|
|
Ubah
|
Salin
|
Hapus
DELETE FROM `penilaian_medis_igd` WHERE `penilaian_medis_igd`.`no_rawat` = \'2024/03/21/000001\'
|
2024/03/21/000001 |
2024-03-21 03:02:14 |
1801018008 |
Autoanamnesis |
|
kejang |
menurut ibu pasien saat di beri asi pasien tiba2 k... |
tidak ada |
tak |
- |
negatif |
Sehat |
15 |
Compos Mentis |
|
103 |
24 |
38,5 |
98 |
10 |
|
Normal |
Normal |
Normal |
Normal |
Normal |
Normal |
Normal |
Normal |
|
- |
|
|
|
kejang demam sederhana |
pyreksin/pct supp 120 mg
turpas 3x1,3 cc
puyer (tr... |
|
|
Ubah
|
Salin
|
Hapus
DELETE FROM `penilaian_medis_igd` WHERE `penilaian_medis_igd`.`no_rawat` = \'2024/03/25/000006\'
|
2024/03/25/000006 |
2024-03-25 13:43:08 |
041 |
Autoanamnesis |
|
Pasien datang dijemput paramedis post ditemukan kl... |
ditemukan disaku jaket terdapat peastik dgn klip+ |
- |
- |
- |
- |
Sehat |
15 |
Compos Mentis |
130/90 |
83 |
20 |
36,3 |
93 |
|
|
Normal |
Normal |
Normal |
Normal |
Normal |
Normal |
Normal |
Normal |
Satatus Lokalis
Tampak luka lecet dibagian dagu da... |
|
|
|
Urinalisis
Methampthetamines (MET) Positif+ |
Intoksikasi Sabu
V. Laceratum R. Oris Inferior |
O2 2lpm
IVFD Ns Loading 500 cc-> 20 tpm
Inj OMZ 40... |
|
|
Ubah
|
Salin
|
Hapus
DELETE FROM `penilaian_medis_igd` WHERE `penilaian_medis_igd`.`no_rawat` = \'2024/03/25/000013\'
|
2024/03/25/000013 |
2024-03-25 21:57:06 |
041 |
Autoanamnesis |
|
Pasien datang dgn keluhan tidak sadarkan diri,diba... |
- |
CHF+
TB Paru Sembuh |
- |
- |
- |
Sehat |
E1V1M1 |
Compos Mentis |
220/120 |
130 |
16 |
40,9 |
79 |
|
|
Normal |
Abnormal |
Normal |
Normal |
Normal |
Normal |
Normal |
Normal |
SpO2 99 dgn NRM 10 lpm
Mata RC-/-, Reflek Pupil-/- |
|
|
|
|
Penurunana Kesadaran ec SH dd SNH
Gagal Napas + HT... |
O2 10 lpm
IVFD Ns 20 tpm Selanjutnya D5% 20 tpm
In... |
|
|
Ubah
|
Salin
|
Hapus
DELETE FROM `penilaian_medis_igd` WHERE `penilaian_medis_igd`.`no_rawat` = \'2024/03/25/000014\'
|
2024/03/25/000014 |
2024-03-25 22:33:59 |
041 |
Autoanamnesis |
|
Pasien datang diantar Keluarga Tiba2 pingsan, refe... |
- |
- |
- |
- |
- |
Sehat |
15 |
Compos Mentis |
120/70 |
90 |
20 |
36,7 |
99 |
|
|
Normal |
Normal |
Normal |
Normal |
Normal |
Normal |
Normal |
Normal |
|
|
|
|
|
Sinkop
GERD |
O2 2lpm NK
IVFD RL loading 500 cc -> 20 tpm
Inj OM... |
|
|
Ubah
|
Salin
|
Hapus
DELETE FROM `penilaian_medis_igd` WHERE `penilaian_medis_igd`.`no_rawat` = \'2024/03/29/000007\'
|
2024/03/29/000007 |
2024-03-29 11:33:42 |
1801018006 |
Autoanamnesis |
|
post kll tol km 221 tampak lukab robek di bibir ka... |
