farmasi - case study

12
LEMBAR PENGUMPUL DATA N RM : Nama : Ny Kasturi ( p ) Umur : 57 Tahun TGL RAWA T ANAMNESA DIAGNOSA P. LABORATORIUM P. PENUNJANG TERAPI OBAT KELUHA N,DLL TD (mmH ) SB ( o C ) NADI (x/Mn t) 08/0 8/20 14 Perut sebah pada bagian kanan atas,m akin lama makin membes ar. Utama : - Cholangiocarcin oma Sekunder : - Hipoalbuminemia - Hiponatremia - Hipokalemia - Hepatomegali - icterus obstructif. Hemoglobin= 11,4 Hematokrit = 32,1 Eritrosit = 4,3 MCH = 26,8 MCV = 75,4 MCHC = 35,5 Leukosit = 5,2 Trombosit = 105 RDW = 18,9 hasil foto rontgen abdomen didapatkan hasil curiga efusi pleura kanan dengan ascites Paracetamol tablet Ranitidin tablet vitamin B complex

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Page 1: farmasi - case study

LEMBAR PENGUMPUL DATA

N RM :

Nama : Ny Kasturi ( p )

Umur : 57 Tahun

TGL

RAW

AT

ANAMNESA

DIAGNOSAP.

LABORATORIUM

P.

PENUNJANGTERAPI OBATKELUH

AN,DLL

TD

(mm

H)

SB

(oC)

NADI

(x/Mnt

)

08/08/

2014

Perut

sebah

pada

bagian

kanan

atas,maki

n lama

makin

membesa

r. Mata

berwarna

kuning

Utama :

- Cholangiocarcinoma

Sekunder :

- Hipoalbuminemia

- Hiponatremia

- Hipokalemia

- Hepatomegali

- icterus obstructif.

Hemoglobin= 11,4

Hematokrit = 32,1

Eritrosit = 4,3

MCH = 26,8

MCV = 75,4

MCHC = 35,5

Leukosit = 5,2

Trombosit = 105

RDW = 18,9

Albumin = 2,6

Ureum = 13

Kreatinin = 0,34

Natrium = 139

Kalium = 3

hasil foto

rontgen

abdomen

didapatkan hasil

curiga efusi

pleura kanan

dengan ascites

Paracetamol tablet

Ranitidin tablet

vitamin B complex

Page 2: farmasi - case study

Klorida =104

Gula darah = 77

09/08/

2014

90/60 37 68 20 Infus NaCl 16 Tpm

diet lunak 1700

kkal

11/08/

2014

100/9

0

37 72 18 Infus NaCl 16 Tpm

diet lunak 1700

kkal

Injeksi tramadol

100 mg p.r.n.

12/08/

2014

100/6

0

375 80 18

15/08/

2014

100/6

0

- 76 18 infus NaCl 16 Tpm

diet Lunak 1700

kkal

Injeksi tramadol

100 mg p.r.n.

Ursodheoxylat

colic acid

250mg/12jam

injeksi omeperazol

40 mg/ 12 jam

infus EAS

200cc/24 jam

Page 3: farmasi - case study

16/08/

2014

Infus NaCl 16 Tpm

diet lunak 1700

kkal

Ursodheoxylat

colic acid

250mg/12jam

injeksi omeperazol

40 mg/ 12 jam

infus EAS

200cc/24 jam

Dulcolax 5 mg/ 2

tab malam

17/08/

2014

Infus NaCl 16 Tpm

diet lunak 1700

kkal

Ursodheoxylat

colic acid

250mg/12jam

Injeksi tramadol

100 mg p.r.n.

injeksi omeperazol

40 mg/ 12 jam

infus EAS

200cc/24 jam

Dulcolax 5 mg/ 2

Page 4: farmasi - case study

tab malam

Transfusi PRC

18/08/

2014

Infus NaCl 16 Tpm

diet lunak 1700

kkal

Ursodheoxylat

colic acid

250mg/12jam

injeksi omeperazol

40 mg / 12 jam

infus EAS 200 cc /

24 jam

Dulcolax 5 mg / 2

tab malam

19/08/

2014

Infus NaCl 16 Tpm

diet lunak 1700

kkal

Ursodheoxylat

colic acid

250mg/12jam

injeksi omeperazol

40 mg / 12 jam

infus EAS 200cc /

24 jam

Dulcolax 5 mg / 2

Page 5: farmasi - case study

tab malam

20/08/

2014

Infus NaCl 16 Tpm

diet lunak 1700

kkal

Ursodheoxylat

colic acid

250mg/12jam

injeksi omeperazol

40 mg/ 12 jam

infus EAS

200cc/24 jam

Dulcolax 5 mg/ 2

tab malam

21/08/

2014

Infus NaCl 16 Tpm

diet lunak 1700

kkal

Ursodheoxylat

colic acid

250mg/12jam

injeksi omeperazol

40 mg/ 12 jam

infus EAS

200cc/24 jam

Dulcolax 5 mg/ 2

tab malam

Page 6: farmasi - case study

22/08/

2014

Infus NaCl 16 Tpm

diet lunak 1700

kkal

Ursodheoxylat

colic acid

250mg/12jam

injeksi omeperazol

40 mg/ 12 jam

infus EAS

200cc/24 jam

Dulcolax 5 mg/ 2

tab malam

27/08/

2014

Infus NaCl 16 Tpm

diet lunak 1700

kkal

Ursodheoxylat

colic acid

250mg/12jam

injeksi omeperazol

40 mg/ 12 jam

infus EAS

200cc/24 jam

KCL 500 mg tab /

8 jam

28/08/ 110/7 36,8 88 20

Page 7: farmasi - case study

2014 0

29/08/

2014

120/8

0

36,5 84 18

30/08/

2014

KCL 32,4 Meq

01/09/

2014

110/7

0

afeb

ris

76 18 Infus NaCl 16 Tpm

diet lunak 1700

kkal

Ursodheoxylat

colic acid

250mg/12jam

injeksi omeperazol

40 mg/ 12 jam

infus EAS

200cc/24 jam

infus aminofusin

500 ml

NaCl 500mg

Kapsul / 8jam

02/09/

2014

Spironolacton

100mg tablet /24

jam

lansoprazol 30mg/

12 jam PO

Omeprazol 40 mg/

Page 8: farmasi - case study

12 jam IV

UDCA 250 mg/ 12

jam PO

03/09/

2014

spironolacton

100mg tablet /24

jam

04/09/

2014

Spironolacton

100mg tablet /24

jam

lansoprazol 30mg/

12 jam PO

Gentamisin 80

mg/12 jam IV

UDCA 250 mg/ 12

jam PO

Cefotaxim 1 g/8

jam IV

05/09/

2014

Spironolacton

100mg tablet /24

jam

lansoprazol 30mg/

12 jam PO

Gentamisin 80

mg/12 jam IV

UDCA 250 mg/ 12

Page 9: farmasi - case study

jam PO

Cefotaxim 1 g/8

jam IV