REKAP TERAPI DAN PEMERIKSAAN LABORATORIUM

Nama : Ny. RainahUmur : 50 thNo. CM : 765732Alamat : Sumur Lubang, Salira, PuloampelDiagnosa :

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

Terapi

14/10/15 15/10/15 16/10/15 17/10/15 18/10/15 19/10/15Cefotaxim 2x1 Cefotaxim 2x1 Cefotaxim 2x1 Cefotaxim 2x1 Cefotaxim 2x1 Cefotaxim 2x1Metronidazol 3x500 Metronidazol 3x500 Metronidazol 3x500 Ranitidin 2x1 Ranitidin 2x1 Ranitidin 2x1Ketorolac 3x1 Ketorolac 3x1 Ketorolac 3x1 Ketorolac 3x1 Ketorolac 3x1 Ketorolac 3x1PCT PCT PCT PCT Metronidazol 3x500 Metronidazol 3x500Prorenal 3x1 Prorenal 3x1 Prorenal 3x1 Prorenal 3x1 Sleeding Scale Sleeding ScaleBicnat 3x1 Bicnat 3x1 Bicnat 3x1 Bicnat 3x1 IVFD Nacl IVFD NaclAsam Folat 3x1 Asam Folat 3x1 Asam Folat 3x1 Asam Folat 3x1Sleeding Scale Sleeding Scale Sleeding Scale Sleeding ScaleKAEN 1B IVFD Nacl IVFD Nacl IVFD NaclIVFD Nacl + Ondan 8mg Ranitidin 2x1 Ranitidin 2x1

27/10/15 28/10/15 29/10/15 30/10/15 31/10/15 1/11/2015Cefotaxim 2x1 Cefotaxim 2x1 PRC Kolf - 1 Cefotaxim 2x1 PRC Kolf - 2 Cefotaxim 2x1Gentamycin 3x80mg Gentamycin 3x80mg Cefotaxim 2x1 Gentamycin 3x80mg Cefotaxim 2x1 Gentamycin 3x80mgKetorolac 3x1 Ketorolac 3x1 Gentamycin 3x80mg Ketorolac 3x1 Gentamycin 3x80mg Ketorolac 3x1Metronidazol 3x500 Metronidazol 3x500 Ketorolac 3x1 Metronidazol 3x500 Ketorolac 3x1 Metronidazol 3x500Prorenal 3x1 Prorenal 3x1 Metronidazol 3x500 Prorenal 3x1 Metronidazol 3x500 Prorenal 3x1Bicnat 3x1 Bicnat 3x1 Prorenal 3x1 Bicnat 3x1 Prorenal 3x1 Bicnat 3x1Asam Folat 3x1 Asam Folat 3x1 Bicnat 3x1 Asam Folat 3x1 Bicnat 3x1 Asam Folat 3x1Hemafort 3x1 Hemafort 3x1 Asam Folat 3x1 Hemafort 3x1 Asam Folat 3x1 Hemafort 3x1Sleeding Scale Sleeding Scale Hemafort 3x1 Sleeding Scale Hemafort 3x1 Sleeding ScaleIVFD Nacl IVFD Nacl Sleeding Scale IVFD Nacl Sleeding Scale IVFD Nacl

IVFD Nacl IVFD Nacl

2/11/2015 3/11/2015 4/11/2015 5/11/2015 6/11/2015 7/11/2015Cefotaxim 2x1 Cefotaxim 2x1 Cefotaxim 2x1 PRC Klof - 3 Cefotaxim 2x1 Cefotaxim 2x1Gentamycin 3x80mg Gentamycin 3x80mg Gentamycin 3x80mg Cefotaxim 2x1 Gentamycin 3x80mg Gentamycin 3x80mgKetorolac 3x1 Ketorolac 3x1 Ketorolac 3x1 Gentamycin 3x80mg Ketorolac 3x1 Ketorolac 3x1

20/10/15 21/10/15 22/10/15 23/10/15 24/10/15 25/10/15 26/10/15Cefotaxim 2x1 Cefotaxim 2x1 Cefotaxim 2x1 Debridement Cefotaxim 2x1 Cefotaxim 2x1 Cefotaxim 2x1

Ranitidin 2x1 Ranitidin 2x1 Ranitidin 2x1 Cefotaxim 2x1Gentamycin 3x80mg

Gentamycin 3x80mg

Gentamycin 3x80mg

Ketorolac 3x1 Ketorolac 3x1 Ketorolac 3x1Gentamycin 3x80mg Ketorolac 3x1 Ketorolac 3x1 Ketorolac 3x1

Metronidazol 3x500 Metronidazol 3x500 Metronidazol 3x500 Ketorolac 3x1 Metronidazol 3x500 Metronidazol 3x500 Metronidazol 3x500Prorenal 3x1 Prorenal 3x1 Prorenal 3x1 Metronidazol 3x500 Prorenal 3x1 IVFD Nacl Prorenal 3x1Bicnat 3x1 Bicnat 3x1 Bicnat 3x1 Prorenal 3x1 Bicnat 3x1 Bicnat 3x1Asam Folat 3x1 Asam Folat 3x1 Asam Folat 3x1 Bicnat 3x1 Asam Folat 3x1 Asam Folat 3x1Sleeding Scale Sleeding Scale Sleeding Scale Asam Folat 3x1 Hemafort 3x1 Hemafort 3x1IVFD Nacl IVFD Nacl IVFD Nacl Hemafort 3x1 Sleeding Scale Sleeding Scale