- |
- |
- |
- |
- |
Sakit Ringan |
15 |
Compos Mentis |
100/70 |
95 |
20 |
36,5 |
99 |
45 |
155 |
Abnormal |
Normal |
Abnormal |
Normal |
Normal |
Normal |
Normal |
Normal |
|
st ocipitalsi= tampak hematom ukuran 1x1 cm
st sho... |
- |
ro schedel ap/ dan sholder joint sx |
- |
hematom ocipitalis sx
vulnus labialis dx
suspek d... |
pronages supp
bersihakan luka
imobilisasi dgn slin... |
|
|
Ubah
|
Salin
|
Hapus
DELETE FROM `penilaian_medis_igd` WHERE `penilaian_medis_igd`.`no_rawat` = \'2024/03/30/000001\'
|
2024/03/30/000001 |
2024-03-30 01:14:16 |
1801018006 |
Autoanamnesis |
|
nyeri perut sejk sing hari dan makin memberat male... |
- |
- |
- |
- |
- |
Sakit Ringan |
15 |
Compos Mentis |
100/70 |
81 |
19 |
36,5 |
98 |
56 |
155 |
Normal |
Normal |
Normal |
Normal |
Normal |
Abnormal |
Normal |
Normal |
nyeri tekan epi gastrium et supra pubik, cva (-) |
|
|
|
Lekosit urine 1-3 lpm |
colic abdomen ec dyspepsia et isk |
observasi
infus ns 20 gtt/m
inj ranitidine 1 amp
i... |
|
|
Ubah
|
Salin
|
Hapus
DELETE FROM `penilaian_medis_igd` WHERE `penilaian_medis_igd`.`no_rawat` = \'2024/03/30/000014\'
|
2024/03/30/000014 |
2024-03-30 22:27:28 |
1801018006 |
Autoanamnesis |
|
os masuk ugd post kll motor yang d kendarain oleh ... |
- |
- |
- |
- |
- |
Sakit Sedang |
15 |
Compos Mentis |
140/90 |
98 |
21 |
36,4 |
99 |
80 |
165 |
Abnormal |
Abnormal |
Abnormal |
Normal |
Normal |
Normal |
Normal |
Normal |
|
st lokalis fasialis = tamapak luka robek d pelipis... |
- |
- |
hb = 14,6
L= 14900 |
multipel vulnus laceratum regio fasialis + open fr... |
heap up 45
bersihkan luka
depp luka dgn kasa
o2... |
|
|
Ubah
|
Salin
|
Hapus
DELETE FROM `penilaian_medis_igd` WHERE `penilaian_medis_igd`.`no_rawat` = \'2024/03/30/000015\'
|
2024/03/30/000015 |
2024-03-30 23:20:16 |
1801018006 |
Autoanamnesis |
|
os masuk ugd post tekana benda tajam pada lemahan ... |
- |
- |
- |
- |
- |
Sakit Sedang |
15 |
Compos Mentis |
110/80 |
94 |
16 |
36,1 |
99 |
48 |
164 |
Normal |
Normal |
Normal |
Normal |
Normal |
Normal |
Normal |
Abnormal |
|
st lokalis 1/3 medial antebracii sx = tampak luka ... |
- |
antebracii ap/l tidak tampak farktur |
hb 15,2
L 15600 |
vulnus scizum regio 1/3 median antebracii sx ec be... |
bersihkan luka
depp luka dengan kasa
inj ats 1 am... |
|
|
Ubah
|
Salin
|
Hapus
DELETE FROM `penilaian_medis_igd` WHERE `penilaian_medis_igd`.`no_rawat` = \'2024/04/01/000013\'
|
2024/04/01/000013 |
2024-04-01 14:33:19 |
041 |
Autoanamnesis |
|
