Ny. Asmah

REKAP TERAPI DAN PEMERIKSAAN LABORATORIUM

Nama : Ny. AsmahUmur : 51 thNo. CM : 976332Alamat : Sumur Lubang, Salira, PuloampelDiagnosa :

DM 2 (Post op debridement ulkus DM pedis sinistra) CKD gr. V Hipertensi

Terapi

23/10/16 24/10/15 25/10/15 26/10/15 27/10/15 28/10/15 29/10/15IVFD NaCl IVFD NaCl IVFD NaCl IVFD NaCl IVFD NaCl IVFD NaCl IVFD NaClCefotaxim 2x1 Cefotaxim 2x1 Cefotaxim 2x1 Cefotaxim 2x1 Cefotaxim 2x1 Cefotaxim 2x1 Cefotaxim 2x1Gentamycin 3x80 Gentamycin 3x80 Gentamycin 3x80 Gentamycin 3x80 Gentamycin 3x80 Gentamycin 3x80 Gentamycin 3x80Ketorolac 3x1 Ketorolac 3x1 Ketorolac 3x1 Ketorolac 3x1 Ketorolac 3x1 Ketorolac 3x1 Ketorolac 3x1PCT PCT PCT PCT PCT PCT PCTSleeding Scale Sleeding Scale Sleeding Scale Sleeding Scale Sleeding Scale Sleeding Scale Sleeding Scale

VIP Albumin3x1 VIP Albumin3x1 VIP Albumin3x1

1/11/2015 2/11/2015 3/11/2015 4/11/20155/11/2015

(Debridement) 6/11/2015 7/11/2015

IVFD NaCl IVFD NaCl IVFD NaCl IVFD NaCl IVFD NaCl PRC kolf -1KCl 50 meq + NaCl

Cefotaxim 2x1 Cefotaxim 2x1 Cefotaxim 2x1 Cefotaxim 2x1 Cefotaxim 2x1 Cefotaxim 2x1 PRC kolf - 2Gentamycin 3x80 Gentamycin 3x80 Gentamycin 3x80 Gentamycin 3x80 Gentamycin 3x80 Gentamycin 3x80 Cefotaxim 2x1

Ketorolac 3x1 Ketorolac 3x1 Ketorolac 3x1 Ketorolac 3x1 Ketorolac 3x1 Ketorolac 3x1Gentamycin 3x80

PCT PCT PCT PCT PCT Sleeding Scale Ketorolac 3x1Sleeding Scale Sleeding Scale Sleeding Scale Sleeding Scale Sleeding Scale Kalnex 3x1 Sleeding ScaleVIP Albumin3x1 VIP Albumin3x1 VIP Albumin3x1 VIP Albumin3x1 VIP Albumin3x1 Vit. K 3x1 Kalnex 3x1

Metronidazol 3x500 Vit. K 3x1Plasminex 3x1 KSR 3x1Vit. K 3x1KCl 25 meq + NaCl

8/11/2015 9/11/2015 10/11/2015 11/11/2015 12/11/2015 13/11/15 14/11/15Cefotaxim 2x1 PRC kolf - 3 Cefotaxim 2x1 Cefotaxim 2x1 Cefotaxim 2x1 Cefotaxim 2x1 Levofloxacin 1x500Ketorolac 3x1 Cefotaxim 2x1 Ketorolac 3x1 Ketorolac 3x1 Ketorolac 3x1 Ketorolac 3x1 Prorenal 3x1Sleeding Scale Ketorolac 3x1 Sleeding Scale Sleeding Scale Sleeding Scale Sleeding Scale Bicnat 3x1Kalnex 3x1 Sleeding Scale Kalnex 3x1 Kalnex 3x1 Kalnex 3x1 Kalnex 3x1 KSR 3x1Vit. K 3x1 Kalnex 3x1 Vit. K 3x1 Vit. K 3x1 Vit. K 3x1 Vit. K 3x1 Sleeding ScaleKSR 3x1 Vit. K 3x1 KCl 10 meq + NaCl IVFD NaCl KSR 3x1 KCl 50 meq + NaCl KCl 50 meq + NaClKCl 50 meq + NaCl KCl 50 meq + NaCl KCl 50 meq + NaCl

