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Keluhan Sesak (+) Sesak (+) Sesak (+) Sesak (+) Sesak (+) Demam (+) Demam (+) Demam (-)
Demam (-) Lemas (+) Batuk (+) Demam (-) Demam (-)
Lemas (+)
TTV TD: 130/80 TD: 110/80 TD: 110/80 TD: 120/80 TD: 110/70 TD: 110/70 TD: 110/70 TD: 110/70
HR: 125 HR: 90 HR: 80 HR: 80 HR: 88 HR: 80 HR: 80 HR: 80
T: 36,7 T: 36,5 T: 36,8 T: 36,8 T: 37 T: 38,6 T: 39 T: 36
RR: 30 RR: 28 RR: 24 RR: 28 RR: 24 RR: 24 RR: 20 RR: 20
Pulmo Vesikuler Vesikuler Vesikuler Vesikuler Vesikuler Vesikuler Vesikuler Vesikuler
(+/+ (+/+ (+/+ (+/+ (+/+ (+/+ (+/+ (+/+
+/- +/- +/- +/- +/- +/- +/- +/-
+/-) +/-) +/-) +/-) +/-) +/-) +/-) +/-)
Diagnosis Dispeneu ec Dispeneu ec - Empiema thorakal Empiema thorakal Phlebitis Phlebitis Piopneumothorax
Abses paru Abses paru Piopneumothorax Piopneumothorax Piopneumothorax kiri
Kerja DD DD kiri terlokalisir kiri kiri
Pneumothorax Pneumothorax -Hiponatremia
DD DD -Hipokalemia
Efusi Pleura Efusi Pleura
Terapi O2 nasal 3lpm O2 nasal 3lpm O2 nasal 3lpm O2 nasal 3lpm O2 nasal 3lpm O2 nasal 3lpm O2 nasal 3lpm O2 nasal 3lpm
IVFD RL/12jam Infus NaCl 3% Infus NaCl Infus NaCl Infus NaCl Infus NaCl Infus NaCl Infus NaCl
Inj.OMZ 1x40mg 500cc/24 jam 0,9% 500cc/8 0,9% 500cc/8 0,9% 500cc/8 0,9% 500cc/8 0,9% 500cc/8 0,9% 500cc/8
PCT 3x500mg dan Nacl 0,9% jam jam jam jam jam jam
Sukralfat syr 500cc/12 jam
4xCI Inj. Inj. Inj. Inj. Inj. Inj. Inj.
Ondancetron Ondancetron Ondancetron Ondancetron Ondancetron Ondancetron Ondancetron
2x4mg 2x4mg 2x4mg 2x4mg 2x4mg 2x4mg 2x4mg
Inj. OMZ Inj. OMZ Inj. OMZ Inj. OMZ Inj. OMZ Inj. OMZ Inj. OMZ
1x40mg 1x40mg 1x40mg 1x40mg 1x40mg 1x40mg 1x40mg
Inf. Inf. Inf. Inf. Inf. Inf. Inf.
Metronidazole Metronidazole Metronidazole Metronidazole Metronidazole Metronidazole Metronidazole
3x500mg 3x500mg 3x500mg 3x500mg 3x500mg 3x500mg 3x500mg
Inj. Ceftazidin Inj. Ceftazidin Inj. Ceftazidin Inj. Ceftazidin Inj. Ceftazidin Inj. Ceftazidin Inj. Ceftazidin
3x 1gr 3x 1gr 3x 1gr stop 3x 1gr stop 3x 1gr stop 3x 1gr stop 3x 1gr stop
KSR 3x1 KSR 3x1 KSR 3x1 KSR 3x1 KSR 3x1 KSR 3x1 KSR 3x1
Ambroxol syr Ambroxol syr Ambroxol syr Ambroxol syr Ambroxol syr Ambroxol syr Ambroxol syr
3xCI 3xCI 3xCI 3xCI 3xCI 3xCI 3xCI
PCT 500mg PCT 500mg PCT 500mg PCT 500mg PCT 500mg PCT 500mg PCT 500mg
4x1 tab 4x1 tab 4x1 tab 4x1 tab 4x1 tab 4x1 tab 4x1 tab
Clindamicyn Clindamicyn Clindamicyn Clindamicyn Clindamicyn Clindamicyn Clindamicyn
2x300mg stop stop stop stop 2x300mg 2x300mg
Sucralfat syr Sucralfat syr Sucralfat syr Sucralfat syr Sucralfat syr Sucralfat syr Sucralfat syr
4xCI 4xCI 3xCI 3xCI 3xCI 3xCI 3xCI
R/ rujuk ke RS Inf. Inf. Inf. Inf. Inf. Inf.