Pasien datang dengan keluhan lemas (+) sakit menel... |
Riw
HT (+) tdk rutin minum obat
DM (-) disangkal |
- |
- |
- |
- |
Sehat |
15 |
Compos Mentis |
140/90 |
75 |
21 |
36,6 |
99 |
|
|
Normal |
Normal |
Normal |
Normal |
Normal |
Normal |
Normal |
Normal |
O/
CM, E4V5M6
TD : 140/90mmhg
N: 75
Rr : 21
T: 36,... |
|
|
|
Trombo 23.000 |
A/
DHF |
Advice dr. EDY Sp.PD
Th/
IVFD NS Loading 1000 -> ... |
|
|
Ubah
|
Salin
|
Hapus
DELETE FROM `penilaian_medis_igd` WHERE `penilaian_medis_igd`.`no_rawat` = \'2024/04/06/000006\'
|
2024/04/06/000006 |
2024-04-06 10:55:39 |
077 |
Autoanamnesis |
|
Kaki terlindas ban mobil |
kaki pasien terlindas ban mobil di depan RS. MHC. ... |
tidak ada |
tidak diketahui |
belum berobat |
tidak ada |
Sehat |
15 |
Compos Mentis |
0 |
120 |
20 |
36,5 |
98 |
12 |
80 |
Normal |
Normal |
Normal |
Normal |
Normal |
Normal |
Normal |
Abnormal |
terdapat luka lecet berukuran kurang lebih 3 cm X ... |
10. terdapat luka lecet berukuran kurang lebih 3 c... |
|
angkle joint DBN |
|
VE ec post terlindas roda mobil |
- bersihkan dan rawat luka
- Cefadrocil SYR 2 x 1 ... |
|
|
Ubah
|
Salin
|
Hapus
DELETE FROM `penilaian_medis_igd` WHERE `penilaian_medis_igd`.`no_rawat` = \'2024/04/07/000002\'
|
2024/04/07/000002 |
2024-04-07 08:55:20 |
1801018006 |
Autoanamnesis |
|
muntah setiap makan dan minum sajak subuh tadi kur... |
- |
- |
- |
- |
- |
Sakit Sedang |
15 |
Compos Mentis |
|
80 |
20 |
36,0 |
98 |
27 |
|
Abnormal |
Abnormal |
Normal |
Normal |
Normal |
Abnormal |
Normal |
Abnormal |
mata cekung +, bu + meningkat, crt >2" |
|
|
|
hb =14,5
l =34.400
ht =49,7 |
vomitus profuse + gead ringan sedang |
rawat inap
diet nasi bubur
ivfd rl rehidrasi 1350c... |
|
|
Ubah
|
Salin
|
Hapus
DELETE FROM `penilaian_medis_igd` WHERE `penilaian_medis_igd`.`no_rawat` = \'2024/04/07/000004\'
|
2024/04/07/000004 |
2024-04-07 12:09:04 |
1801018006 |
Autoanamnesis |
|
post kll tol 228, tampak luka benturanpingan kiri,... |
- |
- |
- |
- |
- |
Sakit Ringan |
15 |
Compos Mentis |
100/60 |
86 |
19 |
36,3 |
98 |
75 |
160 |
Normal |
Normal |
Normal |
Normal |
Normal |
Abnormal |
Normal |
Normal |
|
status lokalis regio flenk area sx = tampak jejas,... |
|
lumbosacral ap/l hasil dbn |
|
soft tissue injury regia flank area sx |
gv luka
kaltrofen 2x100mg
omz 1x20 mg
mps 3x4
k... |
|
|
Ubah
|
Salin
|
Hapus
DELETE FROM `penilaian_medis_igd` WHERE `penilaian_medis_igd`.`no_rawat` = \'2024/04/07/000005\'
|
2024/04/07/000005 |
2024-04-07 11:47:20 |
1801018006 |
Autoanamnesis |
|