Sleeding Scale IVFD Nacl IVFD NaclIVFD Nacl

Metronidazol 3x500 Metronidazol 3x500 Metronidazol 3x500 Ketorolac 3x1 Metronidazol 3x500 Metronidazol 3x500Prorenal 3x1 Prorenal 3x1 Prorenal 3x1 Metronidazol 3x500 Prorenal 3x1 Prorenal 3x1Bicnat 3x1 Bicnat 3x1 Bicnat 3x1 Prorenal 3x1 Bicnat 3x1 Bicnat 3x1Asam Folat 3x1 Asam Folat 3x1 Asam Folat 3x1 Bicnat 3x1 Asam Folat 3x1 Asam Folat 3x1Hemafort 3x1 Hemafort 3x1 Hemafort 3x1 Asam Folat 3x1 Hemafort 3x1 Hemafort 3x1Sleeding Scale Sleeding Scale Sleeding Scale Hemafort 3x1 Sleeding Scale Sleeding ScaleIVFD Nacl IVFD Nacl IVFD Nacl Sleeding Scale IVFD Nacl IVFD Nacl

IVFD Nacl

21/11/15 22/11/15 23/11/15 24/11/15 25/11/15 26/11/15IVFD Nacl IVFD Nacl PRC Kolf - 1 PRC Kolf - 2 IVFD Nacl IVFD NaclCeftriaxon 2x1 Ceftriaxon 2x1 IVFD Nacl IVFD Nacl Ceftriaxon 2x1 Ceftriaxon 2x1Metronidazol 3x500 Metronidazol 3x500 Ceftriaxon 2x1 Ceftriaxon 2x1 Metronidazol 3x500 Metronidazol 3x500Ketorolac 3x1 Ketorolac 3x1 Hemafort 3x1 Metronidazol 3x500 Ketorolac 3x1 Ketorolac 3x1Hemafort 3x1 Hemafort 3x1 Prorenal 3x1 Ketorolac 3x1 Hemafort 3x1 Hemafort 3x1Prorenal 3x1 Prorenal 3x1 Bicnat 3x1 Hemafort 3x1 Prorenal 3x1 Prorenal 3x1Bicnat 3x1 Bicnat 3x1 Omeprazol 2x1 Prorenal 3x1 Bicnat 3x1 Bicnat 3x1Omeprazol 2x1 Omeprazol 2x1 Bicnat 3x1 Omeprazol 2x1 Omeprazol 2x1

Omeprazol 2x1 Ondancentron 3x1 Ondancentron 3x1Ondancentron 3x1  HEMODIALISA

Hasil Laboratorium

Elektrolit Nilai Normal 13/10/15 14/10/15 15/10/15 18/10/15 24/10/15 29/10/15 30/10/15 1/11/2015Na 135 - 155 mmol/l 129,2 138,5K 3,6 - 5,5 mmol/l 3,63 2,39Cl 95 - 107 mmol/l 94,6 93

Fungsi GinjalUr 17 - 43 mg/dl 63 108 69 21 20 19Cr 0,6 - 1,2 mg/dl 2 2,6 1,1 0,7 0,9 0,9

Asam Urat 3,6 - 8,2 mg/dl 11,2 4,3 4,2Fungsi Hati

Albumin 3,4 - 4,8 mg/dl 2,5 2,8SGOT <31 U/L 14 16SGPT <31 U/L 15

HematologiDarah Rutin

Hb 12 - 16 g/dl 10,6 9,6 7,9 8,2 8,5Leukosit 5 - 10 x 10˄3 /uL 27.33 31.16 8.96 13.63 10.98

Trombosit 150 - 450 x 10˄3 /Ul 215 420 555 497 463Hematokrit 37 - 43 % 31,8 29,5 25,5 26,9 27,2

LED <15 mm/jam 90GDS <200 mg/Dl 407 346 396 255 303 118 165 182HAV Non Reactive NRHbsag Non Reactive NRHCV Negative

Gol. Darah A RH +Masa Pembekuan 5 - 15 menitMasa Perdarahan 1 - 6 menit

Elektrolit Nilai Normal 2/11/2015 5/11/2015 6/11/2015 20/11/15 21/11/15 22/11/15 23/11/15 26/11/15Na 135 - 155 mmol/l 136,3 136,8 134,1 133,6 134,4K 3,6 - 5,5 mmol/l 2,4 2,47 2,41 2,1 1,84Cl 95 - 107 mmol/l 94 88,7 92,1 90,5 94,4

Fungsi GinjalUr 17 - 43 mg/dl 56 198 195 181 124Cr 0,6 - 1,2 mg/dl 2,9 12,2 11,2 10,5 6,4

Asam Urat 3,6 - 8,2 mg/dl 9,8 15,4 13 9Fungsi Hati

Albumin 3,4 - 4,8 mg/dl 2,4 3,2SGOT <31 U/L 14SGPT <31 U/L 9

HematologiDarah Rutin

Hb 12 - 16 g/dl 11 10,4 12,1 7,6 8,5 11,3Leukosit 5 - 10 x 10˄3 /uL 12.9 11.7 12.85 19.92 14.47 15.39

Trombosit 150 - 450 x 10˄3 /Ul 472 557 590 440 478 369Hematokrit 37 - 43 % 33,5 33,2 38,4 23,5 26,4 34

LED <15 mm/jamGDS <200 mg/Dl 207 181 114 186 330 226HAV Non ReactiveHbsag Non ReactiveHCV Negative NR

Gol. DarahMasa Pembekuan 5 - 15 menit 11Masa Perdarahan 1 - 6 menit 2