. K, 31 th, DADR,


170/110 mmHg

Rawat jalan


- Mecodiar 3x1 tab

- Dimenhidrinat 3x1 tab dr. LayaliMusafiroh

194

06/11/2013 A

An. A, 2 th, 10 kg, DADRS Rawat inap


10 tpm

- Inj. Ondansetron 2x1/4A

- Kaotin syr 3x1 cth

- L-Bio 3x1 sach

- Zinc 2x1/2 tab

- Plan: DR, widaldr. Layali

Musafiroh

195

06/11/2013 A

Ny. R, obs febris, postpartum 2 minggu

Rawat inap- IVFD RL 20 tpm

- Inj. Scopamin 2x1A

- Erlamol 3x1 tab

- Plan: DR, Urin rutin, widaldr. Layali

Musafiroh

196

06/11/2013 A

Tn. W, 60 th, GEADS Rawat inap

- IVFD RL 30 tpm



- Diastop 3x1 tab- L-Bio 3x1 sach


Musafiroh

197

06/11/2013 ANy. T, 27 th, G2P1A0 uk

39+5 minggu JTHIU

Rawat inap

- IVFD RL 16 tpmdr. Layali

Musafiroh198


44/91

presentasi kaki, puki, in



persalinan

06/11/2013 A

An. Q, 9 bln, 6,5 kg,

GEADS, obs febris susp

Thyfoid fever

Rawat inap


28 tpm (mi) --> RL:D5-1/4NS

1:1 28 tpm (mi)