os masuk igd post kll tol km 228, tampak lebam d b... |
- |
- |
- |
- |
- |
Sakit Ringan |
15 |
Compos Mentis |
- |
100 |
19 |
36,0 |
98 |
20 |
|
Abnormal |
Normal |
Normal |
Normal |
Normal |
Normal |
Normal |
Normal |
|
st lokalis nasal tampak jejas, lebam, nyeri tekan,... |
|
scedel ap/l fraktur - |
|
soft tissue injury regio nasal |
gv luka
opicef 2x125 mg
ibu profen 3x100 mg
v... |
|
|
Ubah
|
Salin
|
Hapus
DELETE FROM `penilaian_medis_igd` WHERE `penilaian_medis_igd`.`no_rawat` = \'2024/04/08/000018\'
|
2024/04/08/000018 |
2024-04-08 21:37:32 |
1801018006 |
Autoanamnesis |
|
kepala pusing sejak magrib disertai dengan mual, m... |
- |
chf fn 2-3 |
- |
bisoprolol 1x2,5mg
spronolacton 1x25 mg
furosemid ... |
- |
Sakit Sedang |
15 |
Compos Mentis |
180/100 |
66 |
19 |
36,5 |
98 |
- |
- |
Normal |
Normal |
Normal |
Normal |
Normal |
Abnormal |
Normal |
Normal |
nyeri ulu hati
crt >2" |
- |
- |
- |
gds 138 |
observasi vomitus ec dyspepsia |
observasi
infus ns asnet
inj omz 40 mg
inj ondance... |
|
|
Ubah
|
Salin
|
Hapus
DELETE FROM `penilaian_medis_igd` WHERE `penilaian_medis_igd`.`no_rawat` = \'2024/04/09/000004\'
|
2024/04/09/000004 |
2024-04-09 14:59:32 |
077 |
Autoanamnesis |
|
post kll sepeda motor |
pasien post KLL motor tunggal, terdapat beberapa l... |
tidak ada |
- tidak ada |
tidak ada |
tidak ada |
Sakit Ringan |
15 |
Compos Mentis |
120/80 |
98 |
20 |
36.8 |
98 |
- |
- |
Normal |
Normal |
Normal |
Normal |
Normal |
Normal |
Normal |
Abnormal |
Terdapat ve multiple tanpa edem |
1,4,5,2,11 : terdapat VE kemerahan berdarah keadaa... |
- |
Menolak |
- |
CKR post KLL sepeda Motor Tunggal |
- Bersihkan luka dan rawat luka dengan salep genta... |
|
|
Ubah
|
Salin
|
Hapus
DELETE FROM `penilaian_medis_igd` WHERE `penilaian_medis_igd`.`no_rawat` = \'2024/04/09/000005\'
|
2024/04/09/000005 |
2024-04-09 15:07:29 |
077 |
Alloanamnesis |
ibu |
post kll sepeda motor tunggal |
Post KLL dibonceng oleh ibu nya, posisi jatuh tert... |
- |
- |
- |
- |
Sakit Ringan |
|
Compos Mentis |
- |
98 |
22 |
36.2 |
98 |
|
|
Abnormal |
Normal |
Normal |
Normal |
Abnormal |
Normal |
Normal |
Abnormal |
terdapat beberapa ve di kepala bahu dan kaki. |
1,2 : terdapat ve berwarna merah keputihan, perdar... |
- |
keluarga menollak dilakukan ro scadle dan ro thora... |
- |
CKR Post KLL sepeda motor tinggal |
- bersihkan luka dan rawat luka dengan salep genta... |
|
|
Ubah
|
Salin
|
Hapus
DELETE FROM `penilaian_medis_igd` WHERE `penilaian_medis_igd`.`no_rawat` = \'2024/04/10/000004\'
|
2024/04/10/000004 |
