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  • Subjektif Objektif Assasment Planning: Tanggal

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    The patient presented with shortness of breath, cough with blood, and a chest x-ray showing a right pleural effusion. Over the next few days, the patient underwent thoracentesis removing over 600cc of fluid, experienced improvement in symptoms, and was discharged with a suspected diagnosis of lung cancer.

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    Lembar Follow Up.docx

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    The patient presented with shortness of breath, cough with blood, and a chest x-ray showing a right pleural effusion. Over the next few days, the patient underwent thoracentesis removing over 600cc of fluid, experienced improvement in symptoms, and was discharged with a suspected diagnosis of lung cancer.

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    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
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    12 views4 pages

    Subjektif Objektif Assasment Planning: Tanggal

    Uploaded by

    atas_nama_trauma
    The patient presented with shortness of breath, cough with blood, and a chest x-ray showing a right pleural effusion. Over the next few days, the patient underwent thoracentesis removing over 600cc of fluid, experienced improvement in symptoms, and was discharged with a suspected diagnosis of lung cancer.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    of 4

    Tanggal

    Subjektif Sesak nafas(+), batuk darah (+),

    Objektif TD: 140/80 mmHg | N: 92x/m | RR: 36x/m K|L : CA (-/-) SI (-/-) PKGB (-/-) Dev. Trakea () Thorak : Paru: Vesikuler<</vesikuler | Fremitus<< (Sx) Ketinggalan gerak (Sx) Rh: (-/-) | Wh (-/-) Cor: BJ 1, 2 Reguler | Bising(-) Abdomen: dalam batas normal

    Assasment -Efusi Pleura dextra, -Suspect Ca Paru

    Planning -Inf Pz 16tpm -O2 3L/m -Drip aminophilin 11/2 ampul -Injeksi cefotaxim 3x1 gr -Injeksi dexametason 3x1 ampul -Codein 3x1 -GG 3x1 -Injeksi asam tranexamat 3x1 ampul -persiapan pungsi

    06 1213

    071213

    Sesak nafas, batuk kering, disertai darah

    TD: 120/80 mmHg | N: 80x/m | RR: 32x/m Thorak : Paru: Vesikuler<</vesikuler | Ketinggalan gerak (Sx) Fremitus<< (Sx) Rh: (-/-) | Wh (-/-)

    -Efusi Pleura dextra, - -Suspect Ca Paru

    -Terapi Lanjut -pungsi pleura (1960)

    081213

    Sesak nafas berkurang, batuk kering +

    TD: 110/70 mmHg | N: 80x/m | RR: 28x/m Thorak : Paru: Vesikuler<</vesikuler | Ketinggalan gerak (Sx) Fremitus<< (Sx) Rh: (-/-) | Wh (-/-)

    -Efusi Pleura dextra, -Suspect Ca Paru

    Terapi Lanjut

    091213

    TD: 120/80 mmHg | N: 80x/m | RR: 28x/m Thorak : Paru: Vesikuler<</vesikuler | Ketinggalan gerak (Sx) Fremitus<< (Sx) Rh: (-/-) | Wh (-/-)

    -Efusi Pleura dextra, -Suspect Ca Paru

    Terapi Lanjut Persiapan pungsi 2

    101213

    TD: 110/80 mmHg | N: 80x/m | RR: 26x/m Thorak : Paru: Vesikuler<</vesikuler | Ketinggalan gerak (Sx) Fremitus<< (Sx) Rh: (-/-) | Wh (-/-)

    -Efusi Pleura dextra, -Suspect Ca Paru

    Terapi Lanjut Pungsi pleura (640cc)

    111213

    TD: 120/80 mmHg | N: 80x/m | RR: 26x/m Thorak : Paru: Vesikuler<</vesikuler | Ketinggalan gerak (Sx) Fremitus<< (Sx) Rh: (-/-) | Wh (-/-)

    -Efusi Pleura dextra, -Suspect Ca Paru

    Terapi Lanjut Foto thorax ulang

    1212-13

    TD: 100/80 mmHg Thorax: Paru : Rh (-/-) | Wh (-/-)

    -Efusi Pleura dextra, -Suspect Ca Paru

    Terapi Lanjut

    131213

    TD: 120/80 mmHg | N: 80x/m | RR: 20x/m Thorak : Paru:

    -Efusi Pleura dextra, -Suspect Ca Paru

    Pasien pulang

    Vesikuler<</vesikuler | Ketinggalan gerak (Sx) Fremitus<< (Sx) Rh: (-/-) | Wh (-/-)

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