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The document reports on the patients in the ward for Wednesday, June 12, 2020. There were 6 total patients, including 2 patients under Dr. Dini for diabetes mellitus with foot ulcers and a decubitus ulcer; and a second patient under Dr. Denny for kidney colic and anemia. Details are provided on a 58-year-old female BPJS patient with diabetes, foot ulcers, and a decubitus ulcer who is being treated with antibiotics, insulin, and wound care. A second 55-year-old female BPJS patient with irregular heartbeat and indigestion is also discussed.
The document reports on the patients in the ward for Wednesday, June 12, 2020. There were 6 total patients, including 2 patients under Dr. Dini for diabetes mellitus with foot ulcers and a decubitus ulcer; and a second patient under Dr. Denny for kidney colic and anemia. Details are provided on a 58-year-old female BPJS patient with diabetes, foot ulcers, and a decubitus ulcer who is being treated with antibiotics, insulin, and wound care. A second 55-year-old female BPJS patient with irregular heartbeat and indigestion is also discussed.
The document reports on the patients in the ward for Wednesday, June 12, 2020. There were 6 total patients, including 2 patients under Dr. Dini for diabetes mellitus with foot ulcers and a decubitus ulcer; and a second patient under Dr. Denny for kidney colic and anemia. Details are provided on a 58-year-old female BPJS patient with diabetes, foot ulcers, and a decubitus ulcer who is being treated with antibiotics, insulin, and wound care. A second 55-year-old female BPJS patient with irregular heartbeat and indigestion is also discussed.
Dokter jaga : dr. Tiara, dr. Meliani/ dr. Hani Pagi: Sore: Perawat/bidan: 1. Diana 1. Heni 2. Dedi 2. Yuni 3. Ela 3. Danang 4. Maya 4. Yua
BPJS 5
UMUM 1
JUMLAH PASIEN BANGSAL 6
RINCIAN PASIEN BANGSAL DPJP: dr. Dini, Sp. PD 1.Ny. L,58 th/BPJS/ruang Nuri 2/diagnosis Diabetes Mellitus + Ulkus DM a/r pedis bilateral + Ulkus Dekubitus 2.Ny. Y,55 th/BPJS/ruang Nuri 2/diagnosis VES + Sinus Aritmia + Dyspepsia DPJP: dr. Denny, Sp. B 1.Ny. A,52 th/BPJS/ruang Nuri 2/diagnosis Kolik renal ec Nefrolitiasis + Anemia 2.Ny. L,51 th/Umum/ruang Nuri 2/diagnosis CKR + VE a/r parietal 3.Tn. A, 32 th/BPJS/ruang Walet 1/diagnosis Ganglion cyst a/r wrist joint sinistra 4.Tn. J,56 th/BPJS/ruang cendrawasih 4/diagnosis Post Laparatomy eksplorasi + anastomose a/I ileus obstruktif ec tumor caecum + adhesi peritoneal grade IV + sepsis sedang PASIEN DILAPORKAN Ny. L / 58 Tahun/BPJS Hasil pemeriksaan darah lengkap (10/6/20): Hb : 7.8 Lym: 14 Anamnesa: L : 15.100 Mid: 16 S: Eri : 2,84 Gran: 70 Pemeriksaan fisik Plt : 184.000 GDP: 87 mg/dl O: Hct : 23.3 KU : CM, tampak sakit sedang TD: 136/80 mmHg Diagnosis: Diabetes Mellitus + Ulkus DM a/r pedis HR : 117 x/min, nadi kuat angkat bilateral + Ulkus Dekubitus RR : 22 x/min T : 36.1 °C Tatalaksana: Mata : SI (-), CA (+/+), • Venflon Thorax : Simetris, retraksi (-) • inj. Ceftriaxone 1 gr/12 jam Cor : S1S2 reg, m (-), g (-) • inj. Furosemid 1 amp/8 jam Pulmo : SND vesikuler (+/+), rh (-/-), wh (-/-) • inj. Aprida 3 x 4 iu Abdomen : supple, BU (+) dbn, NT (-), Ekstremitas : • inj. Lantus 0-0-10iu Akral hangat, CRT <2", nadi teraba kuat angkat, • PO Vip Albumin 3 x 1 caps edema (+/+) pitting • GV perhari Status lokalis 1.Pedis Dekstra et Sinistra: luka +- 8 x 5 cm, jaringan nekrotik (+), pus (+) 2.a/r gluteus luka +- 5 x 4 cm, eritema (+) PASIEN DILAPORKAN Ny. L / 58 Tahun/BPJS Hasil pemeriksaan darah lengkap (10/6/20): Hb : 7.8 L : 15.100 Lym: 14 Anamnesa: Mid: 16 Eri : 2,84 S : Pasien dengan luka di kedua kaki sejak +- 10 Gran: 70 Plt : 184.000 tahunan, awalnya luka kecil, namun semakin meluas Hct : 23.3 GDP: 87 mg/dl dan mengeluarkan nanah sejak 2 bulan ini. Riwayat DM (+) sudah 20 tahun, riwayat minum obat Diagnosis: VES + Sinus Aritmia + Dyspepsia metformin, satu minggu terakhir menggunakan insulin Tatalaksana: •Pemeriksaan fisik O: • Oksigen 3 lpm via NK KU : CM, tampak sakit sedang • IVFD RL (asnet) TD: 136/93 mmHg • inj. Ondancentron 3 x 4 mg HR : 83 x/min, nadi kuat angkat • PO ISDN 5 mg (kp nyeri dada) RR : 20 x/min • PO Bisoprolol 1 x 2.5 mg T : 36.1 °C • PO digoxin 1 x 0.125 mg Mata : SI (-), CA (+/+), • PO Sucralfat syr 2 x 1 C Thorax : Simetris, retraksi (-) • PO Simvastatin 0-0-20 mg Cor : S1S2 reg, m (-), g (-) Pulmo : SND vesikuler (+/+), rh (-/-), wh (-/-) Abdomen : supple, BU (+) dbn, NT (-), Ekstremitas : Akral hangat, CRT <2", nadi teraba kuat angkat,