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5/25/2018 logbook internship
1/91
TanggalKode
Kegiatan
Topik Kegiatan Catatan
Pendamping
Tanda
Tangan
Pendamping
Keterangan
TambahanNo
Diagnosis Penatalaksanaan
(1) (2) (3) (4) (5) (6) (7) (8)
07/09/2013 A
Ny. S, 33 tahun, G2P1A0
uk 38 minggu, JTHIU
prekep puki in partu kala I
fase laten
- Rawat Inap Kebidanan
- Observasi kemajuan
persalinan, awasi tanda-tanda
persalinan Kala IIdr. Layali
Musafiroh
1
07/09/2013 A
Ny. A, 22 th, G1P0A0 uk
12 minggu dengan HEG
- Rawat Inap
- IVFD D5% 20 tpm
- Inj. Ranitidin 3x1A
- Inj. Ondansetron 3x1A
- po Antacyd syr 3x2 cthdr. Layali
Musafiroh
2
07/09/2013 C
Ny. T, 40 th, Dispneu ec
susp CHF
- Rawat Inap
- O2 2-4 l/m
- IVFD D5% 15 tpm
- Inj. Furosemide 2x1 A (iv) -
pasang DC
- Plan: EKG, Ro Thorax PAdr. Layali
Musafiroh
3
07/09/2013 A
Ny. P, 20 th, G1P0A0 uk 39
minggu, JTHIU, preskep,
puka, belum in partu dengan
hipertensi gestasional suspPER dd PEB
- Rawat inap
- IVFD RL 20 tpm
- Nifedipin 2x10 mg
- Plan: Darah Lengkap, Proteinurin
dr. LayaliMusafiroh
4
09/09/2013 A
Tn. S, 51 th, susp TB paru
kasus putus obat
- Rawat Jalan
- Ambroxol 3x1 tab
- Neurodex 3x1 tabdr. Layali
Musafiroh
5
5/25/2018 logbook internship
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- Plan: Ro Thorax PA, sputum
BTA SPS
09/09/2013 A
Ny. M, 24 th, Artralgia susp
CTS
- Rawat jalan
- Na diclofenac 3x25 mg
- Neurodex 1x1 tab- Ranitidin 3x1 tab
- Plan: Fisioterapi
- Edukasi: hindari aktifitas
tangan berlebihdr. Layali
Musafiroh
6
09/09/2013 A
An. S, perempuan, 2 th, 15
kg, DATD+ISPA
- Rawat jalan
- Lacto-B 2x1 sach
- Zinc tab 1x1 tab
- Coparcetin syr 3x1 cthdr. Layali
Musafiroh
7
09/09/2013 B
Tn. S, 55 th, kontrol postClosed Fraktur os Clavicula
Dextra + VL digiti IV
manus dextra
- Rawat jalan- Clindamycin 300 mg 3x1 cap
- Asam mefenamat 3x500 mg
- Ranitidin 3x150 mg
- Edukasi : jaga luka tetap
kering, diet tinggi protein
karena luka lama keringdr. Layali
Musafiroh
8
09/09/2013 A
Tn. S, 40 th, Hipertensi
Stage I, ISPA. TD: 150/90
mmHg
- Rawat Jalan
- Captopril tab 2x12,5 mg
- Ambroxol 3x1 tab
- Bufantacyd 3x2 cth
- Edukasi: diet rendah garamdr. Layali
Musafiroh
9
09/09/2013 B
Tn. S, 40 th, kontrol VL
plantar pedis sinistra
- Rawat Jalan
- Ciprofloxacin 2x500 mg
- Dexamethason 3x0,5mgdr. Layali
Musafiroh
10
5/25/2018 logbook internship
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- Asam Mefenamat 3500 mg
- Ranitidin 3x150 mg
- Edukasi : kontrol 3 hari, jaga
luka tetap kering, diet tinggi
protein
09/09/2013 B
Tn. D, 32 th, kontrol VL
cruris dextra
- Rawat jalan
- Amoxicillin 3x500 mg
- Asam mefenamat 3x500 mg
- Ranitidin 3x150 mg
-Edukasi : antibiotik
dihabiskan, jaga luka tetap
keringdr. Layali
Musafiroh
11
09/09/2013 B
Ny. K, 41 th, LBP post
trauma susp. Fraktur
Kompresi Vertebra Lumbal
- Rawat Jalan
- Na diclofenac 3x25 mg
- Ranitidin 3x150 mg
- Plan: Ro Vertebra
Lumbosacral AP, Konsultasi
Dokter Spesialis Bedahdr. Layali
Musafiroh
12
09/09/2013 B
Tn. M, 34 th, Appendiksitis
kronik
- Rawat Jalan
- Amoxicillin 3x500 mg
- Spasminal 3x1 tab
- Konsultasi Sp.Bdr. Layali
Musafiroh
13
09/09/2013 B
Tn. I, 31 th, kontrol VL
palpebra superior sinistra
- Rawat jalan
- Aff hecting 2
- Neurodex 1x1 tab
- Vitalong C 1x1 tabdr. Layali
Musafiroh
14
09/09/2013 ANy. R, 40 th, Hipertensi
Urgensi, TD: 200/100 mHg
- Rawat jalan (pasien menolak
rawat inap)dr. Layali
Musafiroh15
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- Amlodipin 1x10 mg
- Captopril 3x25 mg
- Neurodex 1x1 tab
09/09/2013 A
Ny. M, 45 th, Mialgia - Rawat jalan
- Meloxicam 3x1 tab- Neurodex 1x1 tab
- Ranitidin 3x150 mgdr. Layali
Musafiroh
16
09/09/2013 A
Ny. M, 31 th, Obs febris
susp Chikungunya BBPV
- Rawat jalan (menolak rawat
inap)
- Betahistine mesylate 2x1ab
- Paracetamol 4x500 mg kp
- Stimuno 2x1 tabdr. Layali
Musafiroh
17
10/09/2013 A
An.P, Perempuan, 9 bl, 7,2
kg. DADRS danRhinofaringitis akut
- Rawat inap
- IVFD RL 36 tpm (mikro)- Inj. Ranitidin 3x1/3A
- Inj. Ondansetron 3x1/3a
- Lacto-B 2x1 sachet
- Zinc 20 mg 1x1/2 tab
- Erlamol syr 3x1 cthdr. Layali
Musafiroh
18
10/09/2013 B
Ny. K, 55 th, kontrol post
Close fraktur humerus
sinistra 1/3 proximal
- Rawat Jalan
- Asam mefenamat 3x500 mg dr. LayaliMusafiroh
19
10/09/2013 A
Ny. P, 25 th, G3P0A2 uk 13
minggu dengan HEG derajat
II
- Rawat inap
- IVFD RL loading 500 cc -->
30 tpm
- RL:D5%:NaCl 0,9% 1:1:1 30
tpm
- Inj. Ranitidin 3x1Adr. Layali
Musafiroh
20
5/25/2018 logbook internship
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- Inj. Ondansetron 3x1A
- Neurosanbe drip 1A/24 jam
10/09/2013 A
An. R, 7 th, 20 kg, DADRS,
obs febris susp Thyfoid
fever
- Rawat Inap - IVFD RL
loading 200 cc--> 30 tpm -->15
tpm- Inj. Chlorampheniol 4x250
mg (iv)
- Inj. Ranitidin 3x1/2A
- Inj Ondansetron 3x1/2A
- Sanmol syr 3x2 cth
- L-Bio 3x1 sachet
- Plan: DL, widaldr. Layali
Musafiroh
21
10/09/2013 A
An. E, 7 th, 23 kg, Ob
Vomitus suspek intoksikasi
makanan
Rawat Jalan
- Antasida doen syr 3x1 cth
- Ranitidin III, Papverin III,
Vit BC III, Vit C II ,mf No.X
3x1dr. Layali
Musafiroh
22
11/09/2013 A
Perempuan, 25 th, P1A0
post partum fisiologis Hari
ke-2 dengan PEB. TD:
130/90 mmHg
- BLPL
- Clindamicyn 3x300 mg
- Nifedipn 1x10mg
- Asam Mefenamat 3x500 mgdr. LayaliMusafiroh
23
11/09/2013 A
Perempuan, 35 th, P2A0
post partum SC atas indikasi
riwayat SC
- IVFD RL 20 tpm
- Inj. Cefriaxon 2x1 gr (iv)
- Inj. Ketorolac 3x1A
- po. Gastrul tab 2x1dr. Layali
Musafiroh
24
11/09/2013 A
Perempuan, 28 tahun,
G2P1A0 uk 37 minggu
JTHIU peskep puka in partu
- Rawat Inap obervasi vk
- IVFD RL 20 tpm
- Nifedipin 2x10 mg sldr. Layali
Musafiroh
25
5/25/2018 logbook internship
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kala I fase aktif dengan PER
12/09/2013 A
Tn. T, 31 th, Ob Febris susp
Thyfoid Fever
- Rawat Inap
- IVFD RL 2 tpm
- Chloramphenicol 4x500 mg
- Paracetamol 4x500 mg- Rantidin 3x150 mg
- Plan : DL, Widaldr. Layali
Musafiroh
26
12/09/2013 A
Tn. S, 30 th, DADRS - Rawat inap
- IVFD RL 20 tpm
- Loperamid 2-1-1
- L-Bio x1 sach
- Omeprazol 2x1 tabdr. Layali
Musafiroh
27
13/09/2013 A
Ny . E, 29 th, G1P0A0 uk
13 minggu dengn heg
derajat II
- Rawat inap
- IVFD RL loading 500 cc -->
30 tpm - RL:D5%:NaCl ,9%
1:1:1 30 tpm
- Inj. Ranitidin 3x1A
- Inj. Ondansetron 3x1A
- Neosanbe drip 1A/24 jamdr. Layali
Musafiroh
28
13/09/2013 A
An. M, 10 th, 27 kg,
DADRS
- Rawat Inap
- IVFD RL 16 tpm
- Inj. Ranitidin 3x1/2 A
- L-Bio 3x1 sachet
- Zinc 1x1 tabdr. Layali
Musafiroh
29
14/09/2013 B
Tn.T, 60 th, Kontrol multpel
VL
- Rawat Jalan
- Asam mefnama 3x500 mg
- Ranitidin 3x150 mg
- Neurodex 1x1 tabdr. Layali
Musafiroh
30
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7/91
14/09/2013 A
An. B, 7 th, 18 kg, GEA
tanpa dehidrasi
- Rawat jalan
- Ranitidin 2x75 mg
- Antacida doen syr 3x1/2 cth
- L-Bio sach 2x1
- Zinc tab 1x1
dr. Layali
Musafiroh
31
14/09/2013 A
An. K, 4 th, 15 kg, GEADS
susp intoksikasi makanan
- Rawat inap
- IVFD RL 14 tpm (ma)
- Inj. Ranitidin 2x1/2A
- Inj Metoclopramid 2x1/2A
- po Norit tab 3x5 tab
- Plan: DLdr. Layali
Musafiroh
32
14/09/20134 A
Tn. S, 54 th, Obs febris susp
Chikungunya dd DHF
- Rawat inap
- IVFD RL 20 tpm
- Paracetamol 4x500 mg
- Neurobion 1x1
- Stimuno 1x1 tabdr. Layali
Musafiroh
33
14/09/2013 B
Tn. S, 54 th , Abdominaal
pain ec GERD, dd gastritis
Rawat inap
- IVFD RL 20 tpm + Ketorolac
1A drip (extra)
- Inj Ranitidin 2x1 A
- po Ciprofloxacin 2x500 mg
- Buscopan 3x1 tab
- Plan: DL, EKGdr. Layali
Musafiroh
34
14/09/2013 A
An. G, 3 th, 8,5 kg, DADRS - Rawat inap
- IVFD RL 36 tpm (mikro)
- Inj. Ondansetron 3x1/3 A
- L-Bio 3x1 sachet
- Zinc 1x1/2 tabdr. Layali
Musafiroh
35
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- Plan: DL
15/09/2013 A
Tn. W, 45 th, GEADS - Rawat inap
- IVFD RL LOADNG 500 CC
20 tpm
- Inj. Ranitidin 2x1A- Mecodiar 2 tab tiap kali BAB
- L-Bio 2x1 sach
- Zinc 1x1 tab - Plan: DLdr. Layali
Musafiroh
36
15/09/2013 A
Ny. U, 21 th, G2P1A0 uk 8
minggu dengan HEG
- Rawat inap
- IVFD RL loading 500 cc -->
30 tpm
- Rl:D5%:NaCl 0,9% 1:1:1 30
tpm
- Neurosanbe drip 1A/24 jam
- Inj Ranitidin 3x1A
- Inj. Metocloperamid 3x1A
- Plan: DL, GDSdr. Layali
Musafiroh
37
15/09/2013 B
Tn. S, 56 th, susp Closed
fraktur antbrachii dextra,
hematom palpebra sinistra,
multipel VE
-Rawat inap-Wound toilet- Immobilisasi spalk+elasticband antebrachii sinistra
- IVFD RL 20 tpm- Inj. Ceftriaxon 2x1 gr (iv,
skintest)
- Inj. Ketorolac 2x1A kp- Inj. Ranitidin 3x1A-Plan: Ro antebrachi sinistra
AP&lateral, Konsultasi dr
sp.OT
dr. Layali
Musafiroh
38
5/25/2018 logbook internship
9/91
16/09/2013 ANy. R, 22 th, G2P0A1 uk 36
minggu dengan konstipasi
- Rawat jalan - Microlac supp
1 tubedr. Layali
Musafiroh39
16/09/203 A
An. P, perempuan, 3, th, 18
kg, GEADS
- Rawat inap
- IVFD RL 56 tpm (mi)
- Inj Ranitidin2x1/2 A- Inj. Ondansetron 2x12A
- Myrasic syr 3x 1 1/2 cth
- Plan: DLdr. Layali
Musafiroh
40
16/09/203 A
Nn. I, 19 th, GEADR Rawat jalan
- Cotrimoxazol forte 2x1
- Loperamid 2-1-1 tab
- Paracetamol 3x1 tab
- Vitazym 3x1 tabdr. Layali
Musafiroh
41
16/09/2013 A
Ny. K, 25 th, G1P0A0 uk
39 minggu JTHIU presbo in
partu kala I fase aktif
Rawat inap
- IVFD RL 16 tpm
- Observasi kemajuan
persalinandr. Layali
Musafiroh
42
17/9/2013 C
Ny. D, 60 tahun, Hipertensi
Emergensi. TD: 200/110
mmHg
Rawat inap
- IVFD RL 20 tpm
- Inj. rantidin 3x1A
- Amlodipin 2x10 mg
- Captopril 3x25 mg
- Paracetamol 2x50 mg
- Plan: DL, GDS, Ureum,
Kreatinin, Ro thorax PA, EKGdr. Layali
Musafiroh
43
21/09/2013 A
Ny. A, 56 th, GEADS - Rawat inap
- IVFD RL 20 tpm
- Inj. Ranitidin 3x1Adr. Layali
Musafiroh
44
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- Inj. Ondansetron 3x1A
- Scopma 3x1 tab
21/09/2013 A
Ny. R, 55 th, Hipertensi
stage II, Gastritis. TD:
170/100 mmHg.