- Paracetamol drops 4x0,7 cc

- Zinc 1x1/2 tab

- L-Bio 2x1/2 sachdr. Layali

Musafiroh

199

06/11/2013 B

Ny. N, 24 th, susp tumor

mammae dextra

Rawat jalan

- Amoxiciin 3x500 mg




- Kontrol ke poli bedah

dr. Layali

Musafiroh

200

07/11/2013 B

Ny. S, 39 th, kontrol VL

capitis+supraorbita sinistra

Rawat jalan

- Ganti balut



- Neurodex 1x1 tab

- Vitalong C 1x1 tabdr. LayaliMusafiroh

201

07/11/2013 A

Tn. A, 17 th, Bronkhitis

kronis

Rawat jalan

- Cefadroxil 2x500 mg

- Fludane plus 3x1 tab- Ranitidin 2x1 tab


Musafiroh

202

07/11/2013 BAn. M, 4 th, 15 kg, kontrol

vulnus amputatum digiti V

Rawat jalan

- Aff hectingdr. Layali

Musafiroh203


45/91

pedis sinistra - Paracetamol syr 3x1 cth

07/11/2013 B

An. A, 13 th, 31 kg, kontrol

VE plantar pedis dextra

Rawat jalan

- Wound toilet, ganti balut



- Gentamisin salep 1xoles

- Bioplasenton salep 1xolesdr. Layali

Musafiroh

204

07/11/2013 A

Ny. S, 59 th, Dispepsia, PV Rawat jalan

- Ranitidin 3x1 tab

- Omeprazol 1x1 tab

- Neurodex 1x1 tab

- Ketokonazol salep 2xolesdr. Layali

Musafiroh

205

07/11/2013 A

Ny. R, 44 th, Dispepsia,

susp anemia

Rawat jalan

- DL: pasien menolak

- Ranitidin 3x150 mg- SF 2x1 tab

- Curvit 3x1 tab


Musafiroh

206

07/11/2013 A

Ny. I, 45 th, konrol post

thyfoid fever

Rawat jalan


- Curvit 3x1 tab

- Ranitidin 3x150 mgdr. LayaliMusafiroh

207

07/11/2013 A

Ny. R, 60 th, Fatigue,

hipertensi terkontrol. TD:110/90 mmHg

Rawat jalan

- Captopril 1x12,5 mg- Neurodex 2x1 tab

- Curvit 3x1 tab


Musafiroh

208

07/11/2013 A Ny. J, 70 th, DADRS, Rawat jalan dr. Layali 209


46/91


161/95 mmHg

- Captopril 3x25 mg

- New diatab 3x1 tab


- L-Bio 3x2 sach

- Ranitidin 2x1 tab

Musafiroh

08/11/2013 A

Tn.S, 53 th, hipertensi stage

I, gastritis. TD: 147/80

mmHG

Rawat jalan


- Ranitidin 3150 mg


Musafiroh

210

08/11/2013 A

Ny R, 38 th, myalgia Rawat jalan




Musafiroh

211

08/11/2013 A

Ny. N, 31 th, obs dyspnea ec

alergi makanan

Rawat inap

- O2 2-3 l/m- IVFD D5% 20 tpm

- Inj. Dexamethason 3x1A

- Loratadin 1x1 tabdr. Layali

Musafiroh

212

09/11/2013 B

An. Z, 13 th, 50 kg, CKR,

hematom reg. Capitis, VE

reg cruris sinistra

Rawat jalan


- Piracetam 3x400 mg


- Neurodex 2x1 tab


dr. Layali

Musafiroh

213

09/11/2013 A

Tn. H, 52 th, GEADS Rawat inap


30tpm


Musafiroh

214


47/91


- New diatabs 3x1 tab

- Scopma 3x1 tab

Plan: DL

09/11/2013 A

Tn. K, 41 th, GEADS Rawat inap


30 tpm




- Kaotin 3x1

- Scopma 3x1 tabdr. Layali

Musafiroh

215

09/11/2013 B

An. M, 4 1/2 th, 13 kg,

Multipel VE

Rawat jalan

- Wound toilet

- Amoxicillin syr 3x1 cth- Paracetamol syrup 3x1 cth

- Bioplasenton gel 2xolesdr. Layali

Musafiroh

216

09/11/2013 B

Ny. S, 45 th, Dislokasi

anterior articulatio

glenohumerale dextra+

fraktur caput humeri dextra

Rawat jalan (menolak konsul

Sp.OT)

- Tramadol 2x50 mg


- Neurodex 2x1 tab

- Plan: Ro shoulder joint dextradr. Layali

Musafiroh

217

09/11/2013 A

An. M, 2 th, 14 kg, GEADS Rawat inap- IVFD RL loading 125 cc -->

15 tpm


- L-Bio 2x1 sachdr. Layali

Musafiroh

218


48/91

- Zinc 1x1 tab

- Plan: DL

09/11/2013 A

Tn. W, 30 th, Obs febris,

konstipasi, candidiasis oral,

susp HIV/AIDS

Rawat jalan (menolak rawat

inap)

- Bisacodyl 2x1 tab


- DMP 3x1 tab

- Curvit 3x1 tab

- Candistatin drops 4x100.000

IUdr. Layali

Musafiroh

219

13/11/2013 A

Tn. S, 70 th, GERD Rawat inap

- IVFD RL 20 tpm



- Lansoprazol tab 2x1- Antasida doen syr 3x2 cth

dr. Layali

Musafiroh

220

13/11/2013 A

Ny. E, 41 th, serangan asma

ringan pada asma

intermitten

Rawat jalan

- Nebulisasi Ventolin 1amp

- Ambroxol 3x30 mgdr. Layali

Musafiroh

221

14/11/2013 A

Tn. S, 72 th, hipertensi stage

II, obs vomitus. TD: 177/89

mmHg. GDS: 101 mg/dl

Rawat inap

- IVFD D5% 20 tpm -->

D5%:RL 1:1 20 tpm


- Inj Ondansetron 3x1A- Inj. Spashi 1A

- Captopril 3x25 mg

- HCT 1x25 mg (1-0-0)dr. Layali

Musafiroh

222

14/11/2013 B Tn. S, 57 th, kontrol Vulnus Rawat jalan dr. Layali 223


49/91

Punctum digiti IV manus

dextra

- Aff hecting 1



- Neurodex 2x1 tab

Musafiroh

14/11/2013 C

Nn. L, 21 th, Multipel VE Rawat jalan




Musafiroh

224

14/11/2013 D

Nn. R, 17 th, anxietas Rawat jalan

- Alprazolam 1x0,25 mg

- Neurobion 1x1 tabdr. Layali

Musafiroh

225

14/11/2013 B

An. A, 10 th, 29 kg, VL

labium superior sinistra

Rawat jalan



- Paracetamol 3x2 cth

dr. Layali

Musafiroh

226

15/11/2013 A

Ny. N, 20 th, G1P0A0 uk 40


partu kala I Iama

Rawat inap

- IVFD RL 16 tpm

- Konsultasi dr. Arif, Sp.OG :

induksi persalinan dengan

Misoprostol 1/8 tab fp tiap 8

jam.dr. Layali

Musafiroh

227

15/11/2013 A

Tn. N, 48 th, DADS,

hipertensi stage I. TD:

140/90 mmHg

Rawat inap


30 tpm- Inj. Ranitidin 2x1A


- Loperamid tab 2-1-1

- Scopma 3x1 tabdr. Layali

Musafiroh

228


50/91

- L-Bio 3x2 sachet


- Plan: DL

15/11/2013 A

Ny. S, 27 th, G4P2A1 uk 40


partu kala II, dengan riwayat

TB

Rawat inap

- Pimpin persalinan

dr. Layali

Musafiroh

229

15/11/2013 A

Ny. L, 40 th, Gastritis akut Rawat inap (APS)

- IVFD RL 20 tpm


- Bufantasid syr x2 cth

- Omeprazol 2x1 tab


Musafiroh

230

18/11/2013 B

Sdr. S, 16 th, VL dan

dislokasi digiti V pedisdextra, Multiple VE

Rawat inap

- Konsultasi dr. Yuli, Sp.OT :motivasi operasi

reposisi+pasang wire

- IVFD RL 16 tpm




- Plan : Ro pedis dextra, DLdr. Layali

Musafiroh

231

18/11/2013 A

Ny. S, 72 th, suspek

hepatitis akut, aritmia. EKG:Ventricular couplet

Rawat inap

- Plan: DL. HBsAg, bilirubintotal, bilirubin direk


D5% 24 tpm


Musafiroh

232


51/91

- Curvit 3x1 tab


- Konsultasi dr. Luqman,

Sp.PD: Dx susp

Cholangiocarcinoma, VES.

Terapi: bisoprolol 1x2,5 mg.

Cek laborat SGOT dan SGPT,

pro USG abdomen di

dr.Alip,Sp.Rad.

20/11/2013 A

Ny. R, 19 th, G2P0A1 uk

42+2 minggu JTHIU

preskep in partu kala I fase

laten

Rawat inap

- IVFD RL 16 tpm



Musafiroh

233

20/11/2013 B

Tn. R, 27 th,VL reg labium

superior, VE genu dextra etsinistra

Rawat jalan

- Ciprofloxacin 2x500 mg- Asam mefenamat 3x500 mg



Musafiroh

234

21/11/2013 C

An. N, 2,5 th, 10,5 kg, KDS.

S:38C.

Rawat inap

- O2 2l/m, nasal canul

- IVFD D5%1/4 NS loading

100 cc --> 12 tpm (ma)

- Stesolid supp 1 (extra)

- Cefadroxil syr 2x1 cth- PCT syr 4x1 cth

- Diazepam 2mg VI, mfla pulv

dtd X, 3x1dr. Layali

Musafiroh

235

21/11/2013 A Tn. M, 52 th, hipertensi Rawat jalan dr. Layali 236


52/91

stage I, ISPA. TD: 140/90

mmHg



- Ambroxol 3x30 mg

- Neurodex 1x1 tab

Musafiroh

24/11/2013 B

An. D, laki-laki, 12 th,

multiple VE.

Rawat jalan


- PCT syr 3x1 cth

- Curcuma syr 3x1 cthdr. Layali

Musafiroh

237

24/11/2013 B

Nn. L, 21 th, VL capitis Rawat jalan




- Neurodex 1x1 tab


Musafiroh

238

24/11/2013 A

An. M, 8 bln, 4,6 kg.GEADS, obs febris susp

thyfoid fever

Rawat inap- IVFD D5% 1/4 NS loading

100 cc --> 24 tpm (mi)

- PCT drops 4x0.6 cc

- L-Bio 2x1/2 sach

- Zinc 1x10 mg

- Plan: DL, Widaldr. LayaliMusafiroh

239

24/11/2013 A

An. N, 5,5 th, 16 kg, KDS Rawat jalan (menolak rawat

inap)

- Amoxicillin 3x1 cth- PCT 3x 1 1/2 cth

- Diazepam 2mg VIII, Vit C

IV, sacharin ad lib mfla pulv

X, 3x1dr. Layali

Musafiroh

240


53/91

24/11/2013 A

Ny. K, 38 th, G5P2A2 uk

41+2 minggu JTHIU

preskep belum in partu




Rawat inap

- IVFD RL 16 tpm

- Konsultasi dr. Arif, Sp.OG:

induksi Misoprostol 1/8 tab fp

tiap 8 jam

- Plan: DL, protein urindr. Layali

Musafiroh

241

24/11/2013 C

Tn. T, 70 th, Observasi

dyspnea susp PPOK dd TB

paru

Rawat inap

- Plan: GDS (104 mg/dl), EKG

(sinus takikardi, P pulmonal

pada lead II, III, aVF), DL, Ur,

Cr, Ro thorax PA.

