|
|
Ubah
|
Salin
|
Hapus
DELETE FROM `penilaian_medis_ralan` WHERE `penilaian_medis_ralan`.`no_rawat` = \'2024/03/26/000005\'
|
2024/03/26/000005 |
2024-03-26 17:08:53 |
D02 |
Autoanamnesis |
|
batuk berdahak,flu 4 hari demam (-)MUAL (-) |
TIDAK ADA |
TIDAK ADA |
TIDAK ADA |
TIDAK ADA |
TIDAK ADA |
Sehat |
15 |
Compos Mentis |
- |
84 |
22 |
36 |
92 |
22,5 |
- |
Normal |
Normal |
Normal |
Normal |
Normal |
Normal |
Normal |
Normal |
|
|
RO THORAKS |
GERD +ISPA |
- |
- |
|
|
Ubah
|
Salin
|
Hapus
DELETE FROM `penilaian_medis_ralan` WHERE `penilaian_medis_ralan`.`no_rawat` = \'2024/03/29/000008\'
|
2024/03/29/000008 |
2024-03-29 13:09:06 |
1801018006 |
Autoanamnesis |
|
Demam 3 hari lalu, batuk pilek, lemas, makan minum... |
- |
- |
- |
obat sirup bapil |
- |
Sakit Ringan |
15 |
Compos Mentis |
- |
100 |
23 |
38,7 |
99 |
11,35 |
78 |
Normal |
Normal |
Abnormal |
Normal |
Normal |
Normal |
Normal |
Normal |
lidah kotor, faring hiperemis, tonsil t2 t2 |
- |
Darah lengkap |
tonsilo faringitis akut |
cefixime 2x1/2 cth
paracetamol 120 mg syr 4x1 cth
... |
- |
|
|
Ubah
|
Salin
|
Hapus
DELETE FROM `penilaian_medis_ralan` WHERE `penilaian_medis_ralan`.`no_rawat` = \'2024/03/30/000011\'
|
2024/03/30/000011 |
2024-03-30 19:08:01 |
1801018006 |
Autoanamnesis |
|
OS post oprasi laparatomi di rs mitra bandar jaya,... |
post op laparamomi |
- |
- |
dari dokter sebelum nya |
- |
Sakit Sedang |
15 |
Compos Mentis |
90/60 |
108 |
20 |
38,1 |
99 |
58 |
170 |
Normal |
Normal |
Normal |
Normal |
Abnormal |
Normal |
Abnormal |
Abnormal |
|
st lokalis abdomen = tampak luka oprasi kering seb... |
- |
obs febris hari 2 ec post oprasi laparatomi + DLI+... |
saran rawat inap, keluarga mau mengunakan bpjs dan... |
rujuk lepas k rsud rbc |
|
|
Ubah
|
Salin
|
Hapus
DELETE FROM `penilaian_medis_ralan` WHERE `penilaian_medis_ralan`.`no_rawat` = \'2024/04/07/000003\'
|
2024/04/07/000003 |
2024-04-07 09:59:05 |
1801018006 |
Autoanamnesis |
|
nyeri ulu hati, perut terasa begah , nafas tersa m... |
- |
- |
- |
- |
- |
Sakit Ringan |
15 |
Compos Mentis |
90/70 |
85 |
20 |
36,0 |
98 |
45 |
145 |
Normal |
Normal |
Normal |
Normal |
Abnormal |
Normal |
Normal |
Normal |
nyeri tekan erpigastrium |
|
ro Thorax hasil dbn
cek DL hasil dbn |
gerd |
omz 2x1
nucral syr 3x2cth
domperidon 3x10 mh
braxi... |
kontol ulang |
|
|
Ubah
|
Salin
|
Hapus
DELETE FROM `penilaian_medis_ralan` WHERE `penilaian_medis_ralan`.`no_rawat` = \'2024/04/07/000006\'
|
2024/04/07/000006 |
2024-04-07 16:00:36 |
1801018006 |
Autoanamnesis |
|
demam (+) sejak 1 hari lalu, post di imunisasi DPT |
- |
- |
- |
- |
- |
Sakit Ringan |
15 |
Compos Mentis |
|
120 |
28 |
39,6 |
|
6,9 |
|
Normal |
Normal |
Normal |
Normal |
Normal |
Normal |
Normal |
Normal |
|
|
- |
observasi febris hari2 pasca imunisasi dpt |
pyrexime 80mg supp
sanmol drop 4x0,7 cc |
- |
|
|
Ubah
|
Salin
|
Hapus