- Rawat inap
- IVFD D5% 20 tpm
- Inj. Ranitidn 3x1A- Inj. Ondansetron 3x1 A
- Catopril 3x 25 mg
- Nifedipin 2x5 mgdr. Layali
Musafiroh
45
21/09/2013 A
Tn. S, 58 th Obs febris susp
thyfoid fever
- Rawat inap
- IVFD RL 20 tpm
- Paracetamol 4x500 mg
- Antacida 3x1 tab
- Plan : DL, Widaldr. Layali
Musafiroh
46
21/09/2013 A
Ny. S, 38 th, Hipertensi
stage I, GEADS
- Rawat inap
- IVFD RL 20 tpm
- Inj. Ranitidin 3x1 A
- Inj. Ondansetron 3x1A
- Captopril 3x12,5 mgdr. Layali
Musafiroh
47
21/09/2013 B
Tn. P, 30 th, Muliple VL - Rawat Jalan
- Wound toilet, hecting luar 3
- Inj. ATS 1.500 IU (im, skin
test)
- Clindamycin 3x300 mg
- Asam mefenamat 350 mg
- Dexamethason 3x0,5 mg
- Ranitidin 3x1tab
- Edukasi: jaga luka tetap
kering, kontrol poliklinikdr. Layali
Musafiroh
48
5/25/2018 logbook internship
11/91
21/09/2013 A
Tn. E, 23 th, GEADS - Rawat inap
- IVFD RL 30 tpm
- Inj. Ranitidin 3x1 A
- Inj. Ondansetron 3x1A
- L-Bio 3x1 sach- Zinc 1x1 tab
- Plan: DLdr. Layali
Musafiroh
49
22/09/20103 A
Ny. T, 35 th,
BPPV+Gastritis akut
- Rawat inap
- IVFD D5%:RL 2:1 20 tpm
- Inj. Ranitidn 3x1 A
- Inj. Difenhidamin 3x1A
- Neurobion drip 1A (extra)
- Omeprazlol 2x1 tab
- Antacida Doen syr 3x2cthdr. Layali
Musafiroh
50
22/09/2013 A
Nn. I, 13 th, 24 kg, Obs
febris 5 hari susp Thyfoid
fever dd DHF
- Rawat inap
- IVFD RL 20 tpm
- Inj. Ranitidin 3x1A
- Inj. Ondansetron 3x1 A
- Paracetamol tab 3x500 mg
- Plan: DL, widaldr. Layali
Musafiroh
51
22/09/2013 C
Ny. T, 60 th, Asma attack
pada asma persistten sedang,
hipertensi stage II, susp TB
paru kasus putus obat. TD:
160/90 mmHg
Rawat inap
- O2 2-4 l/m
- Nebulisasi Ventolin 2,5 mcg
- IVFD RL 20 tpm
- Inj. Ranitidin 2x1 A
- Ambroxol 3x1 tab
- Captopril 3x25 mg
- Paracetamol 3x500 mgdr. Layali
Musafiroh
52
5/25/2018 logbook internship
12/91
- Plan: Ro thorax PA, GDS,
DL, sputum BTA SPS, EKG
22/09/2013 A
An. R, perempuan, 7 bln,
6,5kg, GEADS,
Rinobronkhitis akut
Rawat inap
- IVFD RL loading 100 cc -->
30 tpm (mi)- L-Bio 3x1 sach
- Zinc x1/2 tab
- GG II, CTM II, PCT II, vit C
II mf X 3x1
- Plan: DLdr. Layali
Musafiroh
53
22/09/2013 A
Tn. E, 33 th, Gasroenteritis
kronik, Candidiais oral,
suspek AIDS
- Rawat inap
- IVFD D5% 30 tpm
- Inj. Ranitidin 3x1A
- Antacida Doen syr 3x2 cth
- L-Bio 3x1 sachet
- Zinc 1x1 tab
- Kandstatin drop 4x100.000
IU
- Plan: DL, GDSdr. Layali
Musafiroh
54
23/09/2013 A
Tn. S., 39 th, obs. Febris
susp TF
Rawat jalan
- Chloramphenicol 4x500 mg
- Ranitidin 3x150 mg
- Paracetamol 3x500 mg
- Neurodex 1x1 tab - Plan:
DL, widaldr. Layali
Musafiroh
55
23/09/2013 C
Ny. M, 61 th,Obs dyspnea
ec anemia gravis
- Rawat inap
- O2 3 l/m
- IVFD NaCl 0,9% 20 tpmdr. Layali
Musafiroh
56
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(ma)
- Inj. Ranitidin 3x1A(iv)
Plan: DL, golongan darah,
EKG, Ro thorax
23/09/2013 B
Tn. P, 30 th, VEdorsumpedis dextra et
sinistra
Rawat jalan- Amoxicillin 3x 500 mg
- Asam mefenamat 3x500 mg
-Neurodex1x1tabdr. Layali
Musafiroh
57
23/09/2013 B
Tn.W, 75 th,Obs dyspnea
susp PPOK dd TB paru
Rawat inap
- O2 3l/m
- IVFD RL 20 tpm
- Paracetamol 4x500 mgdr. Layali
Musafiroh
58
24/09/2013 A
Ny. R, 50 th, GEADS Rawat inap
- IVFD RL loading 300cc
30 tpm
- Inj.Ranitidin 2x1A
- Inj. Ondansetron 2x1A
- Cotrimoxazol 2x1tab
- Scopamin plis 2x1 tab
- Zinc tab 1x2
- New diatab 3x1dr. LayaliMusafiroh
59
24/09/2013 C
Ny.M, 45 th,Multple VE,
VL capitis
- Rawat inap
- O2 2l/m
- IVFD RL 30 tpm
- Inj.Ranitidin 3x1A
- Inj.Ondansetron 3x1A
- Ketorolac drip 3x 1 A
- Inj.Neurotam 3x1Adr. Layali
Musafiroh
60
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- Inj.Citicholin 3x 1 A
- Inj. Ceftriaxon 2x1 gr (iv,
skin test)
24/09/2013 C
Ny. R,23 th, VE cruris
dextra
Rawat jalan
- Amoxicillin 3x500 mg- Asam mefenamat 3x500 mg
dr. LayaliMusafiroh
61
24/09/2013 A
An.Aditya,6
th,15kg,Tonsilitiskronik
eksaserbasi akut
Rawat inap
- IVFD RL15 tpm
- Inj.Ceftriaxon 2x250 mg
- Inj.Gentamicin 2x20 mg
- Inj.MP 2x1/2cc
- Luminal II, PCT III,
Domperidon II, Vit. C III mf
X,3x1dr. Layali
Musafiroh
62
24/09/2013 A
Ny.S,28 th, obs.febris susp
DHF dd TF
rawat jalan
- Amoxicillin 3x500 mg
- Ranitidin 3x150 mg
- Neurodex 1x1 tab
- Vitalong C1x1 tabdr. Layali
Musafiroh
63
24/09/2013 A
Tn. A, 25 th, TTH Rawat jalan
- Paracetamol 3x500 mg
- Neurodex 1x1 tab
- Vitalong c 1x1 tabdr. Layali
Musafiroh
64
24/09/2013 A
Tn.S, 75 th,Obs febris susp
Chikungunya
rawat inap
- IVFD RL loading 1000 cc
20 tpm
- Inj. Cefotaxim 2x1 gr
- Inj.Dexamethason 3x1Adr. Layali
Musafiroh
65
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15/91
- Inj. Ranitidin 2x1A
- Paracetamol 4x500 mg
- Luminal 2x1 tab
24/09/2013 A
An.S, 7 th,Obs febris susp
DHF grade II
Rawat inap
- IVFD RL 40 tpm 4jam
20tpm
- Inj. Ranitidin 2x1/2A
- Paracetamol syr 3x1 cth
- DEHAF 2x1
- Curcuma 2x1cthdr. Layali
Musafiroh
66
24/09/2013 A
Tn.S, 38 th,GEADS Rawat inap
- IVFD RL loading 300 tpm
30 tpm
- Inj.Ranitidin3x1A
- New diatab 3x1
- Cotrimoxazol 2x1
- Scopamin plus 2x1
- L-Bio 3x1sach
- Paracetamol 4x500 mgdr. Layali
Musafiroh
67
24/09/2013 A
Ny.D,20 th, G1P0A0 uk
39+4 minggu
JTHIU,preskep,inpartu kala
II lama
rawat inap
-Vakum ekstraksi
dr. Layali
Musafiroh
68
25/09/2013 A
Ny.K,60th, gastritis rawat inap
- IVFD RL 16 tpm
- Inj.Ranitidin 3x1 A
- Antasida doen syr 3x2 cth
- Omeprazol 2x1 tabdr. Layali
Musafiroh
69
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- Curcuma 3x1 tab
25/09/2013 A
An.E,5th,15 kg, Kejang
Demam Sederhana
rawat inap
- IVFD D5%15 tpm
- Inj.Dexamethason 3x2cc
- Luminal 5 mg II, Vit. C 25mgII,PCT 70mg III, mf X,3x1
dr. LayaliMusafiroh
70
25/09/2013 A
An.H,2 th,9 kg,GEA
dehidrasi sedang,
rawat inap
- IVFD RL 300 cc loading-->
36 tpm
- Fuzide syr 3x1 cth
- Sanmol syr 3x3/4 cth
- L-bio 3x1/2sach
- Zinc 1x1/2tabdr. Layali
Musafiroh
71
25/09/2013 B
An.I, 1 th,8,5 kg,
KDS,Rhinofaringitis akut
rawat inap
- IVFD RL loading 200cc -->
30tpm (mi)
- Sanmol syr 3x 3/4cth
- CTM II, GG II,Luminal II,
VitCII,m.f X,3x1dr. Layali
Musafiroh
72
25/09/2013 A
ny. R,50 th,DM tipe 2 degan
GEADS
rawat inap
- IVFD RL loading 500cc --
>24tpm
-Inj.Ranitidin 3x1A
- Inj. Ondansetron1 A (extra)
- Glibenclamide1x5mg (1-0-0)
- New diatab 3x1 tab
- Scopamin plus3x1tab
- PCT 3x500mgdr. Layali
Musafiroh
73
5/25/2018 logbook internship
17/91
25/09/2013 A
An.M,2 th, 9 kg,GEADS rawat inap
-IVFD RL loading 150 cc --
>36tpm (mi)
-L-Bio 3x 1/2sach
- Zinc 1x1/2tab
dr. Layali
Musafiroh
74
25/09/2013 B
An. M,12 th, 20 kg,Obs
febris susp DHFderajat II dd
TF
rawat inap
- IVFD RL loading 400 cc-->
30 tpm
- Inj.Ranitidin 3x1/2A
- sanmol syr4x2 cth
- Stimuno tab 1x1
- DEHAF2x 1/2sach
- Plan: DL, widaldr. Layali
Musafiroh
75
25/09/2013 A
An.M, 9 bln,8,5
kg,GEADS,Rhinofaringitis
akut
rawat inap
- IVFD D5% loading 100 cc-->
40 tpm(mi)
- Sanmol syr 4x1 cth
- Lacto B 3x1/2sach
- Zinc 1x1/2tab
- GG II,CTM II,Vit C III,mf X
3x1dr. Layali
Musafiroh
76
25/09/2013 A
Tn. S,40 th,Vl dorsum pedis
dextra,VE olecranon sinistra
rawat jalan
- wound toilet,hecting luar
- Inj ATS1.500 IU(im,skintest)
- Amoxicillin 3x500 mg -
Asam mefenamat 3x500 mg -
Ranitidin 3x150 mgdr. Layali
Musafiroh
77
5/25/2018 logbook internship
18/91
28/09/2013 AAn. F,14 th, susp Miopia
ODS,
Rujuk Sp.M dr. Layali
Musafiroh78
28/09/2013 C
Tn.M, 23th,VE genu dan
olecranon sinistra
rawat jalan
- Amoxicillin 3x 500 mg
- Asam Mefenamat 3x 500mg- ranitidin 3x 150mg
- Amlodipin 1x5 mgdr. Layali
Musafiroh
79
28/09/2013 B
Ny. T,30 th, G3P2A0 uk 38
minggu JTHIU preskep in
partudgn febris hari ketiga
dan Hipertensi gestasional
susp PER
Rawat inap
- IVFD RL 16tpm
- Nifedipin1x 10 mg
- Paracetamol 3x500 mg
- Plan: DL,protein urindr. Layali
Musafiroh
80
28/09/2013 C