- O2 3 l/m, nasal canul

- IVFD D5%+Aminofilin 1A

20 tpm

- Inj. Ranitidin 2x1A- Inj. Ondansetron 2x1A

- Ambroxol 3x30 mg

- PCT 3x500 mg


Musafiroh

242

24/11/2013 B

Tn. A, 41 th, chest pain post

trauma 2 hari SMRS, VE

manus dextra.

Rawat jalan



- Neurodex 1x1 tab


dr. Layali

Musafiroh

243

25/11/2013 B

Tn I, 26 th, tumor perianal Rawat jalan

- pro konsul Sp.B


- Dexamethason 3x0,5 mgdr. Layali

Musafiroh

244


54/91



25/11/2013 A

Ny.S, 63 th, hipertensi stage

II. TD: 180/100 mmHg

Rawat jalan

- Captopril 3x25 mg

- Amlodipin 1x10 mg


Musafiroh

245

25/11/2013 A

Sdr. T, 19 th, Scabies Rawat jalan

- Scabisid 1xoles malam hari


- Loratadin 1x1 tab

- Edukasi : rendam pakaian

dengan air panas sebelum

dicuci, gunakan pakaian yang

tidak ketat, yang menyerap

keringat, pisahkan pakaianpasien dengan anggota

keluarga lain saat dicuci,

hindari berbagi menggunakan

pakaian.dr. Layali

Musafiroh

246

25/11/2013 BAn. D, 12 th, kontrol

multiple VE

Rawat jalan

- Bioplasenton 3xolesdr. LayaliMusafiroh

247

25/11/2013 A

Ny. R, 60 th, kontrol post

GEADS, hipertensi stage I.

TD: 140/90 mmHg.

Rawat jalan

- Amlodipin 1x5 mg


dr. Layali

Musafiroh

248

25/11/2013 ANy. S, 17 th, kontrol post

SC h-13

Rawat jalan

- Ganti balutdr. Layali

Musafiroh249

25/11/2013 BAn. A, 13 th, kontrol post

ORIF a/i closed fraktur

Rawat jalan

- Ganti balutdr. Layali

Musafiroh250


55/91

antebrachii sinistra

25/11/2013 A

Tn. S, 28 th, susp

limfadenitis colli

Rawat jalan




- kontrol 3 hari kemudiandr. Layali

Musafiroh

251

25/11/2013 A

Ny. S, 28 th, mialgia Rawat jalan



- Sohobion 1x1 tabdr. Layali

Musafiroh

252

25/11/2013 A

An. A, 12 th, 20 kg, ISPA Rawat jalan

- Plan: DL (leukosit

17.500/mm3)

- Cefadroxil syr 2x1 cth

- PCT syr 3x1.5 cth- Ambroxol 3x15 mg

dr. LayaliMusafiroh

253

25/11/2013 A

Tn. J, 32 th, Febris 6 hari

susp thyfoid fever. S:36,2C.

Rawat jalan

- Plan: DL, widal (+1/320)



- PCT 3x500 mg kp

- Sohobion 1x1 tabdr. LayaliMusafiroh

254

26/11/2013 B

Ny. S, 35 th, VL labium

superior externa, labiuminferior interna et mentalis

Rawat jalan

- Wound toilet, hecting luar 2,dalam 6




Musafiroh

255


56/91

- Betadine kumur 3x/hari

26/11/2013 A

An. A, 8 bln, 8 kg, GEADS Rawat inap

- IVFD Rl loading 150 cc -->

32 tpm (mi)

- Cotrimoxazol syr 2x1 cth

- PCT syr 3x1 cth

- L-Bio 2x1/2 sach

- Zinc 1x10 mg


Musafiroh

256

26/11/2013 B

Ny.J, 70 th, fraktur tertutup

linier os ulna 1/3 distal

dextra

Rawat jalan (menolak konsul

Sp.OT)

- Tramadol 2x50 mg

- Thrombophob gel 2xoles

- Plan: Ro wrist joint dextradr. Layali

Musafiroh

257

26/11/2013 A

Ny. R, 40 th, G3P2A0 uk 40minggu JTHIU preskep in




PEB. TD: 153/78 mmHg,

s:38C

Rawat inap- IVFD RL 20 tpm

- Nifedipin 3x10 mg


- Plan: DL, protein urin.