15/11/15 16/11/15 17/11/15 18/11/15 19/11/15 20/11/15Levofloxacin 1x500 Levofloxacin 1x500 Levofloxacin 1x500 Cefixim 2x1 Cefixim 2x1 Cefixim 2x1Prorenal 3x1 Prorenal 3x1 Prorenal 3x1 Prorenal 3x1 Prorenal 3x1 Prorenal 3x1Bicnat 3x1 Bicnat 3x1 Bicnat 3x1 Bicnat 3x1 Bicnat 3x1 Bicnat 3x1KSR 3x1 Amlodipin 1x10 Amlodipin 1x10 Sleeding Scale Sleeding Scale Sleeding Scale

Sleeding Scale KSR 3x1 KSR 3x1Drip kalnex 1 amp + NaCl

Drip kalnex 1 amp + NaCl


IVFD NaCl Allopurinol 1x300 Allopurinol 1x300 Vit. K 3x1 Vit. K 3x1 Vit. K 3x1Sleeding Scale Sleeding Scale Omeprazol 3x1 Omeprazol 3x1 Omeprazol 3x1Drip kalnex 1 amp + NaCl

Drip kalnex 1 amp + NaCl Sucralfat 3x1 Sucralfat 3x1 Sucralfat 3x1Vit. K 3x1 Asam folat 3x1 Asam folat 3x1 Asam folat 3x1Omeprazol 3x1 Hemafort 3x1 Hemafort 3x1 Hemafort 3x1Sucralfat 3x1 Amlodipin 1x10 Amlodipin 1x10Asam folat 3x1 ISDN 3x2,5 ISDN 3x2,5Hemafort 3x1

21/11/15 22/11/15 23/11/15 24/11/15 25/11/15 26/11/15Cefixim 2x1 Cefixim 2x1 Cefixim 2x1 Cefixim 2x1 Cefixim 2x1 Cefixim 2x1Prorenal 3x1 Prorenal 3x1 Prorenal 3x1 Prorenal 3x1 Sucralfat 3x1 Sucralfat 3x1Bicnat 3x1 Bicnat 3x1 Bicnat 3x1 Bicnat 3x1 Asam folat 3x1 Asam folat 3x1Sleeding Scale Sleeding Scale Sleeding Scale Sleeding Scale Hemafort 3x1 Hemafort 3x1Drip kalnex 1 amp + NaCl



Drip kalnex 1 amp + NaCl Prorenal 3x1 Prorenal 3x1

Vit. K 3x1 Vit. K 3x1 Vit. K 3x1 Vit. K 3x1 Bicnat 3x1 Bicnat 3x1Omeprazol 3x1 Omeprazol 3x1 Omeprazol 3x1 Omeprazol 3x1 Bisoprolol 1x2,5 Bisoprolol 1x2,5Sucralfat 3x1 Sucralfat 3x1 Sucralfat 3x1 Sucralfat 3x1 Sleeding scale Sleeding scaleAsam folat 3x1 Asam folat 3x1 Asam folat 3x1 Asam folat 3x1 Antalgin 3x1 Antalgin 3x1Hemafort 3x1 Hemafort 3x1 Hemafort 3x1 Hemafort 3x1 IVFD Martos IVFD MartosAmlodipin 1x10 Amlodipin 1x10 Amlodipin 1x10 Amlodipin 1x10 Omeprazol 3x1 Omeprazol 3x1ISDN 3x2,5 ISDN 3x2,5 ISDN 3x2,5 ISDN 3x2,5 Amlodipin 1x10

ISDN 3x2,5Loading NaCl 150ccIVFD NaCl 750cc

Hasil Laboratorium

Elektrolit Nilai Normal 22/10/15 25/10/15 30/10/15 3/11/2015 5/11/2015 6/11/2015Na 135 - 155 mmol/l 132 136 136,8 134,4 133,9K 3,6 - 5,5 mmol/l 4,71 3,62 2,57 2,21 2,5Cl 95 - 107 mmol/l 97,7 101,1 87,3 84 81,2