An.S,12th, 36kg, Combustio
derajat II-III luas 18%
rawat inap
-IVFD RL16 loading 300 cc-->
30tpm
- Inj.Ranitidin 3x1/2A
- Bioplasenton saelp 3dd ue
-kompres luka/8 jam dengan
NaCldr. Layali
Musafiroh
81
28/09/2013 B
Tn.Y,58 th,Asma attack rawat inap
- O2 4-5 lpm
- Nebulisasi Ventolin 1A
-IVFD D5% 16tpm
- Methylprednisolon tab
2x4mg
- Salbutamol 3x2 mg
- Ambroxol3x30 mgdr. Layali
Musafiroh
82
29/09/2013 A tn. M,59 th, Dm tipe 2 rawat jalan dr. Layali 83
5/25/2018 logbook internship
19/91
dengan motion sickness - Dimenhidrinat 3x1 tab
- Domperidon 2x1 tab
- Ranitidin 3x150mg
- PCT 3x500 mg
- Glibenclamid 1x5 mg- Metformin 3x500 mg
Musafiroh
29/09/2013 B
Ny. S, 60th,obs dyspnea ec
susp CPC decompensata dd
Bronkopneumonia
rawat inap
- O2 4-5lpm
- Inj.Ceftriaxon 2x 1gr (iv)
- Inj.Furosemid 2x1A
- Nifedipin1x10 mg
- Digoxin 1x0,125mg
- Plan: DL, Ur, Cr, GDS, ro
thorax PA, EKGdr. Layali
Musafiroh
84
29/09/2013 BNy.S, 25th, G1P0A0 uk 39
minggu dengan inersia uteri
rawat inap
-Konsul Sp.OGdr. Layali
Musafiroh85
01/10/2013 A
An.L, 13 bulan, 7,5kg,
GEADS, Rhinofaringitis
akut
Rawat inap
- IVFD RL loading 150 cc -->
30 tpm (mi)
- Inj.Ranitidin 2x1/3A
- Lacto b 3x1/2sach
- Zinc 1x1/2tab
- GG II,CTM II,sacharin adlib
mf X 3x1
dr. Layali
Musafiroh
86
01/10/2013 B
Ny.N, 65 th,VL capitis rawat jalan
- wound toilet,hecting luar7
- Clindamycin 3x300 mg
- Asam mefenamat 3x500mgdr. Layali
Musafiroh
87
5/25/2018 logbook internship
20/91
- Ranitidin 3x150 mg
01/10/2013 B
Nn.A,25th,Vulnus punctum
plantar pedis sinistra
rawat jalan
Inj. ATS1500 IU
- Clindamycin3x300 mg
- Asam mefenamat 3x500mg- Ranitidin 3x150 mg
dr. LayaliMusafiroh
88
01/10/2013 B
Ny.T, 21 1th, Vulnus
Punctum plantar pedis
sinistra
Rawat jalan
- Inj. ATS 1.500 IU
- Amoxicillin 3x500 mg
- Asam mefenamat 3x500 mg
- Rantidin 3x150 mgdr. Layali
Musafiroh
89
02/10/2013 A
Ny. T, 50 th, GEADS Rawat inap
- IVFD RL loading 500 cc -->
30 tpm
- Inj. Ranitidin 3x1 A
- Inj. Ondansetron 3x1 A
- Loperamid 2-1-1 tab
- Paracetamol 4x500 mg
- Scopamin plus 3x1 tab
Plan: DLdr. Layali
Musafiroh
90
02/10/2013 A
An. J, 10 th, 25 kg, GEADS rawat inap
- IVFD RL loading 200 cc -->
16 tpm
- Inj. Rantidin 3x1/2 A- Lacto B 3x1 sach
- Zinc tab 1x20 mgdr. Layali
Musafiroh
91
05/10/2013 CTn. D, 60 th, Obs. dyspnea
susp TB paru kasus baru,
- Rawat inap
- O2 3-4 l/m, nasal canuldr. Layali
Musafiroh92
5/25/2018 logbook internship
21/91
hipertensi stage I , TD:
140/90 mmHg
- IVFD D5% 20 tpm
- Inj. Ranitidin 3x1 A
- Amboxol tab 3x30mg
- Amlodipin 1x10mg
- Curcuma 3x1 tab- Plan: DL, EKG, Ur, Cr, GDS,
Ro thorax PA, BTA SPS
05/10/2013 A
Ny. S, 34 th, Gastritis kronik - Rawat inap
- IVFD D5% 20 tpm --> D5%:
RL 1:1
- Inj. Ranitidin 3x1 A
- Inj Ondansetron 3x1 A
- Omeprazol 2x1 tab
- Antasida doen syr 3x2 cthdr. Layali
Musafiroh
93
05/10/2013 A
Nn. S, 19 th, Obs febris susp
TF dd DHF, Gastritis akut
- Rawat inap
- IVFD D5% 20 tpm 2 flab --
> RL 20 tpm
- Inj. Ranitidin 2x1 A
- Inj. Ondansetron 1A (extra)
- PCT 4x500 mg
- Curcuma 1x1 tab
- Plan: Dl, Widal, GDS: 77
mg/dldr. Layali
Musafiroh
94
05/10/2013 A
Ny. S, 55 th, Obs febris suspTF dd DHF
- Rawat inap- IVFD RL loading 500 cc -->
maintenance 20 tpm
- Inj. Ranitidin 3x1 A
- Inj Ondanasetron x1 Adr. Layali
Musafiroh
95
5/25/2018 logbook internship
22/91
- Paracetamol 4x500 mg
- Neurodex 1x1 tab
- Plan: DL, widal
05/10/2013 A
Ny. N, 44 th, BPPV - Rawat inap
- IVFD RL 20 tpm- Inj. Ranitidin 3x1A
- Inj. Ondansetron 3x1A
- Betahstin mesylate 3x1 tab
- Paracetamol 3x500 mg
- Antasida Doen 3x2 cthdr. Layali
Musafiroh
96
05/10/2013 A
Ny. K., 50 th, GEADS,
Hipertensi stage II, susp DM
tipe II. TD: 170/100, GDS:
359 mg/dl
- Rawat inap
- IVFD RL loading 300 cc -->
maintenance 20 tpm
- Inj. Ranitidin 3x1A
- Inj. Ondansetron 3x1 A
- Cotrimoxaol 3x1 tab
- Scopamin plus 3x1 tab
- Captopril 3x25 mg
- Metformin 3x500 mg
- Plan: DL, GDP. G2PP, Ro
thorax PAdr. Layali
Musafiroh
97
05/10/2013 B
An. G, 6 th, 20 kg, VE reg
capitis
- Rawat jalan
- Amoxicillin yr 3x1 cth
- Erlamol syr 2x cth
dr. Layali
Musafiroh
98
05/10/2013 A
Ny. K, 57 th, GERD - Rawat inap (APS)
- IVFD RL16 tpm
- Ranitidin 3x 150mg
- Omeprazol 2x1 tabdr. Layali
Musafiroh
99
5/25/2018 logbook internship
23/91
- Antasida doen syr 3x 2 cth
- Neurodex 1x1 tab
05/10/2013 A
Ny. E, 6 th, DM tipe II,
Hipertensi stage II. TD:
180/100 mmHg, GDS: 143mg/dl
- Rawat jalan
- Glimepirid 1x1 mg
- Captopril 3x 25 mg- Amlodipin 1x10 mg
- Neurodex 1x1 tabdr. Layali
Musafiroh
100
05/10/2013 A
An. E, 9 bln, 9,2 kg,
GEADS
- Rawat inap
- IVFD D5%-1/4 NS loading
100 cc--> maintenance 36 tpm
(mi)
- Lacto-B 2x1/2 sach
- Zinc 1x10 mg
- Paracetamol drop 3x0.9 cc
- Plan: DL dr. LayaliMusafiroh
101
07/10/2013 C
Ny. A, 20 th, obs. vomitus
ec intoksikasi larutan
pemutih pakaian; Tentament
suicide
Rawat inap Bilas lambung
500 cc NaCl --> jernih--
>puasakan 6 jam
- IVFD RL loading 50 cc -->
30 tpm --> 20 tpm
- Inj. Ranitidin 3x1 A
- Norit 3x6 tab
- Alprazolam 1x0,5 mg (0-0-1)
- Plan: DL
dr. Layali
Musafiroh
102
07/10/2013 B
Tn. A, 27 th, Multiple VE - Rawat jalan
- Wound toilet
- Amoxicillin 3x 500 mg
- Paracetamol 3x500 mgdr. Layali
Musafiroh
103
5/25/2018 logbook internship
24/91
- Ranitidin 2x10 mg
- Neurodex 1x1 tab
07/10/2013 B
An. B, 80 th, 20 kg,VL reg
Fontal dextra
- Rawat jalan
- Hecting luar 2
- Amoxicillin syr 3x1 cth- Paracetamol syr 3x1 cth dr. LayaliMusafiroh
104
07/10/2013 C
An. L, 5 th, 8,5 kg, KDS,
obs febris h1. t: 42 C
- Rawat inap
- IVFD RL 12 tpm (ma)
- Paracetamol syr 4x1 cth
- Diazepam 5mg III, Vit C III,
Vit BC III --> No. X, 3x1
- Plan: DLdr. Layali
Musafiroh
105
07/10/2013 A
Tn. S, 80 th, Hipertensi
stage I, Retensio urine susp
BPH. TD: 150/90 mmHg
- Rawat jalan
- Ganti kateter urin
- Ciprofloxacin 2x500 mg
- Ranitidin 2x150 mg -
Captopril 1x12,5 mgdr. Layali
Musafiroh
106
07/10/2013 A
Ny. T,2 th, Gastritis akut - Rawat jalan
- Ranitidin 3150 mg
- Antasida doen syr 3x2 cth
- Omepraol 2x1 tabdr. Layali
Musafiroh
107
07/10/2013 A
An. S, 12 th, 27 kg , Obs
febris susp TF, gastritis
Rawat inap
- IVFD RL 20 tpm
- Inj Ranitidin 2x50 mg- Inj. Ondansettron 2x4 mg
- Paracetamol 4x250 mg
- Antasida syr 3x2 cth
- Plan: DL, Widaldr. Layali
Musafiroh
108
5/25/2018 logbook internship
25/91
07/10/2013 A
Tn. N, 28 th, Vomitus ec
intoksikasi obat kuat
- Rawat jalan
- Domperidon 3x1 tab
- Ranitidin 2x1 tab
- Diazepam 1x2mgdr. Layali
Musafiroh
109
07/10/2013 C
Tn. S, 18 th, CKR, VLlabium superior, Multiple
VE . GCS: E4M6V3.
- Rujuk- IVFD RL loading 500 cc -->
20 tpm
- Inj. cefotaxim 2x 1 gr (iv),
skin test
- Inj. Ranitidin 250 mgdr. Layali
Musafiroh
110
07/10/2013 B
Ny. S, 40 th, Multiple VE - Rawat jalan
- Wound toilet
- Amoxicillin 3x500 mg
- Ranitidin 2x150 mg
- Paracetamol 3x500 mg
- Neurodex 1x1 tabdr. Layali
Musafiroh
111
07/10/2013 B
An. A, 4 th, 12kg, VE reg
facial
- Rawat jalan
- Amoxicillin syr 3x1cth
- PCT syr 3x1 cthdr. Layali
Musafiroh
112
08/10/2013 A
An. L, 5 thh, 8,5 kg, KDS,
obs febris H3 susp thypoid
fever. t: 39,3 C
-Rawat inap - IVFD D5%-
1/4NS loading 100 cc --> 36
tpm (mi)
- Inj. Ranitidin 3x1/2 A
- PCT syr 4x1 cth- Diazepam 5 mg III, Vit C III,
Vit BC III --> No. X, 3x1 -
Plan: Widaldr. Layali
Musafiroh
113
08/10/2013 A An. E, 1 th, 9 kg, GEADS, Rawat inap dr. Layali 114
5/25/2018 logbook internship
26/91
Rhinofaringitis akut - IVFD RL Loading 100 cc-->
36tpm (mi)
- Inj. Ranitidin 2x1/2A
- Paracetamol drop 4x0,9 cc
- L-bio 2x1/2 sach
- Zinc syr 1x1/2 cth
- GG II, CTM III,
Dexamethason 0,5 mg II
sacharin lib --> No.X, 3x1
- Plan: DL
Musafiroh
10/10/2013 A
Ny. V, G1P0A0 usia 19
tahun uk 40 minggu JTHIU
preskep puki belum in partu
dengan ketuban pecah awal.
