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    8 views2 pages

    Follow Up

    Uploaded by

    IndieShou20
    follow up

    Copyright:

    Attribution Non-Commercial (BY-NC)
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    TANGGAL/ HARI/ RAWATAN Keluhan

    18 Januari 2014

    19 Januari 2014

    20 Januari 2014

    21 Januari 2014

    22 Januari 2014

    KU/KP/KG Sensorium Tekanan Darah Frek.nadi Frek.nafas Temperature BB Mata Telinga Hidung Mulut Leher Inspeksi Palpasi Perkusi Auskultasi

    Demam (+), Demam (-), muntah (-), nyeri Demam (-), muntah (-), nyeri muntah (+), perut (+), batuk (+) perut (-), batuk (+) nyeri perut (+), batuk (+) Sedang/buruk/overweight Sedang/sedang/overweight Compos mentis 110/90 mmHg 120/80 mmHg 110/70 mmHg 110/80 mmHg 110/70 mmHg 120x/i 32x/i 38,20C 37 kg 120x/i 110x/i 100x/i 92x/i 28x/i 32x/i 28x/i 24x/i 0 0 0 36,7 C 36,8 C 36,5 C 36,90C 37 kg 37 kg 37,5 kg 37,5 kg STATUS LOKALISATA Dalam Batas Normal Dalam Batas Normal Dalam Batas Normal Mukosa bibir kering Dalam batas normal Pembesaran KGB (-) THORAX Simetris Fusiformis, retraksi (-) SF Ka=Ki Sonpr di kedua lapangan paru SP = vesikuler SP = vesikuler SP = vesikuler SP = vesikuler SP = vesikuler HR : 120x/i HR : 120 x/i HR : 110x/i HR : 100x/i HR : 92 x/i reg reg desah (-) reg desah (-) reg desah (-) reg desah (-) desah (-) RR : 32x/i, reg RR : 28 x/i, RR : 32x/i, reg RR : 28x/i, reg RR : 24 x/i, ronkhi (-) reg ronkhi (-) ronkhi (-) ronkhi (-) reg ronkhi (-) ABDOMEN Simetris Soepel, H/L tidak teraba, nyeri ulu hati (+) Soepel, H/L tidak teraba, nyeri ulu hati (-) Timpani Peristaltik (+) normal pulse 120 x/i pulse 120 x/i pulse 90 x/i pulse 100x/i pulse 92 x/i reg T/V reg T/V reg T/V reg T/V cukup, reg T/V cukup, cukup, akral cukup, akral cukup, akral akral hangat akral hangat dingin CRT < hangat CRT < hangat CRT < CRT < 3, CRT < 3, 3, petekie (+), 3, petekie (+), 3, ptekie (-), ptekei (-), ptekei (-), makulopapular makulopapular makulopapular makulopapular makulopapular (+) (+) (-) (-) (-) Akral dingin, Akral hangat CRT <3

    Inspeksi Palpasi Perkusi Auskultasi Ekstr. Atas

    Ekstr. Bawah

    CRT <3 Genitalia Pem.Darah Lengkap (18.47) WBC:7400 RBC:6,09 HGB:15,6 HCT:46,1 MCV:75,7 MCH:25,6 MCHC:33,8 PLT:42000 Perempuan, tidak ada kelainan (00.29) (07.24) (09.46) (06.50) WBC:8400 WBC:9400 WBC:8500 WBC:8100 RBC:6,03 RBC:4,52 RBC:4,40 RBC:4,57 HGB:15,7 HGB:11,7 HGB:11,4 HGB:11,9 HCT:45,5 HCT:34,2 HCT:35,0 HCT:35,0 MCV:75,5 MCV:75,7 MCV:80 MCV:76,6 MCH:26,0 MCH:25,9 MCH:25,9 MCH:26,0 MCHC:34,5 MCHC:34,2 MCHC:32,6 MCHC:34,0 PLT:23000 PLT:51000 PLT:114000 PLT:185000 (10.44) (21.59) PLT: 25000 PLT: 58000 (17.30) PLT: 28000 (22.35) PLT: 32000 DHF Grade III DHF GRADE II TERAPY

    Diagnosa IVFD Ringer Lactat 20cc/kgBB=740 gtt/i macro IVFD Ringer Lactat 10cc/kgBB=370 gtt/i macro IVFD Ringer Lactat 5cc/kgBB=185 gtt/i macro IVFD Ringer Lactat 3cc/kgBB=111 gtt/i macro Paracetamol 3x500mg Ranitidine 40 mg/12 jam/IV Ambroxol syr 3x cthI

    Pasien PBJ Pada tanggal 22 Januari pukul 11.00 WIB, dan diberikan obat imunos 1x1 tab sehari

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