dr. LayaliMusafiroh

258

26/11/2013 A

Ny. T, 45 th, GEADS. Rawat inap


30 tpm- Inj. Ranitidin 2x1A

- Inj. Ondansetron 2x1a

- Inj. Spashi 1A (extra)


Musafiroh

259


57/91


- Lacto-B 3x2 sach

- Plan: DL

27/11/2013 A

Ny. F, 25 th, G3P2A0 uk

9+3 minggu susp Abortus

imminens dd hemoroid

interna grade I

Rawat inap

- IVFD RL 20 tpm

- Inj. Ketorolac 2x1A

- Inj Ranitidin 2x1A

- Hystolan 3x1 tabdr. Layali

Musafiroh

260

27/11/2013 A

Ny. S, 26 th, G1P0A0 uk 37

minggu JTHIU presbo in


Rawat inap

- IVFD RL 20 tpm



Musafiroh

261

27/11/2013 C

Tn. C, 64 th, Obs

hematemesis susp gastritis

erosiva dd ulkus peptikum.KU/Kes: lemas,

pucat/E3M6V5. TD: 79/49

mmHg. CA +/+

Rujuk

- Pasang NGT, bilas lambung

500 cc- IVFD RL loading 1000 cc-->

40 tpm

- Inj. Pantoprazol 80 mg

- Inj. Asam Tranexamat 1A

- Inj. Vit K 1 Adr. Layali

Musafiroh

262

27/11/2013 B

Ny. S, 37 th, Multiple VE Rawat jalan

- Wound toilet


- Paracetamol 3x500 mg- Mertigo 2x1 tab


Musafiroh

263

29/11/2013 BTn. D, 45 th, VL supraorbita

dextra

Rawat jalan

- Wound toilet, hecting luar 1dr. Layali

Musafiroh264


58/91



- Neurodex 1x1 tab

29/11/2013 A

Ny. S, 37 th, G5P2A2 uk 36


partu kala I lama

Rawat inap

- Konsul dr.Arif, Sp.OG: Inj.

Dexamethason 15 mg



Musafiroh

265

29/11/2013 B

Sdr. N, 20 th, hematom

antebrachii dextra post

dipukuli

Rawat jalan

- Thrombophob gel 2xoles dr. Layali

Musafiroh

266

29/11/2013 A

Ny. I, 25 th, GEADS. TD:

79/56 mm/Hg.

Rawat inap

- Plan: DL, GDS (109 mg/dl)


RL:D5% 1:1 30 tpm- Inj. Ranitidin 2x1A


- Scopamin 3x1 tab

- New diatabs 3x1 tabdr. Layali

Musafiroh

267

01/12/2013 C

Ny. K, 50 th, obs dyspnea

susp CHF dd TB paru kasus

kambuh

Rawat inap

- O2 4l/m

- IVFD D5% 500 cc/24 jam


- Curvit 3x1 tab- Konsul dr. Luqman, Sp.PD :

Ro thoraxdr. Layali

Musafiroh

268

01/12/2013 BTn. A, 30 th, VE manus

dextra et genu sinistra

Rawat jalan

- Wound toiletdr. Layali

Musafiroh269


59/91


- Neurodex 1x1 tab

- Bioplasenton gel 2xoles

01/12/2013 A

Nn. K, 19 th, GEADS Rawat inap


30 tpm



- Scopamin 3x1 tab

- Lacto-B 3x2 sachet

- New diatabs 3x1 tab


Musafiroh

270

02/12/2013 B

Tn. M, 47 th, tumor penis Rawat inap

- IVFD RL+Adona 1A, 20 tpm

- Inj. Cefotaxime 2x1 gr- Inj. Ketorolac 2x1 A

- Inj. Vit.K 1x1 A


- Motivasi rujuk RSU DR.

Karyadi Semarangdr. Layali

Musafiroh

271

02/12/2013 B

Sdr. K, 14 th, Multiple VE,

hematom retroauricula

dextra, antebrachii sinistra

Rawat jalan


- Neurodex 1x1 tab

Visum et repertum

dr. Layali

Musafiroh

272

02/12/2013 BNy. K, 45 th, tumor

nasofaring susp ganas

Rujuk

- IVFD D5% 20 tpmdr. Layali

Musafiroh273

02/12/2013 ANy. S, 45 th, hipertensi stage

I, gastritis

Rawat jalan


Musafiroh274


60/91

- Ranitidin 2x1 tab

- Scopamin 3x1 tab

- Vitazym 2x1 tab

02/12/2013 A

Ny. J, 21 th, G1P0A0 uk 41

minggu JTHIU preskep

puka in partu kala I lama

Rawat inap

- IVFD Rl 20 tpm

- Konsultasi dr. Arif, Sp.OG :

