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PRESENTATION
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25 / 03 / 2015
IDENTITAS
Nama : Tn. K
Usia
No MR : 00106349
: 78 th
TD :150/90
N : 88X/M
S: 37
RR: 24x/M
Thorax :
Sesak 1 minggu
Batuk 1 bulan
Cor S1,S2 tunggal, regular, M-, GParu Sn ves menurun, RH +/+, WZ +/+
22 / 3 / 2015 (IGD)
DIAGNOSIS:
PJK + DECOM CORDIS + PNEUMONIA + TB PARU
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Thorax xray:
TREATMENT :
Pleuropneumoniae D-S
IVFD PZ 10 tpm
Inj furosemid 1 A
ISDN 3x 5 mg
Captopril 2x12.5 mg
Leukosit
11.900
LED/BBS
55/89
Asam Urat
6.7
SGOT/SGPT
77/50
S: Sesak +, Demam +
O: CM
O: GCS 1-1-1
2!
Td
120/60
Td
100/50
88x/m
90x/m
RR 28xm
S
RR 30xm
S
38.9 C
Abd dbn,
Abd dbn,
Ex Akral Hangat
Ex Akral Hangat
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: PJK +Decom cordis +Pneumonia +
TB Paru + Sepsis
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P
38.4 C
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A
: Tambahan
:Captopril stop
Co. Saraf
Curcuma
- Ceftri 2x2g
sputum BTA
- Vit C 2x1
- Pasang NGT-puasa
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23 / 3 / 2015
24/ 3 / 2015
O: GCS 1-1-1
Td
110/70
100x/m
S: Henti jantung
O: GCS 1-1-1
RR 30xm
38.7 C
-x/m
-C
Paru Rh+/+, !
Ex Akral Hangat
Abd dbn,
Ex Akral Hangat
: PJK +Decom cordis +Pneumonia +
TB Paru + Sepsis
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P
tidak teraba
RR apneutic
Td
!
A
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P
:RJP 3 x 5 siklus
Epinephrin 2x1 A
Pct 4x500 mg
Diet 6 x200 cc
IVFD Futrolit : PZ 2:1
02.00
25/3/2015
11.30
O: GCS 1-1-1
Td
tidak teraba
-x/m
RR S
-C
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A
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11.45
25/3/2015