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  • Follow Up Catelia, 29 Juli 2015 Subjek (S) Objek (O)

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    Sulistyawati Wrimun
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    The patient was seen over several follow up visits complaining of fever, abdominal pain, and headache. On examination, the patient appeared moderately ill with anemia and tenderness in the suprapubic and left inguinal regions. The patient was treated with IV fluids, analgesics, antibiotics including ceftriaxone and cefadroxyl, and dexamethasone. Over the course of the visits, the patient's vital signs and symptoms gradually improved until the last visit where there were no further complaints.

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    FOLLOW UP

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    The patient was seen over several follow up visits complaining of fever, abdominal pain, and headache. On examination, the patient appeared moderately ill with anemia and tenderness in the suprapubic and left inguinal regions. The patient was treated with IV fluids, analgesics, antibiotics including ceftriaxone and cefadroxyl, and dexamethasone. Over the course of the visits, the patient's vital signs and symptoms gradually improved until the last visit where there were no further complaints.

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    11 views4 pages

    Follow Up Catelia, 29 Juli 2015 Subjek (S) Objek (O)

    Uploaded by

    Sulistyawati Wrimun
    The patient was seen over several follow up visits complaining of fever, abdominal pain, and headache. On examination, the patient appeared moderately ill with anemia and tenderness in the suprapubic and left inguinal regions. The patient was treated with IV fluids, analgesics, antibiotics including ceftriaxone and cefadroxyl, and dexamethasone. Over the course of the visits, the patient's vital signs and symptoms gradually improved until the last visit where there were no further complaints.

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    of 4

    FOLLOW UP

    Catelia, 29 Juli 2015


    Subjek (S)

    : Demam dan nyeri perut dikeluhkan pasien

    Objek (O)

    a. Keadaan Umum : Sakit sedang


    b. Kesadaran
    : Compos mentis
    c. Tanda Vital
    o Denyut Nadi : 95 kali/menit
    o pernapasan
    : 32 kali/menit
    o Suhu
    : 38,30C
    o TD
    : 90/60 mmHg
    d. Pemeriksaan Fisik
    - Konjungtiva anemis (+/+)
    - nyeri tekan suprapubik dan regio inguinal sinistra
    e. Pemeriksaan Penunjang
    Urinalisi sedimen
    Leukosit 3/LPB (0-1/LPB)
    Eritrosit 1/LPB (0-1/LPB)
    Epitel
    +
    (positif)
    Assesment (A)
    Plan (P)

    : Anemia post perdarahan + ISK


    :
    IVFD Ringer Lactat 20 tetes per menit
    Paracetamol tablet 500mg 3 x 3/4 tablet
    Injeksi ceftriaxon 750 mg/12 jam/iv

    Catelia, 30 Juli 2015


    Subjek (S)

    : pasien mengeluh demam, sakit perut dan sakit kepala

    Objek (O)

    a. Keadaan Umum
    : Sakit sedang
    b. Kesadaran
    : Compos mentis
    c. Tanda Vital
    a. Denyut Nadi : 88 kali/menit, cukup kuat
    b. Pernapasan : 28 kali/menit
    c. Suhu
    : 380C
    d. TD
    : 90/50 mmHg
    d. Pemeriksaan Fisik
    o Konjungtiva anemis (+/+)
    o nyeri tekan suprapubik dan regio inguinal sinistra
    Assesment (A)
    : Anemia post perdarahan + ISK
    Plan (P)
    :

    IVFD Ringer Lactat 20 tetes per menit


    Paracetamol tablet 500mg 3 x 3/4 tablet
    Injeksi ceftriaxon 750 mg/12 jam/iv
    Injeksi dexametason 3 x 1 ampul
    Catelia, 31 Juli 2015
    Subjek (S)

    : Demam dan sakit perut

    Objek (O)

    a. Keadaan Umum
    : Sakit sedang
    b. Kesadaran
    : Compos mentis
    c. Tanda Vital
    a. Denyut Nadi : 84 kali/menit, cukup kuat
    b. Pernapasan : 28 kali/menit
    c. Suhu
    : 37,50C
    d. TD
    : 100/60 mmHg
    d. Pemeriksaan Fisik
    a. Konjungtiva anemis (+/+)
    b. nyeri tekan suprapubik dan regio inguinal sinistra
    Assesment (A)
    :Anemia + ISK
    Plan (P)
    :
    IVFD Ringer Lactat 20 tetes per menit
    Paracetamol tablet 500mg 3 x 3/4 tablet
    Injeksi ceftriaxon 750 mg/12 jam/iv
    Cefadroxyl 2 x 1 kapsul
    Catelia, 01 Agustus 2015
    Subjek (S)

    : pasien mengeluh demam dan sakit perut

    Objek (O)

    a. Keadaan Umum
    : Sakit sedang
    b. Kesadaran
    : Compos mentis
    c. Tanda Vital
    a. Denyut Nadi : 104 kali/menit, cukup kuat
    b. Pernapasan : 36 kali/menit
    c. Suhu
    : 38,50C
    d. TD
    : 100/60 mmHg
    d. Pemeriksaan Fisik
    a. Konjungtiva anemis (+/+)
    b. nyeri tekan suprapubik dan regio inguinal sinistra
    e. Pemeriksaan Penunjang
    Darah rutin
    Wbc 8,04 x 103/ul

    Hb 8,3 g/dl
    Rbc 3,26 x 106/ul

    Plt 323 x 103/ul

    Urinalisis
    Lekosit 1

    Eritrosit 1
    Epitel +
    Batu
    Kristal
    Silinder

    Assesment (A)
    Plan (P)

    : Anemia
    :
    IVFD Lactat 20 tetes per menit
    Cefadroxyl 2 x 1 kapsul
    Paracetamol tablet 500mg 3 x 3/4 tablet
    Injeksi ceftriaxon 750 mg/12 jam/iv

    Catelia, 03 Agustus 2015


    Subjek (S)
    : tidak ada keluhan
    Objek (O)
    :
    a. Keadaan Umum
    : Sakit sedang
    b. Kesadaran
    : Compos mentis
    c. Tanda Vital
    Denyut Nadi : 88 kali/menit, cukup kuat
    Respirasi
    : 24 kali/menit
    Suhu
    : 36,20C
    TD
    : 100/60 mmHg
    f. Pemeriksaan Fisik
    a. Konjungtiva anemis (+/+)
    b. nyeri tekan suprapubik dan regio inguinal sinistra
    Assesment (A)
    : Anemia
    Plan (P)

    :
    Ivfd Ringer Lactat 20 tetes per menit
    Cefadroxyl 2 x 1 kapsul
    Injeksi ceftriaxon 750 mg/12 jam/iv

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