DELETE FROM `penilaian_medis_ralan` WHERE `penilaian_medis_ralan`.`no_rawat` = \'2024/04/07/000008\'
|
2024/04/07/000008 |
2024-04-07 16:05:57 |
1801018006 |
Autoanamnesis |
|
demam sajal 7 hari lalu disertai dengan batuk pile... |
- |
- |
- |
- |
ranitidine |
Sakit Sedang |
15 |
Compos Mentis |
100/70 |
81 |
19 |
35,7 |
99 |
65 |
150 |
Abnormal |
Abnormal |
Abnormal |
Normal |
Normal |
Normal |
Normal |
Normal |
lidah kotor
faring hiperemis |
- |
hb 14,6
L 11.800 |
obs febris hari 7 ec faringitis akut et iba |
samquinor 2x500mg
intunal F 3x1
ersolon 3x4mg
dobr... |
- |
|
|
Ubah
|
Salin
|
Hapus
DELETE FROM `penilaian_medis_ralan` WHERE `penilaian_medis_ralan`.`no_rawat` = \'2024/04/07/000009\'
|
2024/04/07/000009 |
2024-04-07 17:22:46 |
1801018006 |
Autoanamnesis |
|
nyeri ulu hati dan perut terasa nyeri,maual -, mun... |
ppok |
ppok |
- |
- |
- |
Sakit Sedang |
15 |
Compos Mentis |
140/90 |
87 |
22 |
36,0 |
98 |
68 |
162 |
Normal |
Normal |
Normal |
Normal |
Abnormal |
Normal |
Normal |
Normal |
nt (+) epigastrium |
- |
- |
dyspepsia
sindrom dyspepsia |
omz 1x20
nexiblok syr 3x2 cth |
- |
|
|
Ubah
|
Salin
|
Hapus
DELETE FROM `penilaian_medis_ralan` WHERE `penilaian_medis_ralan`.`no_rawat` = \'2024/04/08/000001\'
|
2024/04/08/000001 |
2024-04-08 07:51:26 |
1801018006 |
Autoanamnesis |
|
demam 2 hari lalu naik turun, pilek, mulut radang,... |
- |
- |
- |
- |
- |
Sakit Ringan |
15 |
Compos Mentis |
- |
110 |
23 |
38,8 |
98 |
12 |
|
Normal |
Normal |
Abnormal |
Normal |
Normal |
Normal |
Normal |
Normal |
rongga mulut merah
faring hiperemis |
- |
- |
comond colt + FA |
cefixime syr 2x1/2 cth
sanmol syr 4x1 cth
dexamet... |
- |
|
|
Ubah
|
Salin
|
Hapus
DELETE FROM `penilaian_medis_ralan` WHERE `penilaian_medis_ralan`.`no_rawat` = \'2024/04/08/000006\'
|
2024/04/08/000006 |
2024-04-08 11:11:24 |
1801018006 |
Autoanamnesis |
|
cek narkoba, untuk kuliah |
- |
- |
- |
- |
- |
Sehat |
15 |
Compos Mentis |
100/70 |
80 |
19 |
36,2 |
98 |
- |
- |
Normal |
Normal |
Normal |
Normal |
Normal |
Normal |
Normal |
Normal |
|
- |
hasil cek narkoba DBN |
surat bebas narkoba |
surat bebas narkoba |
- |
|
|
Ubah
|
Salin
|
Hapus
DELETE FROM `penilaian_medis_ralan` WHERE `penilaian_medis_ralan`.`no_rawat` = \'2024/04/08/000007\'
|
2024/04/08/000007 |
2024-04-08 11:07:26 |
1801018006 |
Autoanamnesis |
|
tangan kanan post terjepit kotok, tampak luka lece... |
- |
- |
- |
- |
- |
Sakit Ringan |
15 |
Compos Mentis |
100/70 |
78 |
18 |
36,1 |
98 |
45 |
164 |
Normal |
Normal |
Normal |
Normal |
Normal |
Normal |
Abnormal |
Normal |
|
st lokalis digiti 1 manus dx = tampak luka lecet t... |
v.e digiti 1manus dx |
|
bersihkan luka
cafdroxil 2x1
asam mefenamat 3x1
ra... |
- |
|
|
Ubah
|
Salin
|
Hapus
DELETE FROM `penilaian_medis_ralan` WHERE `penilaian_medis_ralan`.`no_rawat` = \'2024/04/10/000005\'
|
2024/04/10/000005 |
2024-04-10 10:40:14 |
1801018006 |