2024-04-10 08:13:13 |
1801018006 |
Autoanamnesis |
|
nyeri perut kanan tembus pingang sejak 2 hari lalu... |
- |
- |
- |
- |
- |
Sakit Sedang |
15 |
Compos Mentis |
140/100 |
89 |
19 |
36,5 |
98 |
- |
- |
Normal |
Normal |
Normal |
Normal |
Normal |
Abnormal |
Normal |
Normal |
nyeri tekan epi gastrium
cva (-/+) |
- |
- |
- |
L 12.700
hb 13.3
trombo 212000
ht 40
Lu 1-4 |
colic abdomen ec susp BSK |
observasi
infus ns 20 gtt
inj ketorolac 30 mg
inj ... |
|
|
Ubah
|
Salin
|
Hapus
DELETE FROM `penilaian_medis_igd` WHERE `penilaian_medis_igd`.`no_rawat` = \'2024/04/10/000008\'
|
2024/04/10/000008 |
2024-04-10 15:06:02 |
1801018006 |
Autoanamnesis |
|
post kll tol km 230, tampak luka pada bibir sebela... |
- |
- |
- |
- |
- |
Sakit Ringan |
15 |
Compos Mentis |
110/70 |
81 |
19 |
36,5 |
98 |
40 |
- |
Normal |
Normal |
Abnormal |
Normal |
Normal |
Normal |
Normal |
Normal |
|
st lokalis labialis inferior et superior = tampak ... |
- |
- |
- |
vulnus exoriasi labialis inferior sx et odem labia... |
bersihkan kuka
cefadroxil 2x500
asam mefenamat 3x5... |
|
|
Ubah
|
Salin
|
Hapus
DELETE FROM `penilaian_medis_igd` WHERE `penilaian_medis_igd`.`no_rawat` = \'2024/04/10/000010\'
|
2024/04/10/000010 |
2024-04-10 15:10:50 |
1801018006 |
Autoanamnesis |
|
post kll tol km 230 detang dengan DOA |
- |
- |
- |
- |
- |
Sakit Berat |
- |
Koma |
- |
- |
- |
- |
- |
|
|
Normal |
Normal |
Normal |
Normal |
Normal |
Normal |
Normal |
Normal |
pupil dilatasi maksimal |
st lokalis femur sx = tampak vulnus amputatum, den... |
flat |
- |
- |
Deat Of Arrival ec vulnus amputatum regio femur sx |
ekg
perawatan janazah
surat kematian |
|
|
Ubah
|
Salin
|
Hapus
DELETE FROM `penilaian_medis_igd` WHERE `penilaian_medis_igd`.`no_rawat` = \'2024/04/10/000011\'
|
2024/04/10/000011 |
2024-04-10 15:15:47 |
1801018006 |
Autoanamnesis |
|
os masuk igd post kll tol km 230, datang dengan ti... |
- |
- |
- |
- |
- |
Sakit Berat |
4 |
Koma |
- |
- |
1: |
- |
- |
- |
-- |
Normal |
Normal |
Normal |
Normal |
Normal |
Normal |
Normal |
Abnormal |
|
st lokalis femur et pelvis sx : tampak luka robek ... |
flat |
- |
- |
Vulnus laceratum regio proximal femur et pelvis sx... |
tidak bisa d lakulan pemasangan infus
rjp 1 siklus... |
|
|
Ubah
|
Salin
|
Hapus
DELETE FROM `penilaian_medis_igd` WHERE `penilaian_medis_igd`.`no_rawat` = \'2024/04/10/000012\'
|
2024/04/10/000012 |
2024-04-10 18:11:01 |
1801018006 |
Autoanamnesis |
|
demam 3 hari lalu, batuk pilek, lemas , makan minu... |
- |
- |
- |
- |
- |
Sakit Sedang |