induksi misoprostol 1/8 tab pv

tiap 8 jamdr. Layali

Musafiroh

275

03/12/2013 A

Ny. S, 27 th, G3P2A0 uk 12

minggu susp Abortus

insipien

Rawat inap

- IVFD RL 20 tpm dr. Layali

Musafiroh

276

03/12/2013 B

Tn. A, 37 th, colic abdomen

susp ureterolithiasis sinistra,

hipertensi stage II

Rawat inap

- Pasang DC

- IVFD RL 20 tpm

- Inj. Spashi 3x1A- Inj. Ondansetron 2x1A

- Captopril 3x25 mg

- Plan: DL, UL, BNO abdomendr. Layali

Musafiroh

277

03/12/2013 C

Ny. A, 45 th, angina pectoris

susp ACS.

Rawat inap

- EKG : ST elevasi di lead

V4,5,6

- IVFD RL 20 tpm


- Aspilet 2 tab 80 mg,selanjutnya 3x80 mg

- Clopidogrel 2 tab 75 mg,

selanjutnya 1x75 mg

- Amlodipin 1x10 mgdr. Layali

Musafiroh

278


61/91

06/12/2013 A

Ny. D, 32 th, G2P0A1 uk

37+5 minggu JTHIU

preskep in partu kala I fase

laten dengan hipertensi

dalam kehamilan susp PEB.

TD: 160/100 mmHg.

Rawat inap

- IVFD RL 20 tpm

- Nifedipin 10 mg

- Plan: DL, protein urin

dr. Layali

Musafiroh

279

06/12/2013 B

Tn. S, 49 th, V. Amputatum

digiti II manus sinistra

Wound toilet, hecting

situasional

- Rujuk

- Ciprofloxacin tab 500 mg

- Asam mefenamat tab 500 mgdr. Layali

Musafiroh

280

06/12/2013 C

An. R, 2 th, 13 kg, KDS.

S:39C

Rawat inap

- IVFD D5%-1/4 NS 12 tpm

(ma)

- Paracetamol syr 4x1 cth- Diazepam 2 mg III, sacharin

ad libitum mfla pulv dtd X,

3x1dr. Layali

Musafiroh

281

06/12/2013 B

Ny. T, 32 th, VE supraorbita

sinistra

Rawat jalan


- Neurodex 2x1 tab

- Thrombophob gel 3x olesdr. Layali

Musafiroh

282

06/12/2013 B

Ny. I, 28 th, VE supraorbita

dextra

Rawat jalan

- Amoxicillin 3x500 mg- Ranitidin 3x150 mg


Musafiroh

283

06/12/2013 ANy. S, 52 th, Hipertensi

stage II. TD: 180/90 mmHg.

Rawat inap

- EKG: LVHdr. Layali

Musafiroh284


62/91

- IVFD D5% 20 tpm


- Captopril 3x25 mg

- Amlodipin 1x10 mg

06/12/2013 A

Tn. W, 59 th, gastritis Rawat inap (APS)

- IVFD D5% 20 tpm

- Inj. Spashi 1A (extra)

- Omeprazol 2x1 tab

- Ranitidin 3x1 tab

- Antasida 3x2cthdr. Layali

Musafiroh

285

06/12/2013 A

Ny. M, 40 th, G4P3A0 uk

36 minggu JTHIU preskep

in partu kala I fase laten

dengan KPD

Rawat inap

- IVFD RL 20 tpm

- Inj. Amoxicillin 3x1gr (iv)

skintest

- Plan:DL

dr. Layali

Musafiroh

286

08/12/2013 B

Ny. R, 32 th, VL pedis

sinistra

Rawat jalan

- Wound toilet, hecting dalam

2, luar 7

- Inj. ATS 1500 IU (im, skin

test)



- Ranitidin 2x1 tab

- Neurodex 1x1 tab

dr. Layali

Musafiroh

287

08/12/2013 B

An. N, 8 th, 26 kg, VE pedis

sinistra

Rawat jalan

- Wound toilet


- Paracetamol syrup 3x2 cthdr. Layali

Musafiroh

288


63/91

- Thrombophob gel 3x oles

08/12/2013 B

Sdr W, 19 th, VL plantar

pedis sinistra

Rawat jalan


3, luar 9

- Inj. ATS 1500 IU (im,

skintest)