Autoanamnesis |
|
demam 2 hari lalu, batuk, pilek, pusing , lemas, m... |
- |
- |
- |
- |
- |
Sakit Sedang |
15 |
Compos Mentis |
140/100 |
87 |
19 |
37,0 |
98 |
- |
- |
Normal |
Normal |
Abnormal |
Normal |
Normal |
Normal |
Normal |
Normal |
faring hiperemis, nyeri tekan epigastrium |
- |
- |
ISPA + CEFALGIA |
inj ketorolac 1 amp
ciprofloxacine 2x500mg
intunal... |
- |
|
|
Ubah
|
Salin
|
Hapus
DELETE FROM `penilaian_medis_ralan` WHERE `penilaian_medis_ralan`.`no_rawat` = \'2024/04/11/000004\'
|
2024/04/11/000004 |
2024-04-11 14:19:20 |
077 |
Autoanamnesis |
|
sesek nafas |
pasien sesak nafas sejak kemaren sore, batuk dahak... |
- |
Asma Bronkhial |
berobat beli di apotek tapi lupa dibawa |
- Udara dingin |
Sakit Ringan |
15 |
Compos Mentis |
11o/80 |
98 |
24 |
36.9 |
96 |
57,7 |
|
Normal |
Normal |
Abnormal |
Abnormal |
Abnormal |
Normal |
Normal |
Normal |
Tenggotokan tampak kemerahan
Weezhing
NTE |
- |
AL ; 10.500
radiologi : Asma bronkhial |
|
nebulizer ventolin 1amp + Nacl 2cc
kapsul ;
salbut... |
- |
|
|
Ubah
|
Salin
|
Hapus
DELETE FROM `penilaian_medis_ralan` WHERE `penilaian_medis_ralan`.`no_rawat` = \'2024/04/11/000006\'
|
2024/04/11/000006 |
2024-04-11 17:15:30 |
077 |
Autoanamnesis |
|
pipi bengkak bengkak |
pasien mengeluh kedua pipi terasa tebal dan kaku s... |
- |
- |
- sudah berobat 2x tapi tidak tau obat apa |
- kulit sensitif |
Sehat |
15 |
Compos Mentis |
130/90 |
88 |
20 |
37.0 |
99 |
- |
- |
Abnormal |
Normal |
Normal |
Normal |
Normal |
Normal |
Normal |
Normal |
facialis tampak kemerahan dan tebal serta perih sa... |
- |
- |
hipersensitif facialis |
cuci muka memakay sabun lactacyt
- ceirizin 2 x 1
... |
- |
|
|
Ubah
|
Salin
|
Hapus
DELETE FROM `penilaian_medis_ralan` WHERE `penilaian_medis_ralan`.`no_rawat` = \'2024/04/11/000007\'
|
2024/04/11/000007 |
2024-04-11 17:21:35 |
077 |
Autoanamnesis |
|
bab cair > 5x |
os mengeluh bab cair sejak siang tadi lebih dari 5... |
- magh |
- |
- |
- |
Sakit Ringan |
15 |
Compos Mentis |
100/70 |
78 |
20 |
37.0 |
98 |
- |
- |
Normal |
Normal |
Normal |
Normal |
Abnormal |
Normal |
Normal |
Normal |
bising usus meningkat |
- |
- |
GEA tanpa dehidrasi |
minum air putih satu gelas per 2 jam dan per bab c... |
- |
|
|
Ubah
|
Salin
|
Hapus
DELETE FROM `penilaian_medis_ralan` WHERE `penilaian_medis_ralan`.`no_rawat` = \'2024/04/12/000006\'
|
2024/04/12/000006 |
2024-04-12 16:03:17 |
077 |
Autoanamnesis |
|
batuk dan sesak nafas |
os batuk dahak sejak 5 bln yll disertai sesak nafa... |
- |
- |
- guaifenesin 3 x1
- azitromicin 2 x1
- lasal siru... |
- |
Sehat |
4,5,6 |
Compos Mentis |
120/70 |
90 |
22 |
36 |
98 |
- |
- |
Normal |
Normal |
Normal |
Normal |
Abnormal |
Normal |
Normal |
Normal |
NTE (+) |
- |
- |
Susp TB Paru dd PPOK
GERD |
azitromisin 2 x1
lansoprazole 3 x 1
salbutamol 3 ... |
- |
|
|
Ubah
|
Salin
|
Hapus