- Rawat inap kebidanan -
IVFD RL 16 tpm
dr. Layali
Musafiroh
115
10/10/2013 A
An. L, 8 bln, 8,5 kg, Obs
febris suspek DHF dd TF
- Rawat inap
- IVFD RL Loading 100 cc-->
32 tpm (mi)
- Inj. Ranitidin 2x1/2A
- Paracetamol drop 4x0,8 cc
- Plan: DL (trombosit
36.000/mm3, Widal S.thypii
O:1/80dr. Layali
Musafiroh
116
10/10/2013 A
An. Q, 9 bln, 6,8 kg,
GEADS, Rhinofaringitisakut
Rawat inap
- IVFD RL loading 100 cc -->28 tpm (mi)
- Paracetamol drop 4x0,7 cc
- Lacto B 3x1/2 sach
- Zinc 1x1/2 tabdr. Layali
Musafiroh
117
5/25/2018 logbook internship
27/91
- GG II, CTM II,
Dexamethason II, mf No. X,
3x1
10/10/2013 B
Tn. S, 37 th, Open fraktur
tibia et fibula dextra 1/3
medial displaced neglected
- Rawat jalan
- Ro Cruris dextra AP&lateral
- Clindamycin 3x300 mg
- Ranitidin 3x150 mg
- pro Konsultasi Sp.OT, pasien
menolak.dr. Layali
Musafiroh
118
10/10/2013 A
Tn. K., 60 th, Obs febris
susp Thyfoid fever dd DHF
- Rawat inap
- IVFD RL 20 tpm
- Paracetamol 3x500mg
- Curcuma 3x1 tab
- Antasida 3x2 cthdr. Layali
Musafiroh
119
10/10/2013 C
Tn. M, 3 th, Obs
heematemesis-melena up
hepatiis, dd cholelithiasis,
gastritis erosive, ulkus
peptikum
- Rawat inap
- IVFD D5% 20 tpm
- Inj.Ranitidin 3x1A
- Inj. Metoclopramid 3x1A
- Inj. Asam tranamat 3x500 mg
- Curcuma 3x1 tab
- Plan: DL, GDS (87 mg/dl),
HBsAg, Bilirubindr. Layali
Musafiroh
120
10/10/2013 A
An. P, 14 bln, 8 kg, KDK.
s: 38C, kejang 2x
- Rawat inap
- IVFD RL loaoding 100 cc-->aintenance 32 tpm (mi)
- Paracetamol drop 4x0,8 cc
- Luminal 30 mg IV, VIt C III,
Vit BC III, No. X, 3x1 -dr. Layali
Musafiroh
121
5/25/2018 logbook internship
28/91
Plan: DL
10/10/2013 B
Tn. H, 18 th, Vulnus
laseratum digiti II manus
sinistra
- Rawat jalan
- Wound toilet, Hecting luar 1
- Amoxicillin 3x500 mg
- Asam mefenamat 3x500 mg
- Ranitidin 2x150 mg
- Neurodex 1x1 tabdr. Layali
Musafiroh
122
10/10/2013 A
Ny. K, 50 th, Hipertensi
grade II, gastritis.
TD:152/120 mmHg
- Rawat inap
- IVFD RL 20 tpm
- Ranitidin 3x150 mg
- Captopril 3x25 mg
- Amlodipin 1x10 mg
- Neuroex 2x1 tab
- Plan: DL, GDS, Ur, Cr, Ro
thorax PAdr. Layali
Musafiroh
123
10/10/2013 A
Nn. R, 16 th urtikartia Rawat jalan
- Dexamethason 3x1 tab
- Loratadin 1x1 tab
- Paracetamol 3x500 mgdr. Layali
Musafiroh
124
10/10/2013 A
Ny. S, 19 th, G1P0A0 40
minggu JTHIU,prekep, in
partu dengan kala II lama
- Rawat inap
- IVFD RL 20 tpm
- Pimpin persalinan
- Konsultasi dr. Arif, Sp.OGdr. Layali
Musafiroh
125
12/10/2013 A
An. K, 14 bln, 13 kg kontrolpost diare dan faringitis akut
- Rawat jalan- Cefadroxil 2x1 cth
- Cetirizine II, Dexamethason
II, Vit C III, mf No.X, 3x1dr. Layali
Musafiroh
126
12/10/2013 A, B Tn. W, 80 th, kontrol VL - Rawat jalan dr. Layali 127
5/25/2018 logbook internship
29/91
palmar sinistra, hipertensi
stage I. TD: 140/90 mmHg
- Aff hecting
- Captopril 1x12,5 mg
- Neurodex 1x1 tab
Musafiroh
12/10/2013 A
An. M, 2,5 th, 11 kg,
GEADS
- Rawat inap
- IVFD RL loading 100 cc-->
10tm (ma)
- Inj Ranitidin 2x1/2A
- Inj Metoclopramid 2x1/2A
- Lacto-B 2x1 sach
- Zinc 1x20 mg
- Plan: DLdr. Layali
Musafiroh
128
12/10/2013 A
Ny. A, 20 th, kontrol post
intoksikasi bayclin, gastritis
- Rawat jalan
- Ranitidin 3x150 mg
- Omeprazol 2x1 tab
- Vitazym 2x1
- Curcuma 3x1dr. Layali
Musafiroh
129
12/10/2013 A
An. S, 2 th, 12 kg, Febris
usp TF, Rhinofaringitis
akut.
- Rawat jalan
- Cefadroxil 2x1 cth
- Paracetamol syrup 4x1 cth
- Dexamethason II, GG II, Vit
C III, mf no.X, 3x1dr. LayaliMusafiroh
130
12/10/2013 A
Ny. T, 33 th, Hipertensi
stage II. TD: 180/90 mmHg.
- Rawat jalan
- Captopril 3x 25 mg
- Neurox 1x1 tab- SF 1x1 tab
dr. Layali
Musafiroh
131
12/10/2013 BTn. W, 16 th, kontrol VE
reg capitis
- Rawat jalan
- Vitalong C 1x1 tabdr. Layali
Musafiroh132
12/10/2013 A Tn. A, 62 th, gastritis - Rawat jalan dr. Layali 133
5/25/2018 logbook internship
30/91
- Lagesyl syr 3x1 cth
- Laproton 2x30 mg
- Neurobion 1x1 tab
Musafiroh
12/10/2013 A
Ny. S, 25 th, intoksikasi
alkohol, gastritis
- Rawat inap
- IVFD D5% 16 tpm
- Inj. Ranitidin 3x1 A
- Omeprazol 1x1 tab
- Antasida syr 3x2 cthdr. Layali
Musafiroh
134
12/10/2013 C
Tn. R, 65 th, obs dyspnea
susp PPOK, dd TB paru,
pneumothorax.
- Rawat inap
- IVFD RL 16 tpm
- Inj. Ranitidin 2x1A
- Aminofilin 3x1 tab
- Dexamethason 3x1 tab
- Captopril 1x25 mg
- Plan: EKG, Ro thorax PAdr. Layali
Musafiroh
135
12/10/2013 A
An.A, 3 th, 16 kg, observasi
febris susp Thyfoid fever dd
DHF
- Rawat inap
- Plan: DL, widal
- IVFD RL 12 tpm
- Paracetmol syr 3x 1 1/2 cth
- GG III, CTM II, Vit C IIIdr. Layali
Musafiroh
136
15/10/2013 A
Tn. M, 53 th, hipertensi
stage II, susp DM tipe II.
TD: 190/100 mmHg, gds;
258 mg/dl.
- Rawat inap
- IFVD RL 20 tpm
- Captopril 3x25 mg
- HCT 1x1 tab (1-0-0)- Metformin 3x500 mg
- Plan: DL, GDP, GD2PP,
EKG: LVHdr. Layali
Musafiroh
137
15/10/2013 A, B Tn. T, 80 th, multiple VE, - Rawat jalan dr. Layali 138
5/25/2018 logbook internship
31/91
hipertensi stage II. TD:
160/100mmHg
- Amoxicillin 3x500 mg
- Captopril 3x12,5 mg
- Paracetamol 3x500 mg
- Neurodex 2x1 tab
- Vitalong C 1x1 tab
Musafiroh
15/10/2013 A
Ny. N, G1P0A0 usia 31
tahun uk 37 minggu preskep
dengan hipertensi dalam
kehamilan sup PER dd PEB,
susp panggul sempit. TB:
138 cm, TD: 136/90 mmHg
- Rawat inap
- IVFD RL 16 tpm
- Plan: DL, proten urin
dr. Layali
Musafiroh
139
15/10/2013 A
Ny. N, 55 th,Hipertensi
stage II dengan epistaksis.
TD: 180/100 mmHg.
- Rawat jalan
- Captopril 3x25 mg
- Propanolol 1x40 mg
- Kalnex tb 2x500 mg
- Ranitidin 2x150 mgdr. Layali
Musafiroh
140
15/10/2013 B
Tn. R, 60 th, VL dorsum
pedis sinistra
- Rawat jalan
- Wound toilet, hecting
- Inj. ATS 1500 IU, im, skin
test
- Amoxicillin 3x500 mg
- Paracetamol 3x500 mg
- Ranitidin 2x150 mgdr. Layali
Musafiroh
141
15/10/2013 A
Nn. A 29 th, gastritis akut,susp ISK
- Rawat jalan- Amoxicillin 3x500 mg
- Scopamin plus 3x1 tab
- Ranitidin 2x150mg
- Antasida doen syr 3x2cthdr. Layali
Musafiroh
142
5/25/2018 logbook internship
32/91
15/10/2013 A
Ny. K, 65 th, GEADS Rawat inap
- IVFD RL loading 500 cc--
>20 tpm
- Inj.Ranitidin 2x1A
- Miratrim 3x1 tab
- Mecodiar 3x1 tab
- Omegdiar 3x1 tab
-Vosea 3x1 tabdr. Layali
Musafiroh
143
15/10/2013 A
Ny. A, 29 th, G2P1A0 uk 39
minggu dengan hipertensi
dalam kehamilan suspek
PEB. TD: 169/114 mmHg.
- Rawat inap
- IVFD RL 16 tpm
- Nifedipin 4x10 mg
- Plan: DL, protein urindr. Layali
Musafiroh
144
17/10/2013 A
Ny. R, 39 th, G3P2A0 uk 41
minggu JTHIU preskep
dengan hipertensi dalam
kehamilan susp PER dd
PEB. TD: 140/90 mmHg
- Rawat inap observasi
kemajuan persalinan
- Plan: DL, protein urin
- IVFD RL 16 tpm
- Nifedipin 2x10 mg
- Gastrul per vag 1/8 tab tiap 6
jamdr. Layali
Musafiroh
145
17/10/2013 A
An. A, 8 bln, 8 kg, GEADS,
obs febris susp demam
tifoid.
- Rawat inap
- Plan: DL, widal
- IVFD RL loading 150 cc -->
12 tpm
- Inj. Ranitidin 2x1/2 A- Inj. Ondansetron 2x1/2A
- Lacto B 2x1 sach
- Zinc syr 1x1/2 cth
- Paracetamol syr 3x1 cthdr. Layali
Musafiroh
146
5/25/2018 logbook internship
33/91
17/10/2013 B
Tn, D, 53 th, vulnus
laseratum plantar pedis
dextra.
Rawat jalan
- Wound toilet, hecting
- Inj. ATS 1500 IU, im
- Clindamycin 3x300 mg
- Amoxicillin 3x500 mg
- Asam mefenamat 3x500 mg
- Dexamethason 3x0,5 mg
- Ranitidin 3x150 mg
- Neurodex 2x1 tabdr. LayaliMusafiroh
147
17/10/2013 B
Ny. I, 4 th, VE digiti I pedis
dextra
Rawat jalan
- Amoxicilin 3x500 mg
- Asam mefenamat 3x500 mg
- Dexamethason 3x0,5 mg
- Ranitidin 3x150 mg
- Vitalog C 1x1 tabdr. LayaliMusafiroh
148
17/10/2013 B
Tn. D, 55 th, VE reg cruris
dextra
Rawat jalan
- Amoxicilin 3x500mg
- Paracetamol 3x500 mg
- Ranitidin 2x150 mg
- Vitalong C 1x1 tabdr. Layali
Musafiroh
149
18/10/2013 A
Ny. K, 60 th, hipetensi stage
II, gastritis. TD: 180/100
mmHg
- Rawat inap
- IVFD RL 20 tpm
- Inj. Ranitidin 2x1A
- Inj. Metoclopramid 2x1A- Captopril 3x25 mg
- HCT 1x25 mg (1-0-0)
- Curcuma 3x1 tab
- Plan: DLdr. Layali
Musafiroh
150
5/25/2018 logbook internship
34/91
18/10/2013 A
An. K, 1,5 th, 8 kg.
Vomitus, TB paru dalam
pengobatan fase intensif
- Rawat inap
- IVFD RL 30 tpm (mi)
- Domperidon syr 3x1 cth
- Terapi TB dilanjutkandr. Layali
Musafiroh
151
18/10/2013 A
Ny. M, 22 th, G2P1A0 uk
38 minggu JTHIU preskep
puka in partu dengan
hipertensi gestasional
suspek PER. TD 150/90
mmHg.
Rawat inap
- IVFD RL 20 tpm
- Nifedipin 3x10 mg
- Plan: DL, Protein urin
- Observasi kemajuan
persalinandr. Layali
Musafiroh
152
18/10/2013 A
Nn. L, 22 th, GERD dd
gastritis
Rawat jalan
- Ranitidin 3x150 mg
- Lansoprazol 2x1 tab
- Antasid 3x2 cth
- Neurodex 1x1 tabdr. Layali
Musafiroh
153
18/10/2013 A
An. R, 7 bln, Diare Cair
Akut tanpa Dehidrasi, 8,5
kg
Rawat jalan
- L-Bio 3x1/2 sach
- Zinc 1x1/2 tab
- Paracetamol drop 3x0,9 ccdr. Layali
Musafiroh
154
20/10/2013 B
Tn. D, 53 th, kontrol VL
plantar pedis dextra
Rawat jalan
- Ganti balut
- Amoxicillin 3x500 mg
- Asam mefenamat 3x500 mg
- Ranitidin 3x150 mg- Vitalong C 1x1 tab
dr. LayaliMusafiroh
155
20/10/2013 B
Ny. K, 45 th, VE manus
sinistra
Rawat jalan
- Amoxicillin 3x500 mg
- Ranitidin 3x150 mgdr. Layali
Musafiroh
156
5/25/2018 logbook internship
35/91
- Neurodex 1x1 tab
- Vitalong C1x1 tab
20/10/2013 B
Tn. R, 59 th, VE genu
sinistra
Rawat jalan
- Amoxicillin 3x500 mg
- Ibuprofen 2x400 mg
- Ranitidin 2x150 mg
- Neurodex 1x1 tabdr. Layali
Musafiroh
157
20/10/2013 A
Ny. Y, 25 th, Vomitus ec
susp hepatitis akut dd
Cholesistitis, Thyfoid fever
Rawat jalan (menolak rawat
inap)
- Ibuprofen 3x400 mg
- Curcuma 3x1 tab
- Metoclopramid 3x1 tab
- Ranitidin 2x150mg
- Livron B plex 2x1 tabdr. Layali
Musafiroh
158
20/10/2013 A
An. R, perempuan, 5 bln,
5,5 kg, GEADS, febris susp
Thyfoid fever
Rawat inap
- IVFD D5%-1/4NS loading
100 cc --> 22 tpm (mi)
- Lacto-B 2x1/2 sach
- Zinc syr 1x1/2 cth
- PCT drop 3x0,6 cc
- Plan: DL, Widaldr. LayaliMusafiroh
159
23/10/2013 B
Tn. D, 53 th, kontrol VL
plantar pedis dextra
Rawat jalan
- Ganti balut
- Ciprofloxacin 2x500 mg- Metronidazol 3x500 mg
- Asam mefenamat 3x500 mg
- Ranitidin 3x150 mg
- Vitalong C 1x1 tabdr. Layali
Musafiroh
160
5/25/2018 logbook internship
36/91
23/10/2013 A
Ny. S, 50 th,
Laringitis+gastritis akut
Rawat jalan
- Dexamethason 3x0,5 mg
- Paracetamol 3x500 mg
- Ranitidin 3x1 tab
- Lansoprazol 1x1 tabdr. Layali
Musafiroh
161
23/10/2013 A
Ny. K, 53 th, DM tipe II.