Fungsi GinjalUr 17 - 43 mg/dl 76 29 24 23Cr 0,6 - 1,2 mg/dl 0,6 0,7 0,8 1,1

Asam Urat 3,6 - 8,2 mg/dl 7,3 5,9Fungsi Hati

Albumin 3,4 - 4,8 mg/dl 2,3SGOT <31 U/L 15 24SGPT <31 U/L 9 8

HematologiDarah Rutin

Hb 12 - 16 g/dl 10,8 10,3 10,6 7,6Leukosit 5 - 10 x 10˄3 /uL 24.11 14.43 9.6 13.17

Trombosit 150 - 450 x 10˄3 /Ul 424 407 472 282Hematokrit 37 - 43 % 32,6 31,8 32,1 24,3

LED <15 mm/jam 20GDS <200 mg/Dl 336 184 138 149 174HAV Non ReactiveHbsag Non ReactiveHCV Negative

Gol. Darah A Rh +Masa Pembekuan 5 - 15 menit 10Masa Perdarahan 1 - 6 menit 2Protrombine Time 9,7 - 13,1 detik

APTT 25,5 - 42,1 detik

Elektrolit Nilai Normal 9/11/2015 9/11/2015 10/11/2015 11/11/2015 12/11/2015 13/11/15

Na 135 - 155 mmol/l 129,7 129,8 132,5 131,9 132K 3,6 - 5,5 mmol/l 2,04 2,47 2,64 2,62 2,46Cl 95 - 107 mmol/l 78,4 81,3 86,5 88,9 89,9

Fungsi Ginjal

Ur 17 - 43 mg/dl 59 63Cr 0,6 - 1,2 mg/dl 4,1 5,5

Asam Urat 3,6 - 8,2 mg/dl 7,4Fungsi Hati

Albumin 3,4 - 4,8 mg/dl 3,1SGOT <31 U/LSGPT <31 U/L


Hb 12 - 16 g/dl 10,5 11,9 12,1Leukosit 5 - 10 x 10˄3 /uL 13.27 15.38 15.84

Trombosit 150 - 450 x 10˄3 /Ul 227 224 244Hematokrit 37 - 43 % 32,5 36,9 36,8

LED <15 mm/jamGDS <200 mg/Dl 190 194 157 163 106HAV Non ReactiveHbsag Non ReactiveHCV Negative

Gol. DarahMasa

Pembekuan 5 - 15 menitMasa

Perdarahan 1 - 6 menitProtrombine

Time 9,7 - 13,1 detikAPTT 25,5 - 42,1 detik

Elektrolit Nilai Normal 14/11/15 15/11/15 17/11/15 19/11/15 23/11/15Na 135 - 155 mmol/l 135,6K 3,6 - 5,5 mmol/l 3,9Cl 95 - 107 mmol/l 97

Fungsi GinjalUr 17 - 43 mg/dl 65 83 87Cr 0,6 - 1,2 mg/dl 6,8 5,6 4,3

Asam Urat 3,6 - 8,2 mg/dl 8,3 5Fungsi Hati

Albumin 3,4 - 4,8 mg/dl 3,2 3,3SGOT <31 U/LSGPT <31 U/L


Hb 12 - 16 g/dl 11,1 11 11,1Leukosit 5 - 10 x 10˄3 /uL 15.61 20.28 19.23

Trombosit 150 - 450 x 10˄3 /Ul 308 316 301Hematokrit 37 - 43 % 34 33,5 33,1

LED <15 mm/jamGDS <200 mg/Dl 175 175 145HAV Non ReactiveHbsag Non ReactiveHCV Negative

Gol. DarahMasa Pembekuan 5 - 15 menit 10Masa Perdarahan 1 - 6 menit 2Protrombine Time 9,7 - 13,1 detik 12

APTT 25,5 - 42,1 detik 41,7INR 1,1

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Ny. Asmah