DELETE FROM `penilaian_medis_ralan` WHERE `penilaian_medis_ralan`.`no_rawat` = \'2024/04/12/000010\'
|
2024/04/12/000010 |
2024-04-13 03:15:05 |
077 |
Autoanamnesis |
|
tertusuk duri ikan di tenggorokan |
pasien sekitar 2 jam SMRS tertusuk duri ikan saat ... |
- |
- |
- belum mengkonsumsi ikan |
- |
Sakit Ringan |
4,5,6 |
Compos Mentis |
140/90 |
92 |
20 |
36,3 |
98 |
- |
- |
Normal |
Normal |
Abnormal |
Normal |
Normal |
Normal |
Normal |
Normal |
tampak duri ikan menancap di laring sebelah kiri d... |
- |
- |
corpal laring tertusuk duri ikan |
- pengambilan korpal tidak bisa dilakukan karena s... |
- |
|
|
Ubah
|
Salin
|
Hapus
DELETE FROM `penilaian_medis_ralan` WHERE `penilaian_medis_ralan`.`no_rawat` = \'2024/04/12/000011\'
|
2024/04/12/000011 |
2024-04-13 03:21:14 |
077 |
Autoanamnesis |
|
mudah lelah dan sesak nafas |
pasien mudah lelah saat beraktifitas dengan tenggo... |
HT (+) |
- |
- amlodipin 5mg |
- |
Sakit Sedang |
4,5,6 |
Compos Mentis |
140/100 |
93 |
23 |
36.6 |
98 |
- |
- |
Normal |
Normal |
Normal |
Normal |
Abnormal |
Normal |
Normal |
Normal |
NTE (+) |
- |
Ekg : normal EKG
ro thorax : Cardiomegali |
GERD
Cardiomegali
HT |
edukasi
makan rendah garam
jaga makan hindari peda... |
- |
|
|
Ubah
|
Salin
|
Hapus
DELETE FROM `penilaian_medis_ralan` WHERE `penilaian_medis_ralan`.`no_rawat` = \'2024/04/12/000013\'
|
2024/04/12/000013 |
2024-04-12 23:58:37 |
077 |
Alloanamnesis |
kekluarga |
Rongten pinggul |
pasien dulu pernah rongten di yukum ada keretakan ... |
patah tulang pinggang |
- |
- |
- |
Sakit Sedang |
4,5,5 |
Compos Mentis |
120/80 |
98 |
20 |
36,7 |
98 |
- |
- |
Normal |
Normal |
Normal |
Normal |
Normal |
Normal |
Abnormal |
Normal |
kaki tidak mampu berjalan |
- |
Ro pinggul : terdapat osteoporosis multiple di tul... |
OA |
- edukasi mengenai penyakit
- makan nutrisi cukup... |
-- |
|
|
Ubah
|
Salin
|
Hapus
DELETE FROM `penilaian_medis_ralan` WHERE `penilaian_medis_ralan`.`no_rawat` = \'2024/04/15/000005\'
|
2024/04/15/000005 |
2024-04-15 16:34:15 |
1801018006 |
Autoanamnesis |
|
sakit gigi bawah 2 hari, tidak bengkak |
- |
- |
- |
- |
|
Sehat |
15 |
Compos Mentis |
- |
100 |
19 |
36,3 |
98 |
15 |
- |
Normal |
Abnormal |
Normal |
Normal |
Normal |
Normal |
Normal |
Normal |
st lokalis dental : tampak gigi bolong |
- |
- |
gingivitis M5 |
amoxisilin syr 3x125 mg
ibu profen 3x100mg
dexa 0... |
konsul dokter gigi |
|
|
Ubah
|
Salin
|
Hapus
DELETE FROM `penilaian_medis_ralan` WHERE `penilaian_medis_ralan`.`no_rawat` = \'2024/04/15/000008\'
|
2024/04/15/000008 |
2024-04-16 00:00:49 |
1801018006 |
Autoanamnesis |
|
nyeri dada tembus punggu belakang sejak 4 hari lal... |
- |
- |
- |
- |
- |
Sakit Ringan |
15 |
Compos Mentis |
130/90 |
62 |
19 |
36,3 |
98 |
- |
- |
Normal |
Normal |
Normal |
Normal |
Abnormal |
Normal |
Normal |
Normal |
nyeri tekan epigastrium |
- |
ro dan ekg terlampir |
obs chest pain ec susp CAD + dyspesia+ kardiomegal... |