- Ranitidin 2x1 tab


Musafiroh

289

08/12/2013 A

Ny. R, 50 th, GEADS,

hipertensi stage I. TD:

150/90 mmHg

Rawat inap


30 tpm


- Inj. Ondansetron 2x1A- Loperamid 2-1-1

- Lacto-b 3x2 sach



Musafiroh

290

08/12/2013 A

Ny.I, 32 th, faringitis akut Rawat jalan

- Ciprofloxacin 2x 500 mg



- Curcumex 3x1tabdr. Layali

Musafiroh

291

08/12/2013 A

Sdr. A, 24 th, susp thyfoid.

S: 36,2C, GDS: 79 mg/dl

Rawat inap (APS)

- IVFD D5% 20 tpm --> RL 20

tpm


Musafiroh

292


64/91


08/12/2013 A

Nn. I, 28 th, gastriti post

intoksikasi alkohol. GDS:

69 mg/dl.

Rawat jalan (menolak RI)

- Omeprazol 2x1 tab

- Ranitidin 3x1 tab


Musafiroh

293

09/12/2013 A

Ny.D, 41 th, gastritis akut Rawat jalan

- Omeprazol 2x1 tab

- Ranitidin 3x1 tab

- Antasid tab 3x1


Musafiroh

294

09/12/2013 A

An. S, 8 th, 19 kg, obs febris

susp thyfoid fever dd DHF.

S:38C

Rawat inap

- IVFD D5%-1/4NS 15 tpm

(ma)


- Inj. Ondansetron 2x1/2 tab- PCT syr 3x2 cth

- Curcuma syr 3x1 cth


Musafiroh

295

09/12/2013 A

An. L, 14 th, gastritis akut

dd dismenorea

Rawat inap

- IVFD RL 20 tpm


- Inj. Spashi 3x1A

- Omeprazol 2x1 tab


dr. Layali

Musafiroh

296

09/12/2013 B

Tn.L, 24 th, VL&VE reg

mentalis, susp closed fraktur

antebrachii sinistra distal

Wound toilet, hecting luar 3

- Immobilisasi wrist joint

sinistra

- Ro wrist joint dextradr. Layali

Musafiroh

297


65/91




- Neurodex 1x1 tab

09/12/2013 A

An. F, 6 bln, 8 kg. GEADS Rawat inap

- IVFD RL loading 100 cc-->36 tpm (mi)


- L-Bio 2x1 sach

- Zinc 1x1/2 tab

- PCT drops 3x0,8 ccdr. Layali

Musafiroh

298

12/12/2013 B

Ny. R, 60 th, V. Punctm

manus dextra, hipertensi

stage II. TD: 180/100

mmHg

Rawat jalan



- Asam mefenamat 3x500 mg- Ranitidin 3x150 mg

- Captopril 3x25 mg

- Thrombophob gel 3x olesdr. Layali

Musafiroh

299

12/12/2013 C

Ny. D, 26 th, G2P1A0

dengan retensio plasenta.

TD: 100/80 mmHg

Rawat inap


RL 500 cc+ Oxytosin 1 amp

drip 20 tpm

- Manual plasenta

- Inj. Methergin 1A (im)

- Inj. Amoxicillin 3x1 gr (iv,

skintest)


- SF 2x1 tabdr. Layali

Musafiroh

300


66/91

- Plan: DL (Hb 9,4 g/dl,

leukosit 11.970/mm3,

Trombosit 156.000/mm3)

13/12/2013 A

Ny. B, 24 th, G1P0A0 uk

16+1 minggu dengan

hiperemesis gravidarum danfebris

Rawat inap


RL:D5:NaCl:Aminofluid1:1:1:1 30 tpm

- Drip Neurosanbe 1A/24 jam





Musafiroh

301

13/12/2013 A

AN. M, 5 th, 17 kg,

Hydradenitis supurativa,

rhinofaringitis

Rawat jalan

- Cefadroxil syr 2x1 cth

- Coparcetin kid cough 3x1 cth- Loratadin III, sacharin ad lib

pulv No.X, 3x1dr. Layali

Musafiroh

302

14/12/2013 B

Sdr. W, 19 th, kontrol VL


Rawat jalan

- Wound toilet, ganti balut


- Metronidazol 3x500 mg

- Huferalgin 3x1 tab



Musafiroh

303

14/12/2013 A

Ny. M, 57th, Dm tipe II

terkontrol. GDP: 92 mg/dl.