GDS: 285 mg/dl
Rawat jalan
- Glimepirid 1x1 mg
- Metformin 2x500 mg
- Neurodex 2x1 tabdr. Layali
Musafiroh
162
23/10/2013 A
Ny. E, 26 th, Febris susp
Thyfoid fever. S:38,5C
Plan: DL, Widal. Hasil:
Leukosit 6.300/mm3, Widal S.
Typhii O dan H: +1/320
-Rawat jalan
- Ciprofloxacin 2x500 mg
- Paracetamol 3x500 mg
- Ranitidin 3x150 mg
- Neurodex 1x1 tab
- Edukasi: tirah baring, diet
lunak.dr. Layali
Musafiroh
163
23/10/2013 A
Ny. S, 61 th, Osteoarthritis
Genu sinistra
Rawat jalan
- Na diclofenac 2x25 mg
- Ranitidin 2x150 mg
- Livron B plex 1x1 tab
-Fisioterapi
dr. Layali
Musafiroh
164
23/10/2013 A
Nn. F, 18 th, BPPV Rawat jalan
- Betahistin mesylate 2x1 tab
- Ranitidin 2x1 tab
- Neurodex 1x1 tabdr. Layali
Musafiroh
165
5/25/2018 logbook internship
37/91
- Saran konsultasi dr. Sp.S
23/10/2013 A
Tn. T, 43 th, Gasritis,
kontrol post GEADS
Rawat jalan
- Ranitidin 2x1 tab
- Antasida doen syr 3x2 cth
- Neurodex 1x1 tabdr. Layali
Musafiroh
166
23/10/2013 B
Tn. N, kontrol post op
Tumor supraorbita dextra
Rawat jalan
- Aff hecting 2
- Neurodex 1x1 tab
- Vitalong C 1x1 tabdr. Layali
Musafiroh
167
23/10/2013 A
Ny. D, 60 th, DM tipe II,
dispepsia. GDS: ##high.
TD: 130/90 mmHg
rawat jalan (menolak rawat
inap)
- Glibenclamid 2x5 mg
- Metformin 3x500 mg
- Lansoprazol 1x30 mg
- Neurodex 1x1 tabdr. Layali
Musafiroh
168
23/10/2013 A
An. B, 5 th, Febris suspek
thyfoid fever. S:39C, BB 20
kg.
rawat jalan
- Amoxicillin syr 3x1 cth
- PCT syr 3x1 1/2 cth
- Curcuma 3x1 cth
- Plan: DL, widaldr. Layali
Musafiroh
169
24/10/2013 A
Ny. S, 44 th, ODS
Konjungtivitis kronik
Rawat jalan
- Gentamisin tetes mata 3x3
tetes ODSdr. Layali
Musafiroh
170
24/10/2013 A
An. D, perempuan, 5 th, 15kg, Observasi febris hari ke-
4 susp Thyfoid fever dd
DHF
Plan: DL (Trombosit178.00.mm3, leukosit
4300/mm3), Widal S. Thyphii
O dan H: +1/320
- Rawat inapdr. Layali
Musafiroh
171
5/25/2018 logbook internship
38/91
- IVFD RL loading 100 cc -->
15 tpm (ma)
- Inj. Ranitidin 2x1/2A
- Thiamphenicol syr 3x1 cth
- PCT syr 3x1 1/2 cth
- Curcuma syr 3x1 cth
24/10/2013 A
Ny. C, 30 th, G3P2A0 uk
39+6 minggu JTHIU
preskep puka dengan
hipertensi gestasional susp
PEB. TD: 160/100 mmHg
Plan: DL, protein urin
- Rawat inap
- IVFD RL 16 tpm
- Nifedipin 4x10 mg
- Observasi kemajuan
persalinandr. Layali
Musafiroh
172
24/10/2013 A
Tn. S, 25 th, Observasi
febris suspek malaria dd
thyfoid fever. S:39C
Plan: DL, Widal, Apusan darah
tepi Plasmodium
- Rawat inap
- IVFD RL 20 tpm
- Inj. Ranitidin 2x1A
- Pct 3x500 mg
- Neurodex 2x1 tabdr. Layali
Musafiroh
173
24/10/2013 A
Tn. H, 72 tahun, hipertensi
stage II, Diare akut tanpa
dehidrasi. TD: 165/100
mmHg.
Rawat jalan
- Captopril 3x25 mg
- HCT 1x5 mg (1-0-0)
- Ranitidin 2x150 mg
- Antasida 3x2cth- Lacto-B 3x2 sach
dr. LayaliMusafiroh
174
25/10/2013 B
Tn. T, 37 th, Multple VE Rawat jalan
- Wound toilet
- Amoxicillin 3x500 mgdr. Layali
Musafiroh
175
5/25/2018 logbook internship
39/91
- Ranitidin 2x150 mg
- Vit. C 1x1 tab
25/10/2013 B
Ny. K, 36 th, VL dorsum
pedis dextra, VE pedis
sinistra
Rawat jalan
- Wound toilet, hecting luar 2
- Amoxicillin 3x500 mg
- Paracetamol 3x500 mg
- Ranitidin 2x150 mg
- Vit. C 1x1 tabdr. Layali
Musafiroh
176
25/10/2013 A
Tn. A, 27 th, myalgia post
trauma
Rawat jalan
- Neurodex 2x1 tab
- Vitalong C 1x1 tabdr. Layali
Musafiroh
177
25/10/2013 A
Ny. T, 50 th, Observasi
febris susp Thyfoid fever dd
DHF. S: 39C
Plan: DL (Leukosit
14.000/mm3, trombosit
258.000/mm3), Widal -
(S.typhii O dan H: +1/160),
GDS: 97mg/dl. EKG: sinus
takikardi
- Rawat inap
- IVFD RL loading 500 cc -->
30 tpm --> RL:D5% 1:1 30
tpm
- Inj. Ranitidin 2x1A
- Ciprofloxacin 2x500 mg
- Paracetamol 4x500 mg
dr. Layali
Musafiroh
178
25/10/2013 A
An. J, 5 th, 15 kg, GEADS Rawat inap
- IVFD RL loading 150 cc --
>12 tpm
- Inj. Ranitidin 2x1/2Adr. Layali
Musafiroh
179
5/25/2018 logbook internship
40/91
- Amoxicillin syr 3x1 cth
- L.Bio 2x1 sach
- Zinc syr 1x1 cth
- Plan: DL
25/10/2013 A, B
Tn. M, 45 th, Hernia
scrotalis dextra+dispepsia
Rawat jalan (pro konsultasi
Sp.B, menolak)
- Scopma plus 3x1 tab
- Paracetamol 2x500 mg
- Ranitidin 2x150 mg
- Antasida doen 3x2cth
- Curcuma 3x1 cthdr. Layali
Musafiroh
180
26/10/2013 A
Tn.S, 80 th, Bronkhitis akut,
hipertensi terkontrol. TD:
130/90 mmHg
Rawat jalan
- Ambroxol 3x30 mg
- Erlamol 3x1 cth
- Bufantasid 3x1 tab
- Neurodex 1x1 tabdr. Layali
Musafiroh
181
26/10/2013 B
Tn.D, 53 th, kontrol VL
plantar pedis dextra
Rawat jalan
- Aff hecting 3
- po. Metronidazol 3x500 mg
- Ciprofloxacin 2x500 g
- Dexamethason 3x0,5 mg
- Ranitidin 3x150 mg
- Vitalong C 1x1 tabdr. Layali
Musafiroh
182
26/10/2013 A
An. R, 12 th, 23 kg, Obs.Febris susp thyfoid fever dd
DHF
Rawat inap- IVFD D5%-1/4NS loading
200 cc--> 16 tpm
- Inj. Ranitidin 2x1/2A
- Paracetamol 3x1/2tabdr. Layali
Musafiroh
183
5/25/2018 logbook internship
41/91
- L-Bio 2x1 sach
- Curcuma 3x1 cth
- Plan: DL, Widal
26/10/2013 A
Tn. M, 40 th, LBP Rawat jalan
- Na diclofenac 2x25 mg
- Ranitidin 2x150 mg
- Neurodex 2x1 tabdr. Layali
Musafiroh
184
26/10/2013 A
Ny. P, 45 th, Gastritis akut Rawat inap
- IVFD RL 20 tpm
- Inj. Ranitidin 2x1A
- Bufantasid tab 2x1
- Curvit 3x1 tabdr. Layali
Musafiroh
185
26/10/2013 B
Tn. K, 50 th, susp
ureterolithiasis sinistra
Rawat jalan
- Nefrolit 3x1 tab
- Spasminal 3x1 tab
- Analtram 3x1 tabdr. Layali
Musafiroh
186
02/11/2013 A
Ny. D, 60 th, Gastritis, susp
ISK
Rawat inap
- IVFD RL 20 tpm
- Inj. Metoclopramid 3x1 A
- Inj. Ranitidin 3x1A
- Omeprazol tab 1x1
- Curvit 3x1 tab
- Paracetamol 3x500 mg
- Plan: DL, UL
dr. Layali
Musafiroh
187
02/11/2013 A
An. A, 10 th, 20 kg, Obs.
