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Follow up

Tanggal /
Hari
Perawatan
04/08/2014

Nyeri ulu hati (+),

CM, N = 79x/i; TD Susp.


= 110/70 mmHg; RR Peritonitis
= 24x/i, T = 36,5; an
(-/-), ikt (-/-), Rh
(-/-), Wh (-/-), NTE
(+), BU (+) normal

Nyeri ulu hati (+),


warna urin seperti
teh tua

CM; N = 84x/i; TD= 120/70 mmHg;


RR = 20x/i; T =
36,5; an (-/-), ikt
(-/-), Sn.vesikuler,
Rh (-/-), Wh (-/-),
NTE (+), BU (+)
normal

Nyeri ulu hati (+),


perut kembung,
warna urin oranye
kekuningan

CM, N = 84x/i; TD= 120/80 mmHg;


RR = 20x/i; T =
36,4; an (-/-); ikt
(-/-); NTE (+)

Pancreatitis
akut

- IVFD RL 20 tpm
- Inj ketorolac 3 x 1 amp (iv)
- Inj. Ceftriaxone 2x1 gr dlm
NaCl 100 cc
- Metronidazole inf 3x1 fls
- Cek lab CEA,CA 19-9,
lipase, amilase

CM, N = 80x/i; TD= 150/90 mmHg;


RR = 22x/i; T =
36,6; an(-/-),
ikt(-/-), NTE (+)

Pancreatitis
akut

Hari IV

Nyeri ulu hati (+),


perut kembung
berkurang, warna
urin kuning jernih

- Puasa
- IVFD RL 20 tpm
- Inj. Ranitidin 2 x 1 amp (iv)

08/08/2I014

Nyeri ulu hati (+)

CM, N = 78x/i, TD= 140/90 mmHg;


RR = 22x/i; T =
36,5; an(-/-),
ikt(-/-), NTE (+)

Pancreatitis
akut

- IVFD RL 20 tpm
- Inj. Ranitidin 2 x 1 amp (iv)

Nyeri ulu hati << ,)

CM, N = 80x/i; TD= 130/80 mmHg;


RR = 20x/i; T =
36,4; an (-/-); ikt
(-/-), NTE (+)

Pancreatitis
akut

- Aff infus
- Boleh pulang

Hari I

05/08/2014
Hari II

06/08/2014
Hari III

07/08/2014

Hari V

09/08/2014
Hari VI

Abdominal pain dd
susp.
Pancreatitis
akut
susp. Ulkus
peptikum
-

Puasa
IVFD RL 20 tpm
Pasang kateter & NGT
Inj ketorolac 3 x 1 amp (iv)
Inj. cefotaxime 2x1 amp (iv)
Metronidazole inf 3x1 fls
Konsul Bedah
Diet bebas
IVFD RL 20 tpm
Inj ketorolac 3 x 1 amp (iv)
Inj. Ceftriaxone 2x1 gr dlm
NaCl 100 cc
Metronidazole inf 3x1 fls
Aff NGT
Cek lab BSN, BSPP
USG Abdomen

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