isdn 1x5 mg
cpg 1x75
omz 2x1
lanpepsa syr 3x2 cth
... |
saran kontrol dr.sp.pd |
|
|
Ubah
|
Salin
|
Hapus
DELETE FROM `penilaian_medis_ralan` WHERE `penilaian_medis_ralan`.`no_rawat` = \'2024/04/16/000001\'
|
2024/04/16/000001 |
2024-04-16 06:43:46 |
1801018006 |
Autoanamnesis |
|
demam (+) sajak 3 hari lalu naik turun |
- |
- |
- |
- |
- |
Sehat |
|
Compos Mentis |
- |
100 |
20 |
38,3 |
98 |
8,9 |
- |
Normal |
Abnormal |
Normal |
Normal |
Normal |
Normal |
Normal |
Normal |
tampak gusi merah |
- |
- |
gingivitis |
pyrexime 90 mg supp
dexa 0,1 mg
ctm 0,5 mg
parace... |
- |
|
|
Ubah
|
Salin
|
Hapus
DELETE FROM `penilaian_medis_ralan` WHERE `penilaian_medis_ralan`.`no_rawat` = \'2024/04/17/000014\'
|
2024/04/17/000014 |
2024-04-17 20:06:01 |
1801018006 |
Autoanamnesis |
|
demam (+) 4 hari lalu, batuk pilek, ma/mi kurang |
- |
- |
- |
- |
- |
Sakit Ringan |
15 |
Compos Mentis |
- |
109 |
23 |
36,9 |
99 |
8 |
|
Normal |
Abnormal |
Abnormal |
Normal |
Normal |
Normal |
Normal |
Normal |
- |
- |
- |
ispa |
cefixime 2x2cc
paracetamol 4x3/4 cth
ambroxol 4 m... |
- |
|
|
Ubah
|
Salin
|
Hapus
DELETE FROM `penilaian_medis_ralan` WHERE `penilaian_medis_ralan`.`no_rawat` = \'2024/04/22/000002\'
|
2024/04/22/000002 |
2024-04-22 11:56:58 |
077 |
Autoanamnesis |
|
perut begah |
pasien mengeluh perut sering begah kadang terasa p... |
GERD |
- |
- sucralfat
- 3 jeis obat yang tidak berlebel. |
- |
Sakit Ringan |
4,5,6 |
Compos Mentis |
130/80 |
98 |
19 |
36,7 |
98 |
- |
- |
Normal |
Normal |
Normal |
Normal |
Abnormal |
Normal |
Normal |
Normal |
NTE (+) |
kekuatan otot 5/5-5/5 |
- |
GERD |
ULcera 4 x 2 cth
Lansoprazo 2 x 1
ondancetron 3 x ... |
- |
|
|
Ubah
|
Salin
|
Hapus
DELETE FROM `penilaian_medis_ralan` WHERE `penilaian_medis_ralan`.`no_rawat` = \'2024/04/26/000005\'
|
2024/04/26/000005 |
2024-04-26 17:20:19 |
1801018006 |
Autoanamnesis |
|
nyeri ulu hati, mual,lemas, ma/mi kurang,susah tid... |
- |
- |
- |
- |
- |
Sakit Ringan |
15 |
Compos Mentis |
150/100 |
92 |
19 |
36,5 |
98 |
65 |
- |
Normal |
Normal |
Normal |
Normal |
Abnormal |
Normal |
Normal |
Normal |
nt(+) epigastriun |
- |
DL dan GDS dalam batas normal |
gerd + psikosomatis |
cefixime 2x200mg
scopma plus 3x1
omz 2x20mg
braxid... |
- |
|
|
Ubah
|
Salin
|
Hapus
DELETE FROM `penilaian_medis_ralan` WHERE `penilaian_medis_ralan`.`no_rawat` = \'2024/05/01/000006\'
|
2024/05/01/000006 |
2024-05-01 15:02:16 |
077 |
Autoanamnesis |
|
tergigit kucing 3 hari yll |
tergigit kucing 3 hari yang lalu, sudah ke rs tapi... |
- |
- |
cefadroxil syr 2 x 3/4 cth
pct 3 x 3/4 cth |
- |
Sehat |
e4v5m6 |
Compos Mentis |
- |
98 |
20 |
36.8 |
|
- |
- |
Normal |
Normal |
Normal |
Normal |
Normal |
Normal |
Abnormal |
Normal |
tampak bekas luka gigitan kucing dan cakaran kucin... |
- |
- |
- vulnus morsum kucing |
- sc vaksin rabies lanjut IM vaksin Rabies 1 ml.
-... |
- |