Febris 4 hari susp DHF dd
Thyfoid fever
Rawat inap
- IVFD RL loading 200 cc-->
15 tpm
- Inj. Metoclopramid 2x1/2 Adr. Layali
Musafiroh
188
5/25/2018 logbook internship
42/91
- Inj. Ranitidin 2x1/2 A
- Paracetamol syr 3x2 cth
- Curvit 3x1 tab
- DEHAF 2x1 sch
02/11/2013 A
Ny. M, 33 th, P2A1 susp
abortus komplet dd abortus
inkomplet
Rawat jalan (APS)
- Clindamycin 3x300 mg
- Asam mefenamat 3x500 mg
- Livron B plex 1x1 tabdr. Layali
Musafiroh
189
02/11/2013 A
Ny. R, 29 th, G4P1A2 uk 39
minggu presbo puka in partu
kala I fase aktif dengan
KPD
Rawat inap
- IVFD RL 16 tpm
- Inj. Amoxicillin 3x1 gr (iv)
Observasi kemajuan persalinandr. Layali
Musafiroh
190
02/11/2013 A
Ny. T, 23 th, G1P0A0 uk 40
mgg presbo puka in partu
kala I fase aktif
Rawat inap
- IVFD RL 20 tpm
- Observasi kemajuan
persalinandr. Layali
Musafiroh
191
02/11/2013 C
Ny. S, 60 th, Obs dyspnea
susp BrPn dd CHF, TB paru
Rawat inap
- O2 2-3 l/m, nasal canul
- IVFD RL 20 tpm
- Inj. Cefotaxim 2x1 gr (iv,
skin test)
- Inj. Furosemid 1A (extra)
- Inj. Ranitidin 2x1A
- Ambroxol 3x30 mgPlan: DL, Ur, Cr, Ro thorax
PAdr. Layali
Musafiroh
192
06/11/2013 AAn. Z, 3 th, 16 kg, GEADR Rawat jalan
- Zinc 1x1 tabdr. Layali
Musafiroh193
5/25/2018 logbook internship
43/91
- L-Bio 3x1 sach
- Norvom syr 3x1/2 cth
06/11/2013 A
Tn. K, 31 th, DADR,
hipertensi stage II. TD:
170/110 mmHg
Rawat jalan
- Captopril 3x12,5 mg
- Mecodiar 3x1 tab
- Dimenhidrinat 3x1 tab dr. LayaliMusafiroh
194
06/11/2013 A
An. A, 2 th, 10 kg, DADRS Rawat inap
- IVFD RL loading 100 cc-->
10 tpm
- Inj. Ondansetron 2x1/4A
- Kaotin syr 3x1 cth
- L-Bio 3x1 sach
- Zinc 2x1/2 tab
- Plan: DR, widaldr. Layali
Musafiroh
195
06/11/2013 A
Ny. R, obs febris, postpartum 2 minggu
Rawat inap- IVFD RL 20 tpm
- Inj. Scopamin 2x1A
- Erlamol 3x1 tab
- Plan: DR, Urin rutin, widaldr. Layali
Musafiroh
196
06/11/2013 A
Tn. W, 60 th, GEADS Rawat inap
- IVFD RL 30 tpm
- Inj. Ranitidin 3x1A
- Inj. Ondansetron 3x1A
- Diastop 3x1 tab- L-Bio 3x1 sach
- Plan: DLdr. Layali
Musafiroh
197
06/11/2013 ANy. T, 27 th, G2P1A0 uk
39+5 minggu JTHIU
Rawat inap
- IVFD RL 16 tpmdr. Layali
Musafiroh198
5/25/2018 logbook internship
44/91
presentasi kaki, puki, in
partu kala I fase aktif
- Observasi kemajuan
persalinan
06/11/2013 A
An. Q, 9 bln, 6,5 kg,
GEADS, obs febris susp
Thyfoid fever
Rawat inap
- IVFD RL loading 100 cc-->
28 tpm (mi) --> RL:D5-1/4NS
1:1 28 tpm (mi)
- Paracetamol drops 4x0,7 cc
- Zinc 1x1/2 tab
- L-Bio 2x1/2 sachdr. Layali
Musafiroh
199
06/11/2013 B
Ny. N, 24 th, susp tumor
mammae dextra
Rawat jalan
- Amoxiciin 3x500 mg
- Asam mefenamat 3x500 mg
- Dexamethason 3x0,5 mg
- Ranitidin 3x150 mg
- Kontrol ke poli bedah
dr. Layali
Musafiroh
200
07/11/2013 B
Ny. S, 39 th, kontrol VL
capitis+supraorbita sinistra
Rawat jalan
- Ganti balut
- Ciprofloxacin 2x500 mg
- Asam mefenamat 3x500 mg
- Neurodex 1x1 tab
- Vitalong C 1x1 tabdr. LayaliMusafiroh
201
07/11/2013 A
Tn. A, 17 th, Bronkhitis
kronis
Rawat jalan
- Cefadroxil 2x500 mg
- Fludane plus 3x1 tab- Ranitidin 2x1 tab
- Vitalong C 1x1 tabdr. Layali
Musafiroh
202
07/11/2013 BAn. M, 4 th, 15 kg, kontrol
vulnus amputatum digiti V
Rawat jalan
- Aff hectingdr. Layali
Musafiroh203
5/25/2018 logbook internship
45/91
pedis sinistra - Paracetamol syr 3x1 cth
07/11/2013 B
An. A, 13 th, 31 kg, kontrol
VE plantar pedis dextra
Rawat jalan
- Wound toilet, ganti balut
- Ciprofloxacin 2x250 mg
- Paracetamol 3x250 mg
- Gentamisin salep 1xoles
- Bioplasenton salep 1xolesdr. Layali
Musafiroh
204
07/11/2013 A
Ny. S, 59 th, Dispepsia, PV Rawat jalan
- Ranitidin 3x1 tab
- Omeprazol 1x1 tab
- Neurodex 1x1 tab
- Ketokonazol salep 2xolesdr. Layali
Musafiroh
205
07/11/2013 A
Ny. R, 44 th, Dispepsia,
susp anemia
Rawat jalan
- DL: pasien menolak
- Ranitidin 3x150 mg- SF 2x1 tab
- Curvit 3x1 tab
- Neurodex 1x1 tabdr. Layali
Musafiroh
206
07/11/2013 A
Ny. I, 45 th, konrol post
thyfoid fever
Rawat jalan
- Chloramphenicol 4x500 mg
- Curvit 3x1 tab
- Ranitidin 3x150 mgdr. LayaliMusafiroh
207
07/11/2013 A
Ny. R, 60 th, Fatigue,
hipertensi terkontrol. TD:110/90 mmHg
Rawat jalan
- Captopril 1x12,5 mg- Neurodex 2x1 tab
- Curvit 3x1 tab
- Paracetamol 3x500 mgdr. Layali
Musafiroh
208
07/11/2013 A Ny. J, 70 th, DADRS, Rawat jalan dr. Layali 209
5/25/2018 logbook internship
46/91
hipertensi stage II. TD:
161/95 mmHg
- Captopril 3x25 mg
- New diatab 3x1 tab
- Scopamin plus 3x1 tab
- L-Bio 3x2 sach
- Ranitidin 2x1 tab
Musafiroh
08/11/2013 A
Tn.S, 53 th, hipertensi stage
I, gastritis. TD: 147/80
mmHG
Rawat jalan
- Captopril 3x12,5 mg
- Ranitidin 3150 mg
- Neurodex 2x1 tabdr. Layali
Musafiroh
210
08/11/2013 A
Ny R, 38 th, myalgia Rawat jalan
- Na diclofenac 2x25 mg
- Ranitidin 2x150 mg
- Neurodex 1x1 tabdr. Layali
Musafiroh
211
08/11/2013 A
Ny. N, 31 th, obs dyspnea ec
alergi makanan
Rawat inap
- O2 2-3 l/m- IVFD D5% 20 tpm
- Inj. Dexamethason 3x1A
- Loratadin 1x1 tabdr. Layali
Musafiroh
212
09/11/2013 B
An. Z, 13 th, 50 kg, CKR,
hematom reg. Capitis, VE
reg cruris sinistra
Rawat jalan
- Amoxicillin 3x500 mg
- Piracetam 3x400 mg
- Ranitidin 3x150 mg
- Neurodex 2x1 tab
- Paracetamol 3x500 mg
dr. Layali
Musafiroh
213
09/11/2013 A
Tn. H, 52 th, GEADS Rawat inap
- IVFD RL loading 300 cc-->
30tpm
- Inj. Ranitidin 3x1Adr. Layali
Musafiroh
214
5/25/2018 logbook internship
47/91
- Inj. Ondansetron 3x1A
- New diatabs 3x1 tab
- Scopma 3x1 tab
Plan: DL
09/11/2013 A
Tn. K, 41 th, GEADS Rawat inap
- IVFD RL loading 500 cc-->
30 tpm
- Inj. Ranitidin 3x1A
- Inj. Ondansetron 3x1A
- Loperamid 2-1-1 tab
- Kaotin 3x1
- Scopma 3x1 tabdr. Layali
Musafiroh
215
09/11/2013 B
An. M, 4 1/2 th, 13 kg,
Multipel VE
Rawat jalan
- Wound toilet
- Amoxicillin syr 3x1 cth- Paracetamol syrup 3x1 cth
- Bioplasenton gel 2xolesdr. Layali
Musafiroh
216
09/11/2013 B
Ny. S, 45 th, Dislokasi
anterior articulatio
glenohumerale dextra+
fraktur caput humeri dextra
Rawat jalan (menolak konsul
Sp.OT)
- Tramadol 2x50 mg
- Ranitidin 2x150 mg
- Neurodex 2x1 tab
- Plan: Ro shoulder joint dextradr. Layali
Musafiroh
217
09/11/2013 A
An. M, 2 th, 14 kg, GEADS Rawat inap- IVFD RL loading 125 cc -->
15 tpm
- Inj. Ondansetron 3x1/3A
- L-Bio 2x1 sachdr. Layali
Musafiroh
218
5/25/2018 logbook internship
48/91
- Zinc 1x1 tab
- Plan: DL
09/11/2013 A
Tn. W, 30 th, Obs febris,
konstipasi, candidiasis oral,
susp HIV/AIDS
Rawat jalan (menolak rawat
inap)
- Bisacodyl 2x1 tab
- Paracetamol 4x500 mg
- DMP 3x1 tab
- Curvit 3x1 tab
- Candistatin drops 4x100.000
IUdr. Layali
Musafiroh
219
13/11/2013 A
Tn. S, 70 th, GERD Rawat inap
- IVFD RL 20 tpm
- Inj. Ranitidin 3x1A
- Inj. Ondansetron 3x1A
- Lansoprazol tab 2x1- Antasida doen syr 3x2 cth
dr. Layali
Musafiroh
220
13/11/2013 A
Ny. E, 41 th, serangan asma
ringan pada asma
intermitten
Rawat jalan
- Nebulisasi Ventolin 1amp
- Ambroxol 3x30 mgdr. Layali
Musafiroh
221
14/11/2013 A
Tn. S, 72 th, hipertensi stage
II, obs vomitus. TD: 177/89
mmHg. GDS: 101 mg/dl
Rawat inap
- IVFD D5% 20 tpm -->
D5%:RL 1:1 20 tpm
- Inj. Ranitidin 3x1A
- Inj Ondansetron 3x1A- Inj. Spashi 1A
- Captopril 3x25 mg
- HCT 1x25 mg (1-0-0)dr. Layali
Musafiroh
222
14/11/2013 B Tn. S, 57 th, kontrol Vulnus Rawat jalan dr. Layali 223
5/25/2018 logbook internship
49/91
Punctum digiti IV manus
dextra
- Aff hecting 1
- Amoxicillin 3x500 mg
- Ranitidin 3x150 mg
- Neurodex 2x1 tab
Musafiroh
14/11/2013 C
Nn. L, 21 th, Multipel VE Rawat jalan
- Amoxicillin 3x500 mg
- Ranitidin 3x150 mg
- Neurodex 2x1 tabdr. Layali
Musafiroh
224
14/11/2013 D
Nn. R, 17 th, anxietas Rawat jalan
- Alprazolam 1x0,25 mg
- Neurobion 1x1 tabdr. Layali
Musafiroh
225
14/11/2013 B
An. A, 10 th, 29 kg, VL
labium superior sinistra
Rawat jalan
- Wound toilet, hecting luar 1
- Amoxicillin syr 3x1 cth
- Paracetamol 3x2 cth
dr. Layali
Musafiroh
226
15/11/2013 A
Ny. N, 20 th, G1P0A0 uk 40
minggu JTHIU preskep in
partu kala I Iama
Rawat inap
- IVFD RL 16 tpm
- Konsultasi dr. Arif, Sp.OG :
induksi persalinan dengan
Misoprostol 1/8 tab fp tiap 8
jam.dr. Layali
Musafiroh
227
15/11/2013 A
Tn. N, 48 th, DADS,
hipertensi stage I. TD:
140/90 mmHg
Rawat inap
- IVFD RL loading 300 cc -->
30 tpm- Inj. Ranitidin 2x1A
- Inj. Ondansetron 2x1A
- Loperamid tab 2-1-1
- Scopma 3x1 tabdr. Layali
Musafiroh
228
5/25/2018 logbook internship
50/91
- L-Bio 3x2 sachet
- Captopril 3x12,5 mg
- Plan: DL
15/11/2013 A
Ny. S, 27 th, G4P2A1 uk 40
minggu JTHIU preskep in
partu kala II, dengan riwayat
TB
Rawat inap
- Pimpin persalinan
dr. Layali
Musafiroh
229
15/11/2013 A
Ny. L, 40 th, Gastritis akut Rawat inap (APS)
- IVFD RL 20 tpm
- Inj. Ranitidin 3x1A
- Bufantasid syr x2 cth
- Omeprazol 2x1 tab
- Curvit 3x1 tabdr. Layali
Musafiroh
230
18/11/2013 B
Sdr. S, 16 th, VL dan
dislokasi digiti V pedisdextra, Multiple VE
Rawat inap
- Konsultasi dr. Yuli, Sp.OT :motivasi operasi
reposisi+pasang wire
- IVFD RL 16 tpm
- Inj. Ranitidin 2x1A
- Amoxicillin 3x500 mg
- Asam mefenamat 3x500 mg
- Plan : Ro pedis dextra, DLdr. Layali
Musafiroh
231
18/11/2013 A
Ny. S, 72 th, suspek
hepatitis akut, aritmia. EKG:Ventricular couplet
Rawat inap
- Plan: DL. HBsAg, bilirubintotal, bilirubin direk
- IVFD RL loading 500 cc -->
D5% 24 tpm
- Inj. Ranitidin 2x1Adr. Layali
Musafiroh
232
5/25/2018 logbook internship
51/91
- Curvit 3x1 tab
- Paracetamol 3x1 tab
- Konsultasi dr. Luqman,
Sp.PD: Dx susp
Cholangiocarcinoma, VES.
Terapi: bisoprolol 1x2,5 mg.
Cek laborat SGOT dan SGPT,
pro USG abdomen di
dr.Alip,Sp.Rad.
20/11/2013 A
Ny. R, 19 th, G2P0A1 uk
42+2 minggu JTHIU
preskep in partu kala I fase
laten
Rawat inap
- IVFD RL 16 tpm
- Observasi kemajuan
persalinandr. Layali
Musafiroh
233
20/11/2013 B
Tn. R, 27 th,VL reg labium
superior, VE genu dextra etsinistra
Rawat jalan
- Ciprofloxacin 2x500 mg- Asam mefenamat 3x500 mg
- Vitalong C 1x1 tab
- Neurodex 1x1 tabdr. Layali
Musafiroh
234
21/11/2013 C
An. N, 2,5 th, 10,5 kg, KDS.
S:38C.
Rawat inap
- O2 2l/m, nasal canul
- IVFD D5%1/4 NS loading
100 cc --> 12 tpm (ma)
- Stesolid supp 1 (extra)
- Cefadroxil syr 2x1 cth- PCT syr 4x1 cth
- Diazepam 2mg VI, mfla pulv
dtd X, 3x1dr. Layali
Musafiroh
235
21/11/2013 A Tn. M, 52 th, hipertensi Rawat jalan dr. Layali 236
5/25/2018 logbook internship
52/91
stage I, ISPA. TD: 140/90
mmHg
- Ciprofloxacin 2x500 mg
- Captopril 3x12,5 mg
- Ambroxol 3x30 mg
- Neurodex 1x1 tab
Musafiroh
24/11/2013 B
An. D, laki-laki, 12 th,
multiple VE.
