Scribd Logo
Upload

Welcome to Scribd!

  • Progress Follow Up: Tanggal Catatan Perkembangan Pasien Terapi

    Uploaded by

    dokunimus
    9 views4 pages
    The patient has been experiencing increasing swelling in their legs and hands, shortness of breath, and abdominal distension over several days. Examinations showed elevated blood pressure, edema, ascites, and reduced lung sounds. Imaging found congestive heart failure, pleural effusion, free abdominal fluid, and suspected kidney disease. The patient's condition deteriorated further with worsening edema and cyanosis.

    Original Description:

    lk ckd ode 4

    Original Title

    LK CKD ODE 4

    Copyright

    © © All Rights Reserved

    Available Formats

    DOC, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    Report this Document
    The patient has been experiencing increasing swelling in their legs and hands, shortness of breath, and abdominal distension over several days. Examinations showed elevated blood pressure, edema, ascites, and reduced lung sounds. Imaging found congestive heart failure, pleural effusion, free abdominal fluid, and suspected kidney disease. The patient's condition deteriorated further with worsening edema and cyanosis.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as doc, pdf, or txt
    9 views4 pages

    Progress Follow Up: Tanggal Catatan Perkembangan Pasien Terapi

    Uploaded by

    dokunimus
    The patient has been experiencing increasing swelling in their legs and hands, shortness of breath, and abdominal distension over several days. Examinations showed elevated blood pressure, edema, ascites, and reduced lung sounds. Imaging found congestive heart failure, pleural effusion, free abdominal fluid, and suspected kidney disease. The patient's condition deteriorated further with worsening edema and cyanosis.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as doc, pdf, or txt
    of 4

    I.

    PROGRESS FOLLOW UP
    Tanggal
    7-2-2013

    Catatan Perkembangan Pasien


    S : lemas (+), kedua kaki bengkak, Sesak
    nafas (+)
    O:
    KU : lemas, CM
    TD 140/60 mmHg
    HR : 90 x/menit
    RR : 23 x/menit
    T : 36,7 oC
    Kepala : mesocephal
    Mata : Conj. Anemis +/+
    Thorak : Cor BJ I-II regular
    Pulmo SDV +/+, RBH +/+
    Abdomen : Kembung, ascites (+), BU (-)
    Ekstremitas : oedem
    +
    USG :
    - Suspect CKD duplex
    - Congestive hepar
    - Efusi pleura duplex
    - Cairan bebas intra abdomen

    8-2-2013

    Terapi
    Infus NaCl 8 tpm
    Inj. Ceftri 2x1
    Furosemid
    3xII
    ampule
    Novorapid 3x8iu
    Amlodipin 10 mg
    1x1
    Callos 3x1
    As. Folat 1x1
    Pasang DC

    Foto Thorax :
    - Cardiomegali
    - Efusi pleura duplex
    - Oedem pulmo
    S : lemas (+), kedua tangan bengkak, Sesak
    nafas (+)
    O:
    KU : lemas, CM
    TD 160/110 mmHg
    HR : 92 x/menit
    RR : 23 x/menit
    T : 36,7 oC
    Kepala : mesocephal
    Mata : Conj. Anemis +/+
    Thorak : Cor BJ I-II regular
    Pulmo SDV +/+, RBH +/+
    Abdomen : Kembung, ascites (+), BU (-)
    + +
    +

    Infus NaCl 6 tpm


    Inj. Ceftri 2x1
    Furosemid
    3xII
    ampule
    Novorapid 3x8iu
    Amlodipin 10 mg
    1x1
    Callos 3x1
    As. Folat 1x1
    Transfusi PRC II

    Ekstremitas : oedem

    9-2-2013

    S : lemas (+), , Sesak nafas (+), perut sebah


    O:
    KU : lemas, CM
    TD 190/80 mmHg
    HR : 90 x/menit
    RR : 26 x/menit
    T : 36,7 oC
    Kepala : mesocephal
    Mata : Conj. Anemis +/+
    Thorak : Cor BJ I-II regular
    Pulmo SDV +/+, RBH +/+
    Abdomen : Kembung, ascites (+), BU (-)
    Ekstremitas : oedem
    + +
    +

    10-2-2013

    11-2-2013

    S : perut makin besar, nyeri perut


    O:
    KU : baik, CM
    TD 170/100 mmHg
    HR : 94 x/menit
    RR : 24 x/menit
    T : 36,7 oC

    Infus NaCl 8 tpm


    Inj. Ceftri 2x1
    Furosemid
    3xII
    ampule
    Novorapid 3x8iu
    Amlodipin 10 mg
    1x1
    Callos 3x1
    As. Folat 1x1

    S : perut , makin besar


    O:
    KU : lemas, CM
    TD 160/90 mmHg
    HR : 91 x/menit
    RR : 22 x/menit
    T : 36,7 oC
    Kepala : mesocephal
    Mata : Conj. Anemis +/+
    Thorak : Cor BJ I-II regular
    Pulmo SDV +/+, RBH +/+
    Abdomen : Kembung, ascites (+), BU (-)
    + +
    Ekstremitas : oedem
    +

    Infus NaCl 8 tpm


    Inj. Ceftri 2x1
    Furosemid
    3xII
    ampule
    Novorapid 3x8iu
    Amlodipin 10 mg
    1x1
    Callos 3x1
    As. Folat 1x1

    +
    -

    Infus NaCl 8 tpm


    Inj. Ceftri 2x1
    Furosemid
    3xII
    ampule
    Novorapid 3x8iu
    Amlodipin 10 mg
    1x1

    Kepala : mesocephal
    Mata : Conj. Anemis +/+
    Thorak : Cor BJ I-II regular
    Pulmo SDV +/+, RBH +/+
    Abdomen : Kembung, ascites (+), BU (-)
    Ekstremitas : oedem
    + +
    sianosis

    Callos 3x1
    As. Folat 1x1

    Pulang Paksa

    II.

    ALUR KETERKAITAN MASALAH

    Hipertensi Grade II
    TD 160/100
    RPD 2 th
    Diabetes Mellitus
    GDS H 539
    RPD 2 th

    Anemia
    Hb, Eritrosit, Ht
    CKD Stage IV
    LFG 18 ml/menit

    Terapi
    Ureum
    Creatinin
    Natrium
    Kalium

    USG :
    Congestive Hepar
    Effusi Pleura Duplex
    Cairan Bebas intra abdomen
    Susp. CKD Duplex
    Foto Thorax
    Cardiomegali
    Effusi pleura duplex
    Oedem pulmo

    Hipoalbuminemia
    Albumin

    You might also like