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No.Kode : Diagnosis Masuk: Tgl MRS Kondisi MRS Tgl Pindah Ruangan Tgl KRS Kondisi KRS
Nama : Asmaidar Retensi Urine ec (catat jam MRS) (catat jam KRS)
Usia : 37 thn (P ) Batu Staghorn 12/9/2017, 17:01 Baik 12/9/2017 Arafah 3 Perbaikan
BB : Dextra + dj stent 16/9/2017 Raudhah 2 18/9/2017, 12.00
No. RM : 1133975 insitu sinistra
Biaya : Rp. 25.687.088
Alamat : Pulo Tengoh, Darul Makmur
Diagnosis Keluar:
Batu Staghorn
Dextra + dj stent
insitu sinistra
Hari ke- 1 2 3 4
Diagnosis
Retensi Urine ec Batu Staghorn Post Extended litotripsi Dextra + Post Extended litotripsi Dextra + Post Extended litotripsi Dextra +
Dextra Insersi DJ stent Dextra + aff DJ stent Insersi DJ stent Dextra + aff DJ Insersi DJ stent Dextra + aff DJ
Sinistra + Batu staghorn Dextra + stent Sinistra + Batu staghorn stent Sinistra + Batu staghorn
Hidronefrosis Dextra + ISK Dextra + Hidronefrosis Dextra + Dextra + Hidronefrosis Dextra +
ISK ISK
Tanda vital TD: 108/69 mmHg TD: 110/80 mmHg TD: 110/80 mmHg TD: 110/70 mmHg
(N, RR, temp) N: 86x/i N: 78x/i N: 80x/i N: 80x/i
RR: 20x/i RR: 22x/i RR: 20x/i RR: 20x/i
T: 36,8 C T: 36,5 C T: 36,0 C T: 36,0 C
Penemuan fisik yang penting Status Lokalisata er Suprapubik Status Lokalisata er Suprapubik Status Lokalisata er Suprapubik Status Lokalisata er Suprapubik
I: Bulging (+) I: Bulging (+) I: Luka post op ditutup verban, I: Luka post op ditutup verban,
P: soepel P: soepel kesan kering kesan kering
Drain: serohemoragik
Tindakan AB profilaksis: Iv Ceftriaxone 1 Operasi extended litotripsi + aff dj AB terapi: Iv Ceftriaxone 2 gr/24j AB terapi: Iv Ceftriaxone 2 gr/24j
(apabila dilakukan tindakan pada px, misalnya operasi, tulis gr/12j stent Sinistra + insersi dj stent Dextra
prosedur operasi, pemakaian AB profilaksis/terapi, dosis
AB, waktu pemberian, lama penggunaan, dosis ulang)
AB profilaksis: Iv Ceftriaxone 1
gr/12j
Antibiotika & Regimen dosis : Iv Ceftriaxone 1 gr/12j (P) Iv Ceftriaxone 1 gr/12j (P) Iv Ceftriaxone 1 gr/12j (E) Iv Ceftriaxone 1 gr/12j (E)
(E=Empiris/D=Definitive/P=Profilaksis)
Hari ke- 5 6 7
Tanggal 16/9/2017 17/9/2017 18/9/2017
Diagnosis
Post Extended litotripsi Dextra + Post Extended litotripsi Dextra + Post Extended litotripsi Dextra +
Insersi DJ stent Dextra + aff DJ Insersi DJ stent Dextra + aff DJ stent Insersi DJ stent Dextra + aff DJ
stent Sinistra + Batu staghorn Sinistra ec Batu staghorn Dextra stent Sinistra ec Batu staghorn
Dextra + Hidronefrosis Dextra + Dextra + hidronefrosis Dextra
ISK
Pemeriksaan penunjang:
- Laboratorium (DL,UL,FL, CRP)
- Foto Thorax
- Lain-lain
Antibiotika & Regimen dosis : Iv Ceftriaxone 1 gr/12j (P) Iv Ceftriaxone 1 gr/12j (P) Iv Ceftriaxone 1 gr/12j (E)
(E=Empiris/D=Definitive/P=Profilaksis)
No.Kode : Diagnosis Masuk: Tgl MRS Kondisi MRS Tgl Pindah Ruangan Tgl KRS Kondisi KRS
Nama : (catat jam MRS) (catat jam KRS)
Usia : ( L/ P )
BB :
No. RM : Diagnosis Keluar:
Biaya :
Alamat :