Rawat jalan
- Amoxicillin syr 3x1 cth
- PCT syr 3x1 cth
- Curcuma syr 3x1 cthdr. Layali
Musafiroh
237
24/11/2013 B
Nn. L, 21 th, VL capitis Rawat jalan
- Wound toilet, hecting luar 2
- Ciprofloxacin 2x500 mg
- Asam mefenamat 3x500 mg
- Neurodex 1x1 tab
- Vitalong C 1x1 tabdr. Layali
Musafiroh
238
24/11/2013 A
An. M, 8 bln, 4,6 kg.GEADS, obs febris susp
thyfoid fever
Rawat inap- IVFD D5% 1/4 NS loading
100 cc --> 24 tpm (mi)
- PCT drops 4x0.6 cc
- L-Bio 2x1/2 sach
- Zinc 1x10 mg
- Plan: DL, Widaldr. LayaliMusafiroh
239
24/11/2013 A
An. N, 5,5 th, 16 kg, KDS Rawat jalan (menolak rawat
inap)
- Amoxicillin 3x1 cth- PCT 3x 1 1/2 cth
- Diazepam 2mg VIII, Vit C
IV, sacharin ad lib mfla pulv
X, 3x1dr. Layali
Musafiroh
240
5/25/2018 logbook internship
53/91
24/11/2013 A
Ny. K, 38 th, G5P2A2 uk
41+2 minggu JTHIU
preskep belum in partu
dengan hipertensi dalam
kehamilan susp PER dd
PEB. TD: 151/72 mmHg
Rawat inap
- IVFD RL 16 tpm
- Konsultasi dr. Arif, Sp.OG:
induksi Misoprostol 1/8 tab fp
tiap 8 jam
- Plan: DL, protein urindr. Layali
Musafiroh
241
24/11/2013 C
Tn. T, 70 th, Observasi
dyspnea susp PPOK dd TB
paru
Rawat inap
- Plan: GDS (104 mg/dl), EKG
(sinus takikardi, P pulmonal
pada lead II, III, aVF), DL, Ur,
Cr, Ro thorax PA.
- O2 3 l/m, nasal canul
- IVFD D5%+Aminofilin 1A
20 tpm
- Inj. Ranitidin 2x1A- Inj. Ondansetron 2x1A
- Ambroxol 3x30 mg
- PCT 3x500 mg
- Curvit 3x1 tabdr. Layali
Musafiroh
242
24/11/2013 B
Tn. A, 41 th, chest pain post
trauma 2 hari SMRS, VE
manus dextra.
Rawat jalan
- Amoxicillin 3x500 mg
- Asam mefenamat 3x500 mg
- Neurodex 1x1 tab
- Vitalong C 1x1 tab
dr. Layali
Musafiroh
243
25/11/2013 B
Tn I, 26 th, tumor perianal Rawat jalan
- pro konsul Sp.B
- Ciprofloxacin 2x500 mg
- Dexamethason 3x0,5 mgdr. Layali
Musafiroh
244
5/25/2018 logbook internship
54/91
- Asam mefenamat 3x500 mg
- Ranitidin 2x150 mg
25/11/2013 A
Ny.S, 63 th, hipertensi stage
II. TD: 180/100 mmHg
Rawat jalan
- Captopril 3x25 mg
- Amlodipin 1x10 mg
- Neurodex 1x1 tabdr. Layali
Musafiroh
245
25/11/2013 A
Sdr. T, 19 th, Scabies Rawat jalan
- Scabisid 1xoles malam hari
- Dexamethason 3x0,5 mg
- Loratadin 1x1 tab
- Edukasi : rendam pakaian
dengan air panas sebelum
dicuci, gunakan pakaian yang
tidak ketat, yang menyerap
keringat, pisahkan pakaianpasien dengan anggota
keluarga lain saat dicuci,
hindari berbagi menggunakan
pakaian.dr. Layali
Musafiroh
246
25/11/2013 BAn. D, 12 th, kontrol
multiple VE
Rawat jalan
- Bioplasenton 3xolesdr. LayaliMusafiroh
247
25/11/2013 A
Ny. R, 60 th, kontrol post
GEADS, hipertensi stage I.
TD: 140/90 mmHg.
Rawat jalan
- Amlodipin 1x5 mg
- Lansoprazol 1x1 tab
dr. Layali
Musafiroh
248
25/11/2013 ANy. S, 17 th, kontrol post
SC h-13
Rawat jalan
- Ganti balutdr. Layali
Musafiroh249
25/11/2013 BAn. A, 13 th, kontrol post
ORIF a/i closed fraktur
Rawat jalan
- Ganti balutdr. Layali
Musafiroh250
5/25/2018 logbook internship
55/91
antebrachii sinistra
25/11/2013 A
Tn. S, 28 th, susp
limfadenitis colli
Rawat jalan
- Amoxicillin 3x500 mg
- Dexamethason 3x0,5 mg
- Paracetamol 3x500 mg
- kontrol 3 hari kemudiandr. Layali
Musafiroh
251
25/11/2013 A
Ny. S, 28 th, mialgia Rawat jalan
- Na diclofenac 1x25 mg
- Ranitidin 2x150 mg
- Sohobion 1x1 tabdr. Layali
Musafiroh
252
25/11/2013 A
An. A, 12 th, 20 kg, ISPA Rawat jalan
- Plan: DL (leukosit
17.500/mm3)
- Cefadroxil syr 2x1 cth
- PCT syr 3x1.5 cth- Ambroxol 3x15 mg
dr. LayaliMusafiroh
253
25/11/2013 A
Tn. J, 32 th, Febris 6 hari
susp thyfoid fever. S:36,2C.
Rawat jalan
- Plan: DL, widal (+1/320)
- Ciprofloxacin 2x500 mg
- Ranitidin 2x150 mg
- PCT 3x500 mg kp
- Sohobion 1x1 tabdr. LayaliMusafiroh
254
26/11/2013 B
Ny. S, 35 th, VL labium
superior externa, labiuminferior interna et mentalis
Rawat jalan
- Wound toilet, hecting luar 2,dalam 6
- Ciprofloxacin 2x500 mg
- Asam mefenamat 3x500 mg
- Ranitidin 2x150 mgdr. Layali
Musafiroh
255
5/25/2018 logbook internship
56/91
- Betadine kumur 3x/hari
26/11/2013 A
An. A, 8 bln, 8 kg, GEADS Rawat inap
- IVFD Rl loading 150 cc -->
32 tpm (mi)
- Cotrimoxazol syr 2x1 cth
- PCT syr 3x1 cth
- L-Bio 2x1/2 sach
- Zinc 1x10 mg
- Plan: DLdr. Layali
Musafiroh
256
26/11/2013 B
Ny.J, 70 th, fraktur tertutup
linier os ulna 1/3 distal
dextra
Rawat jalan (menolak konsul
Sp.OT)
- Tramadol 2x50 mg
- Thrombophob gel 2xoles
- Plan: Ro wrist joint dextradr. Layali
Musafiroh
257
26/11/2013 A
Ny. R, 40 th, G3P2A0 uk 40minggu JTHIU preskep in
partu kala I fase aktif
dengan hipertensi dalam
kehamilan susp PER dd
PEB. TD: 153/78 mmHg,
s:38C
Rawat inap- IVFD RL 20 tpm
- Nifedipin 3x10 mg
- Paracetamol 3x500 mg
- Plan: DL, protein urin.
dr. LayaliMusafiroh
258
26/11/2013 A
Ny. T, 45 th, GEADS. Rawat inap
- IVFD RL loading 500 cc -->
30 tpm- Inj. Ranitidin 2x1A
- Inj. Ondansetron 2x1a
- Inj. Spashi 1A (extra)
- Paracetamol 3x500 mgdr. Layali
Musafiroh
259
5/25/2018 logbook internship
57/91
- Loperamid 2-1-1 tab
- Lacto-B 3x2 sach
- Plan: DL
27/11/2013 A
Ny. F, 25 th, G3P2A0 uk
9+3 minggu susp Abortus
imminens dd hemoroid
interna grade I
Rawat inap
- IVFD RL 20 tpm
- Inj. Ketorolac 2x1A
- Inj Ranitidin 2x1A
- Hystolan 3x1 tabdr. Layali
Musafiroh
260
27/11/2013 A
Ny. S, 26 th, G1P0A0 uk 37
minggu JTHIU presbo in
partu kala I fase aktif
Rawat inap
- IVFD RL 20 tpm
- Observasi kemajuan
persalinandr. Layali
Musafiroh
261
27/11/2013 C
Tn. C, 64 th, Obs
hematemesis susp gastritis
erosiva dd ulkus peptikum.KU/Kes: lemas,
pucat/E3M6V5. TD: 79/49
mmHg. CA +/+
Rujuk
- Pasang NGT, bilas lambung
500 cc- IVFD RL loading 1000 cc-->
40 tpm
- Inj. Pantoprazol 80 mg
- Inj. Asam Tranexamat 1A
- Inj. Vit K 1 Adr. Layali
Musafiroh
262
27/11/2013 B
Ny. S, 37 th, Multiple VE Rawat jalan
- Wound toilet
- Amoxicillin 3x500 mg
- Paracetamol 3x500 mg- Mertigo 2x1 tab
- Neurodex 1x1 tabdr. Layali
Musafiroh
263
29/11/2013 BTn. D, 45 th, VL supraorbita
dextra
Rawat jalan
- Wound toilet, hecting luar 1dr. Layali
Musafiroh264
5/25/2018 logbook internship
58/91
- Amoxicillin 3x500 mg
- Asam mefenamat 3x500 mg
- Neurodex 1x1 tab
29/11/2013 A
Ny. S, 37 th, G5P2A2 uk 36
minggu JTHIU preskep in
partu kala I lama
Rawat inap
- Konsul dr.Arif, Sp.OG: Inj.
Dexamethason 15 mg
- Observasi kemajuan
persalinandr. Layali
Musafiroh
265
29/11/2013 B
Sdr. N, 20 th, hematom
antebrachii dextra post
dipukuli
Rawat jalan
- Thrombophob gel 2xoles dr. Layali
Musafiroh
266
29/11/2013 A
Ny. I, 25 th, GEADS. TD:
79/56 mm/Hg.
Rawat inap
- Plan: DL, GDS (109 mg/dl)
- IVFD RL loading 500 cc-->
RL:D5% 1:1 30 tpm- Inj. Ranitidin 2x1A
- Inj. Ondansetron 2x1A
- Scopamin 3x1 tab
- New diatabs 3x1 tabdr. Layali
Musafiroh
267
01/12/2013 C
Ny. K, 50 th, obs dyspnea
susp CHF dd TB paru kasus
kambuh
Rawat inap
- O2 4l/m
- IVFD D5% 500 cc/24 jam
- Inj. Ranitidin 3x1A
- Curvit 3x1 tab- Konsul dr. Luqman, Sp.PD :
Ro thoraxdr. Layali
Musafiroh
268
01/12/2013 BTn. A, 30 th, VE manus
dextra et genu sinistra
Rawat jalan
- Wound toiletdr. Layali
Musafiroh269
5/25/2018 logbook internship
59/91
- Amoxicillin 3x500 mg
- Neurodex 1x1 tab
- Bioplasenton gel 2xoles
01/12/2013 A
Nn. K, 19 th, GEADS Rawat inap
- IVFD RL loading 300 cc-->
30 tpm
- Inj. Ranitidin 3x1A
- Inj. Ondansetron 3x1A
- Scopamin 3x1 tab
- Lacto-B 3x2 sachet
- New diatabs 3x1 tab
- Plan: DLdr. Layali
Musafiroh
270
02/12/2013 B
Tn. M, 47 th, tumor penis Rawat inap
- IVFD RL+Adona 1A, 20 tpm
- Inj. Cefotaxime 2x1 gr- Inj. Ketorolac 2x1 A
- Inj. Vit.K 1x1 A
- Inj. Ranitidin 2x1A
- Motivasi rujuk RSU DR.
Karyadi Semarangdr. Layali
Musafiroh
271
02/12/2013 B
Sdr. K, 14 th, Multiple VE,
hematom retroauricula
dextra, antebrachii sinistra
Rawat jalan
- Asam mefenamat 3x500 mg
- Neurodex 1x1 tab
Visum et repertum
dr. Layali
Musafiroh
272
02/12/2013 BNy. K, 45 th, tumor
nasofaring susp ganas
Rujuk
- IVFD D5% 20 tpmdr. Layali
Musafiroh273
02/12/2013 ANy. S, 45 th, hipertensi stage
I, gastritis
Rawat jalan
- Omeprazol 2x1 tabdr. Layali
Musafiroh274
5/25/2018 logbook internship
60/91
- Ranitidin 2x1 tab
- Scopamin 3x1 tab
- Vitazym 2x1 tab
02/12/2013 A
Ny. J, 21 th, G1P0A0 uk 41
minggu JTHIU preskep
puka in partu kala I lama
Rawat inap
- IVFD Rl 20 tpm
- Konsultasi dr. Arif, Sp.OG :
induksi misoprostol 1/8 tab pv
tiap 8 jamdr. Layali
Musafiroh
275
03/12/2013 A
Ny. S, 27 th, G3P2A0 uk 12
minggu susp Abortus
insipien
Rawat inap
- IVFD RL 20 tpm dr. Layali
Musafiroh
276
03/12/2013 B
Tn. A, 37 th, colic abdomen
susp ureterolithiasis sinistra,
hipertensi stage II
Rawat inap
- Pasang DC
- IVFD RL 20 tpm
- Inj. Spashi 3x1A- Inj. Ondansetron 2x1A
- Captopril 3x25 mg
- Plan: DL, UL, BNO abdomendr. Layali
Musafiroh
277
03/12/2013 C
Ny. A, 45 th, angina pectoris
susp ACS.
Rawat inap
- EKG : ST elevasi di lead
V4,5,6
- IVFD RL 20 tpm
- Inj. Ranitidin 2x1A
- Aspilet 2 tab 80 mg,selanjutnya 3x80 mg
- Clopidogrel 2 tab 75 mg,
selanjutnya 1x75 mg
- Amlodipin 1x10 mgdr. Layali
Musafiroh
278
5/25/2018 logbook internship
61/91
06/12/2013 A
Ny. D, 32 th, G2P0A1 uk
37+5 minggu JTHIU
preskep in partu kala I fase
laten dengan hipertensi
dalam kehamilan susp PEB.
TD: 160/100 mmHg.