TD: 100/70 mmHg

Rawat jalan

- Glimepirid 1x1 mg



Musafiroh

304


67/91

14/12/2013 A

Ny. M, 51 th,

CHF&cardiomiopati

dilatasi. TD: 130/80 mmHg

Rawat jalan

- Furosemid 1x20 mg

- Digoxin 2x1/2 tab

- Aspilet 1x1 tab

- Letonal 1x25 mg

- Curcuma 1x1 tab

dr. Layali

Musafiroh

305

14/12/2013 A

Ny. K, 65 th, low back

pain&gastritis

Rawat jalan


- Calc os 1x1 tab

- Omeprazol 2x1 tab


Musafiroh

306

14/12/2013 A

Ny.L, 54 th, hipertensi stage

II+gastritis. TD: 160/90

mmHg

Rawat jalan

- Amlodipin 1x10 mg


- Ranitidin 2x150 mg- Curvit 3x1 tab

dr. LayaliMusafiroh

307

14/12/2013 A

Ny. K, 42 th,

gastritis&migrain

Rawat jalan


- Omeprazol 2x1 tab

- Ranitidin 3x1tab

- Neurodex 1x1 tabdr. LayaliMusafiroh

308

15/12/2013 BNn. R, 18 th, tumor

mammae dextra pro operasi

Rawat inap

- Puasakan mulai pukul 06.00dr. Layali

Musafiroh309

18/12/2013 B

Sdr. W, 19 th, kontrol VLplantar pedis sinistra Rawat jalan- Aff hecting selang-seling

- Clindamisin 3x300 mg


- Ranitidin 2x1 tabdr. Layali

Musafiroh

310


68/91

18/12/2013 A

Ny. M, 45 th, gastritis

kronik

Rawat jalan


- Ranitidin 2x1 tab


Musafiroh

311

18/12/2013 A

Ny. F, 41 th, gastriris akut Rawat jalan

- Omeprazol 1x1 tab- Ranitidin 2x1 tab


- Diazepam 2 mg 1x1 (malam)dr. Layali

Musafiroh

312

18/12/2013 A

Tn. A, 24 th, thyfoid fever.

S:38C, S.thyphii O: +1/160

Rawat jalan

- Ciprofloxacin2x500 mg

- Paracetamol 3x500 mh

- Ranitidin 2x1tab

- Neurode 1x1 tabdr. Layali

Musafiroh

313

18/12/2013 A

Tn. I, 32 th, hipertensiterkontrol, cephalgia. TD:

110/80 mmHg.

Rawat jalan- Amlodipin 1x5 mg

- Histigo 3x1 tab

- Neurodex 1x1 tab

- Diazepam 2mg 1x1 (malam)dr. Layali

Musafiroh

314

18/12/2013 A

Tn. S, 39 th, Insomnia Rawat jalan

- Alprazolam 0,5 mg 1x1

(malam)

- Diazepam 2mg 1x1 (malam)dr. Layali

Musafiroh

315

19/12/2013 B

Sdr. F, 20 th, V. Amputatum

digiti V manus sinistra.

Rawat jalan


2, luar 7

- Inj. ATS 1500 IU (im, skin

test)dr. Layali

Musafiroh

316


69/91



- Ranitidin 2x1 tab


19/12/2013 B

Tn. D, 38 th, VL capitis Rawat jalan

- Wound toilet, hecting luar 10- Ciprofloxacin 2x500 mg


- Tramadol 2x50 mg

- Ranitidin 2x1 tab


Musafiroh

317

20/12/2013 A

Ny. R, 50 th, observasi

febris h-7 susp thyfoid fever

dd DHF. S:39C

Rawat inap

- IVFD RL 20 tpm


- Paracetamol 4x500 mg k.p- Curcuma 3x1 tab

- Plan: DL, widal.dr. Layali

Musafiroh

318

20/12/2013 A

Tn. K, 31 th, Obs febris susp

thyfoid dd DHF. S: 37,9C.

TD: 96/60 mmHg.

Rawat inap

- IVFD RL lading 500 cc--> 30

tpm




- Neurodex 1x1 tab

- Plan: DL,

logbook internship

Documents

susp tb parukasus putus

po antacyd syr 3x2 cthdr

coparcetin syr 3x1 cthdr

jthiuprekep puki in

furosemide 2x1 a iv

vitalong c 1x1 tabdr

na diclofenac 3x25 mg

diet tinggi proteinkarena