tipe B Levofloxacin Levofloxacin Levofloxacin Levofloxacin Levofloxacin Levofloxacin
1x750mg 1x750mg (H-2) 1x750mg (H-2) 1x750mg (H-2) 1x750mg (H-2) 1x750mg (H-2)
drip 1amp drip 1amp drip 1amp drip 1amp drip 1amp Drip 1amp
ketorolac/8jam ketorolac/8jam ketorolac/8jam ketorolac/8jam ketorolac/8jam ketorolac/8jam
NaCl kapsul NaCl kapsul NaCl kapsul NaCl kapsul NaCl kapsul NaCl kapsul
3x1 3x1 3x1 3x1 3x1 3x1
Rifampisin Rifampisin Rifampisin Rifampisin Rifampisin Rifampisin
1x450mg 1x450mg 1x450mg 1x450mg 1x450mg 1x450mg
(pagi) (pagi) (pagi) (pagi) (pagi) (pagi)
TB Vit 1x1 TB Vit 1x1 TB Vit 1x1 TB Vit 1x1 TB Vit 1x1 TB Vit 1x1
(pagi) (pagi) (pagi) (pagi) (pagi) (pagi)
Pirazinamide Pirazinamide Pirazinamide Pirazinamide Pirazinamide Pirazinamide
1x1000mg 1x1000mg 1x1000mg 1x1000mg 1x1000mg 1x1000mg
(malam) (malam) (malam) (malam) (malam) (malam)
Etambutol Etambutol Etambutol Etambutol Etambutol Etambutol
1x1000mg 1x1000mg 1x1000mg 1x1000mg 1x1000mg 1x1000mg
(malam) (malam) (malam) (malam) (malam) (malam)
Ondancetron
Jam 16.00 pasien 2x4mg
mendapatkan As.mefenamat
pemasangan 3x1
WSD oleh
dr.Faik, Sp.P
(laporan
terlampir)
01/06/18 02/06/18 03/06/18 04/06/18 05/06/18 06/06/18
Demam (+) Demam (+) Demam (-) Demam (-) Demam (-) Demam (-)
TD: 110/70 TD: 110/70 TD: 110/70 TD: 110/70 TD: 110/70 TD: 110/70
HR: 80 HR: 80 HR: 80 HR: 80 HR: 80 HR: 80
T: 38,6 T: 39 T: 36 T: 36 T: 36 T: 36
RR: 24 RR: 20 RR: 20 RR: 20 RR: 20 RR: 20
Vesikuler Vesikuler Vesikuler Vesikuler Vesikuler Vesikuler
(+/+ (+/+ (+/+ (+/+ (+/+ (+/+
+/- +/- +/- +/+ +/+ +/-
+/-) +/-) +/-) +/+) +/+) +/-)
Cairan per WSD Cairan per WSD Cairan per WSD Cairan per WSD Cairan per WSD Cairan per WSD
300cc (cairan 100cc (cairan 100cc (cairan minimal 200cc 100cc
transudate kuning transudate kuning transudate kuning
jernih) jernih) jernih)
Phlebitis Phlebitis Piopneumothorax kiri Piopneumothorax kiri Piopneumothorax kiri Empiema thorax kiri ec
Piopneumothorax kiri Piopneumothorax kiri TB dd non TB
BPF
O2 nasal 3lpm O2 nasal 3lpm O2 nasal 3lpm O2 nasal 3lpm O2 nasal 3lpm Pasien direncanakan
Infus NaCl 0,9% Infus NaCl 0,9% Infus NaCl 0,9% Infus NaCl 0,9% Infus NaCl 0,9% rujuk ke RSUD Kota
500cc/8 jam 500cc/8 jam 500cc/8 jam 500cc/8 jam 500cc/8 jam Bekasi kemudian
pasien menolak dan
Inj. Ondancetron Inj. Ondancetron Inj. Ondancetron Inj. Ondancetron Inj. Ondancetron pulang APS, obat
2x4mg 2x4mg 2x4mg 2x4mg 2x4mg pulang:
Inj. OMZ 1x40mg Inj. OMZ 1x40mg Inj. OMZ 1x40mg Inj. OMZ 1x40mg Inj. OMZ 1x40mg 1. Levofloxacin
Inf. Metronidazole Inf. Metronidazole Inf. Metronidazole Inf. Metronidazole Inf. Metronidazole 1x75mg
Inj. Ceftazidin 3x 1gr Inj. Ceftazidin 3x 1gr Inj. Ceftazidin 3x 1gr Inj. Ceftazidin 3x 1gr Inj. Ceftazidin 3x 1gr 1x500mg