Rawat inap
- IVFD RL 20 tpm
- Nifedipin 10 mg
- Plan: DL, protein urin
dr. Layali
Musafiroh
279
06/12/2013 B
Tn. S, 49 th, V. Amputatum
digiti II manus sinistra
Wound toilet, hecting
situasional
- Rujuk
- Ciprofloxacin tab 500 mg
- Asam mefenamat tab 500 mgdr. Layali
Musafiroh
280
06/12/2013 C
An. R, 2 th, 13 kg, KDS.
S:39C
Rawat inap
- IVFD D5%-1/4 NS 12 tpm
(ma)
- Paracetamol syr 4x1 cth- Diazepam 2 mg III, sacharin
ad libitum mfla pulv dtd X,
3x1dr. Layali
Musafiroh
281
06/12/2013 B
Ny. T, 32 th, VE supraorbita
sinistra
Rawat jalan
- Amoxicillin 3x500 mg
- Neurodex 2x1 tab
- Thrombophob gel 3x olesdr. Layali
Musafiroh
282
06/12/2013 B
Ny. I, 28 th, VE supraorbita
dextra
Rawat jalan
- Amoxicillin 3x500 mg- Ranitidin 3x150 mg
- Neurodex 2x1 tabdr. Layali
Musafiroh
283
06/12/2013 ANy. S, 52 th, Hipertensi
stage II. TD: 180/90 mmHg.
Rawat inap
- EKG: LVHdr. Layali
Musafiroh284
5/25/2018 logbook internship
62/91
- IVFD D5% 20 tpm
- Inj. Ranitidin 2x1 A
- Captopril 3x25 mg
- Amlodipin 1x10 mg
06/12/2013 A
Tn. W, 59 th, gastritis Rawat inap (APS)
- IVFD D5% 20 tpm
- Inj. Spashi 1A (extra)
- Omeprazol 2x1 tab
- Ranitidin 3x1 tab
- Antasida 3x2cthdr. Layali
Musafiroh
285
06/12/2013 A
Ny. M, 40 th, G4P3A0 uk
36 minggu JTHIU preskep
in partu kala I fase laten
dengan KPD
Rawat inap
- IVFD RL 20 tpm
- Inj. Amoxicillin 3x1gr (iv)
skintest
- Plan:DL
dr. Layali
Musafiroh
286
08/12/2013 B
Ny. R, 32 th, VL pedis
sinistra
Rawat jalan
- Wound toilet, hecting dalam
2, luar 7
- Inj. ATS 1500 IU (im, skin
test)
- Amoxicillin 3x500 mg
- Asam mefenamat 3x500 mg
- Ranitidin 2x1 tab
- Neurodex 1x1 tab
dr. Layali
Musafiroh
287
08/12/2013 B
An. N, 8 th, 26 kg, VE pedis
sinistra
Rawat jalan
- Wound toilet
- Amoxicillin syr 3x1 cth
- Paracetamol syrup 3x2 cthdr. Layali
Musafiroh
288
5/25/2018 logbook internship
63/91
- Thrombophob gel 3x oles
08/12/2013 B
Sdr W, 19 th, VL plantar
pedis sinistra
Rawat jalan
- Wound toilet, hecting dalam
3, luar 9
- Inj. ATS 1500 IU (im,
skintest)
- Ciprofloxacin 2x500 mg
- Asam mefenamat 3x500 mg
- Ranitidin 2x1 tab
- Neurodex 2x1 tabdr. Layali
Musafiroh
289
08/12/2013 A
Ny. R, 50 th, GEADS,
hipertensi stage I. TD:
150/90 mmHg
Rawat inap
- IVFD RL loading 500 cc-->
30 tpm
- Inj. Ranitidin 2x1A
- Inj. Ondansetron 2x1A- Loperamid 2-1-1
- Lacto-b 3x2 sach
- Captopril 3x12,5 mg
- Plan: DLdr. Layali
Musafiroh
290
08/12/2013 A
Ny.I, 32 th, faringitis akut Rawat jalan
- Ciprofloxacin 2x 500 mg
- Dexamethason 3x0,5 mg
- Paracetamol 3x500 mg
- Curcumex 3x1tabdr. Layali
Musafiroh
291
08/12/2013 A
Sdr. A, 24 th, susp thyfoid.
S: 36,2C, GDS: 79 mg/dl
Rawat inap (APS)
- IVFD D5% 20 tpm --> RL 20
tpm
- Inj. Ranitidin 2x1Adr. Layali
Musafiroh
292
5/25/2018 logbook internship
64/91
- Inj. Ondansetron 2x1A
08/12/2013 A
Nn. I, 28 th, gastriti post
intoksikasi alkohol. GDS:
69 mg/dl.
Rawat jalan (menolak RI)
- Omeprazol 2x1 tab
- Ranitidin 3x1 tab
- Curvit 3x1 tabdr. Layali
Musafiroh
293
09/12/2013 A
Ny.D, 41 th, gastritis akut Rawat jalan
- Omeprazol 2x1 tab
- Ranitidin 3x1 tab
- Antasid tab 3x1
- Neurodex 1x1 tabdr. Layali
Musafiroh
294
09/12/2013 A
An. S, 8 th, 19 kg, obs febris
susp thyfoid fever dd DHF.
S:38C
Rawat inap
- IVFD D5%-1/4NS 15 tpm
(ma)
- Inj. Ranitidin 2x1/2 A
- Inj. Ondansetron 2x1/2 tab- PCT syr 3x2 cth
- Curcuma syr 3x1 cth
- Plan: DL, widaldr. Layali
Musafiroh
295
09/12/2013 A
An. L, 14 th, gastritis akut
dd dismenorea
Rawat inap
- IVFD RL 20 tpm
- Inj. Ranitidin 3x1A
- Inj. Spashi 3x1A
- Omeprazol 2x1 tab
- Paracetamol 3x1 tab
dr. Layali
Musafiroh
296
09/12/2013 B
Tn.L, 24 th, VL&VE reg
mentalis, susp closed fraktur
antebrachii sinistra distal
Wound toilet, hecting luar 3
- Immobilisasi wrist joint
sinistra
- Ro wrist joint dextradr. Layali
Musafiroh
297
5/25/2018 logbook internship
65/91
- Amoxicillin 3x500 mg
- Asam mefenamat 3x500 mg
- Ranitidin 3x150 mg
- Neurodex 1x1 tab
09/12/2013 A
An. F, 6 bln, 8 kg. GEADS Rawat inap
- IVFD RL loading 100 cc-->36 tpm (mi)
- Inj. Ondansetron 2x1/3A
- L-Bio 2x1 sach
- Zinc 1x1/2 tab
- PCT drops 3x0,8 ccdr. Layali
Musafiroh
298
12/12/2013 B
Ny. R, 60 th, V. Punctm
manus dextra, hipertensi
stage II. TD: 180/100
mmHg
Rawat jalan
- Ciprofloxacin 2x500 mg
- Dexamethason 3x0,5 mg
- Asam mefenamat 3x500 mg- Ranitidin 3x150 mg
- Captopril 3x25 mg
- Thrombophob gel 3x olesdr. Layali
Musafiroh
299
12/12/2013 C
Ny. D, 26 th, G2P1A0
dengan retensio plasenta.
TD: 100/80 mmHg
Rawat inap
- IVFD RL loading 500 cc-->
RL 500 cc+ Oxytosin 1 amp
drip 20 tpm
- Manual plasenta
- Inj. Methergin 1A (im)
- Inj. Amoxicillin 3x1 gr (iv,
skintest)
- Asam mefenamat 3x500 mg
- SF 2x1 tabdr. Layali
Musafiroh
300
5/25/2018 logbook internship
66/91
- Plan: DL (Hb 9,4 g/dl,
leukosit 11.970/mm3,
Trombosit 156.000/mm3)
13/12/2013 A
Ny. B, 24 th, G1P0A0 uk
16+1 minggu dengan
hiperemesis gravidarum danfebris
Rawat inap
- IVFD RL loading 500 cc -->
RL:D5:NaCl:Aminofluid1:1:1:1 30 tpm
- Drip Neurosanbe 1A/24 jam
- Inj. Ranitidin 3x1A
- Inj. Ondansetron 3x1A
- Paracetamol 3x500 mg
- Plan: DL, widaldr. Layali
Musafiroh
301
13/12/2013 A
AN. M, 5 th, 17 kg,
Hydradenitis supurativa,
rhinofaringitis
Rawat jalan
- Cefadroxil syr 2x1 cth
- Coparcetin kid cough 3x1 cth- Loratadin III, sacharin ad lib
pulv No.X, 3x1dr. Layali
Musafiroh
302
14/12/2013 B
Sdr. W, 19 th, kontrol VL
plantar pedis sinistra
Rawat jalan
- Wound toilet, ganti balut
- Clindamycin 3x300 mg
- Metronidazol 3x500 mg
- Huferalgin 3x1 tab
- Ranitidin 3x150 mg
- Vitalong C 1x1 tabdr. Layali
Musafiroh
303
14/12/2013 A
Ny. M, 57th, Dm tipe II
terkontrol. GDP: 92 mg/dl.
TD: 100/70 mmHg
Rawat jalan
- Glimepirid 1x1 mg
- Metformin 2x500 mg
- Ranitidin 2x150 mgdr. Layali
Musafiroh
304
5/25/2018 logbook internship
67/91
14/12/2013 A
Ny. M, 51 th,
CHF&cardiomiopati
dilatasi. TD: 130/80 mmHg
Rawat jalan
- Furosemid 1x20 mg
- Digoxin 2x1/2 tab
- Aspilet 1x1 tab
- Letonal 1x25 mg
- Curcuma 1x1 tab
dr. Layali
Musafiroh
305
14/12/2013 A
Ny. K, 65 th, low back
pain&gastritis
Rawat jalan
- Na diclofenac 1x25 mg
- Calc os 1x1 tab
- Omeprazol 2x1 tab
- Ranitidin 3x150 mgdr. Layali
Musafiroh
306
14/12/2013 A
Ny.L, 54 th, hipertensi stage
II+gastritis. TD: 160/90
mmHg
Rawat jalan
- Amlodipin 1x10 mg
- Captopril 3x12,5 mg
- Ranitidin 2x150 mg- Curvit 3x1 tab
dr. LayaliMusafiroh
307
14/12/2013 A
Ny. K, 42 th,
gastritis&migrain
Rawat jalan
- Paracetamol 3x500 mg
- Omeprazol 2x1 tab
- Ranitidin 3x1tab
- Neurodex 1x1 tabdr. LayaliMusafiroh
308
15/12/2013 BNn. R, 18 th, tumor
mammae dextra pro operasi
Rawat inap
- Puasakan mulai pukul 06.00dr. Layali
Musafiroh309
18/12/2013 B
Sdr. W, 19 th, kontrol VLplantar pedis sinistra Rawat jalan- Aff hecting selang-seling
- Clindamisin 3x300 mg
- Vitalong C 1x1 tab
- Ranitidin 2x1 tabdr. Layali
Musafiroh
310
5/25/2018 logbook internship
68/91
18/12/2013 A
Ny. M, 45 th, gastritis
kronik
Rawat jalan
- Lansoprazol 2x1 tab
- Ranitidin 2x1 tab
- Curvit 2x1 tabdr. Layali
Musafiroh
311
18/12/2013 A
Ny. F, 41 th, gastriris akut Rawat jalan
- Omeprazol 1x1 tab- Ranitidin 2x1 tab
- Paracetamol 3x500 mg
- Diazepam 2 mg 1x1 (malam)dr. Layali
Musafiroh
312
18/12/2013 A
Tn. A, 24 th, thyfoid fever.
S:38C, S.thyphii O: +1/160
Rawat jalan
- Ciprofloxacin2x500 mg
- Paracetamol 3x500 mh
- Ranitidin 2x1tab
- Neurode 1x1 tabdr. Layali
Musafiroh
313
18/12/2013 A
Tn. I, 32 th, hipertensiterkontrol, cephalgia. TD:
110/80 mmHg.
Rawat jalan- Amlodipin 1x5 mg
- Histigo 3x1 tab
- Neurodex 1x1 tab
- Diazepam 2mg 1x1 (malam)dr. Layali
Musafiroh
314
18/12/2013 A
Tn. S, 39 th, Insomnia Rawat jalan
- Alprazolam 0,5 mg 1x1
(malam)
- Diazepam 2mg 1x1 (malam)dr. Layali
Musafiroh
315
19/12/2013 B
Sdr. F, 20 th, V. Amputatum
digiti V manus sinistra.
Rawat jalan
- Wound toilet, hecting dalam
2, luar 7
- Inj. ATS 1500 IU (im, skin
test)dr. Layali
Musafiroh
316
5/25/2018 logbook internship
69/91
- Ciprofloxacin 2x500 mg
- Dexamethason 3x0,5 mg
- Ranitidin 2x1 tab
- Vitalong C 1x1 tab
19/12/2013 B
Tn. D, 38 th, VL capitis Rawat jalan
- Wound toilet, hecting luar 10- Ciprofloxacin 2x500 mg
- Dexamethason 3x0,5 mg
- Tramadol 2x50 mg
- Ranitidin 2x1 tab
- Vitalong C 1x1 tabdr. Layali
Musafiroh
317
20/12/2013 A
Ny. R, 50 th, observasi
febris h-7 susp thyfoid fever
dd DHF. S:39C
Rawat inap
- IVFD RL 20 tpm
- Inj. Ranitidin 3x1 A
- Paracetamol 4x500 mg k.p- Curcuma 3x1 tab
- Plan: DL, widal.dr. Layali
Musafiroh
318
20/12/2013 A
Tn. K, 31 th, Obs febris susp
thyfoid dd DHF. S: 37,9C.
TD: 96/60 mmHg.
Rawat inap
- IVFD RL lading 500 cc--> 30
tpm
- Inj. Ranitidin 3x1A
- Inj. Ondansetron 3x1A
- Paracetamol 3x500 mg
- Neurodex 1x1 tab
- Plan: DL,