15 |
Compos Mentis |
110/70 |
127 |
20 |
38,0 |
95 |
77 |
-- |
Abnormal |
Normal |
Normal |
Normal |
Normal |
Abnormal |
Normal |
Normal |
lidah kotor
faring hiperemis
nt epigastrium |
- |
- |
- |
gds 210
L 12.00 |
observasi febris hari 3 ec ispa dd iba |
observasi
infus ns 20 gtt/m + neurobion 1 amp
inj ... |
|
|
Ubah
|
Salin
|
Hapus
DELETE FROM `penilaian_medis_igd` WHERE `penilaian_medis_igd`.`no_rawat` = \'2024/04/10/000013\'
|
2024/04/10/000013 |
2024-04-10 17:11:43 |
1801018006 |
Autoanamnesis |
|
post di gigit kucing 1 jam smrs |
- |
- |
- |
- |
- |
Sakit Ringan |
15 |
Compos Mentis |
- |
111 |
24 |
36,4 |
98 |
10,10 |
- |
Normal |
Normal |
Normal |
Normal |
Normal |
Normal |
Normal |
Normal |
|
st lokalis antebracii : tampak gigitan kucing |
- |
- |
- |
cat bite |
gv luka
cafdroxil syr 125 2x3/4 cth
pulvis
ctm 0,... |
|
|
Ubah
|
Salin
|
Hapus
DELETE FROM `penilaian_medis_igd` WHERE `penilaian_medis_igd`.`no_rawat` = \'2024/04/10/000014\'
|
2024/04/10/000014 |
2024-04-10 18:03:43 |
1801018006 |
Autoanamnesis |
|
nyei bak sejak 2 minggu lalu, keluar cairan dari k... |
-- |
- |
- |
- |
- |
Sakit Ringan |
15 |
Compos Mentis |
110/80 |
71 |
19 |
26,7 |
98 |
46,5 |
- |
Normal |
Normal |
Normal |
Normal |
Normal |
Normal |
Abnormal |
Normal |
nt + supra pubik |
- |
- |
- |
DL dan UL |
ISK dd GO |
cefixime 2x200 mg
ulcetra 3x1 tab
mps 4 mg 3x1 tab... |
|
|
Ubah
|
Salin
|
Hapus
DELETE FROM `penilaian_medis_igd` WHERE `penilaian_medis_igd`.`no_rawat` = \'2024/04/10/000015\'
|
2024/04/10/000015 |
2024-04-10 20:32:29 |
1801018006 |
Autoanamnesis |
|
demam sejak sore hari ini, pilek, tengorokan sakit... |
- |
- |
- |
- |
- |
Sakit Ringan |
|
Compos Mentis |
100/60 |
88 |
19 |
37,2 |
98 |
66 |
175 |
Normal |
Normal |
Abnormal |
Normal |
Normal |
Normal |
Normal |
Normal |
faring hiperemis
tonsil T2 & T1 |
|
- |
- |
- |
TFA |
opicef 2x1
paratusin 3x1
mps 4 mg 3x1
caviplek 2x1 |
|
|
Ubah
|
Salin
|
Hapus
DELETE FROM `penilaian_medis_igd` WHERE `penilaian_medis_igd`.`no_rawat` = \'2024/04/10/000016\'
|
2024/04/10/000016 |
2024-04-10 22:39:13 |
1801018006 |
Autoanamnesis |
|
Demam 7 hari, mual, muntah, batuk pilek dan diare |
- |
- |
- |
- |
- |
Sehat |
4,5,6 |
Compos Mentis |
100/70 |
80 |
20 |
36,7 |
98 |
- |
- |
Normal |
Normal |
Normal |
Normal |
Normal |
Normal |
Normal |
Normal |
|
- |
- |
- |
trombosit 145.000
IgG/IgM +
Widal O 1/160, H 1/80 |
Febris hari ke 7 ec DBD + typoid sub klinis + extr... |
Infus NS 20 gtt
Inj Ondan 8 mg
Inj OMZ
Inj pct fl... |