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    DBD Tanpa Syok + Susp. ISK: Follow Up

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    dessyeva
    This document contains medical records from follow up visits of a child patient seen from 09/11/2015 to 12/11/2015 for fever, black stool, cough, and abdominal pain. The initial assessment found the child to have a fever of 36.7°C, tachycardia, decreased hemoglobin and hematocrit levels indicating blood loss. The child was given IV fluids, antibiotics, antipyretics and hematinics. Over the follow up visits the child's condition improved with resolution of fever and bleeding by the last visit on 12/11/2015 where vital signs were normalizing and the child was discharged with oral medications.

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    DBD Tanpa Syok + Susp. ISK: Follow Up

    Uploaded by

    dessyeva
    15 views4 pages
    This document contains medical records from follow up visits of a child patient seen from 09/11/2015 to 12/11/2015 for fever, black stool, cough, and abdominal pain. The initial assessment found the child to have a fever of 36.7°C, tachycardia, decreased hemoglobin and hematocrit levels indicating blood loss. The child was given IV fluids, antibiotics, antipyretics and hematinics. Over the follow up visits the child's condition improved with resolution of fever and bleeding by the last visit on 12/11/2015 where vital signs were normalizing and the child was discharged with oral medications.

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    FOLLOW UP DHF.doc

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    This document contains medical records from follow up visits of a child patient seen from 09/11/2015 to 12/11/2015 for fever, black stool, cough, and abdominal pain. The initial assessment found the child to have a fever of 36.7°C, tachycardia, decreased hemoglobin and hematocrit levels indicating blood loss. The child was given IV fluids, antibiotics, antipyretics and hematinics. Over the follow up visits the child's condition improved with resolution of fever and bleeding by the last visit on 12/11/2015 where vital signs were normalizing and the child was discharged with oral medications.

    Copyright:

    © All Rights Reserved
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    Download as doc, pdf, or txt
    15 views4 pages

    DBD Tanpa Syok + Susp. ISK: Follow Up

    Uploaded by

    dessyeva
    This document contains medical records from follow up visits of a child patient seen from 09/11/2015 to 12/11/2015 for fever, black stool, cough, and abdominal pain. The initial assessment found the child to have a fever of 36.7°C, tachycardia, decreased hemoglobin and hematocrit levels indicating blood loss. The child was given IV fluids, antibiotics, antipyretics and hematinics. Over the follow up visits the child's condition improved with resolution of fever and bleeding by the last visit on 12/11/2015 where vital signs were normalizing and the child was discharged with oral medications.

    Copyright:

    © All Rights Reserved
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    of 4

    Ilmu Kesehatan Anak

    FOLLOW UP
    S
    Keluhan
    09/11/2015
    Pkl. 08.00
    Demam (+);
    BAB hitam (+);
    Batuk berdahak
    (+)

    KU
    KS
    TD
    HR
    RR
    T
    Kulit
    Paru
    I
    P
    A
    Jantung
    I
    P
    A

    :
    :
    :
    :
    :
    :
    :

    O
    Pemeriksaan
    Tampak Sakit Sedang
    Compos Mentis
    100/60 mmHg
    80 x/menit
    28 x/menit
    36,7C
    Ptekie (+)

    : Simetris, retraksi (-)


    : Ekspansi Simetris
    : Vesikuler +/+, Ronkhi
    -/-Wheezing -/-

    A
    Assesment

    P
    Rencana
    IVFD RL XVgtt/mnt
    PCT syrup 3 x 11/2 cth
    Curcuma syrup 2 x 1

    cth
    Ambroxol syrup 3 x

    DBD tanpa syok + Susp. ISK

    1/2 cth
    -

    Cek Hb, Ht,


    trombosit, Urine
    Lengkap, Kultur
    urine.

    : Ictus cordis tidak terlihat


    : Ictus cordis teraba
    : BJ I/II Reguler, Murmur (-)

    Abdomen
    I
    : Datar
    A
    : Bising usus (+) 12x/ menit
    P
    : Organomegali (-), turgor
    kulit normal, Nyeri tekan di
    seluruh lapangan abdomen
    P
    : Timpani (+)
    Ekstremitas :
    Edema superior -/-Edema
    inferior -/-, Sianosis
    superior -/- Sianosis
    Hb
    Ht
    Trombosit

    12,4 g/dL
    33%
    40.000/L
    inferior -/-, Ptekie superior
    +/+ Ptekie inferior +/+

    Hasil lab darah :


    Ht : (40-33)/33 x100%
    : 0,2121x100% = 21%

    11

    Ilmu Kesehatan Anak


    10/11/2015
    Demam (+),
    batuk, agak
    sesak, BAB
    hitam (-), gusi
    berdarah (-) dan
    mimisan (-),
    nyeri perut (+)

    KU
    KS
    TD
    HR
    RR
    T
    Kulit
    Paru
    I
    P
    A
    Jantung
    I
    P
    A

    :
    :
    :
    :
    :
    :
    :

    Tampak Sakit Sedang


    Compos Mentis
    100/60 mmHg
    120 x/menit
    40 x/menit
    37,8C
    Ptekie (+) pada tangan
    kanan.

    DBD tanpa syok +


    susp. ISK

    1.
    2.
    3.
    4.
    5.

    : Simetris, retraksi (-)


    : Ekspansi Simetris
    : Vesikuler +/+, Ronkhi
    -/-Wheezing -/-

    Cek DR ulang
    Terapi :
    IVFD RL XVgtt/mnt
    (makro)
    Inj. Ceftriaxone
    600mg/12jam
    Inj. Ranitidine
    20mg/12jam
    PCT syrup 3 x 11/2 cth
    Inj. Furosemide 15
    mg/12 jam kemudian
    stop

    : Ictus cordis tidak terlihat


    : Ictus cordis teraba
    : BJ I/II Reguler, Murmur (-)

    Abdomen
    I
    : Datar
    A
    : Bising usus (+) 10x/ menit
    P
    : Organomegali (-), turgor
    kulit normal, nyeri tekan di
    seluruh lapang abdomen
    P
    : Timpani (+)
    Ekstremitas :
    Edema superior -/-Edema
    inferior -/-, Sianosis
    superior -/- Sianosis
    inferior -/-, Ptekie superior
    -/+ Ptekie inferior -/Hasil laboratorium
    Hb
    Ht
    Trombosit

    10,1
    27%
    160000/L

    Nitrit

    Urobilinogen

    Warna

    Kuning

    Kejernihan

    Jernih

    BJ

    1,016

    Keton

    Ht : (33-27)/27 x100%
    : 0,222x100% = 22%
    11/11/2015
    Demam (-), BAB
    hitam (-) dan
    BAK normal.

    KU
    KS
    TD
    HR
    RR
    T

    :
    :
    :
    :
    :
    :

    Tampak Sakit Sedang


    Compos Mentis
    100/70 mmHg
    112 x/menit
    24 x/menit
    37,5C

    Kulit

    : Ptekie (-)

    DBD tanpa syok +


    susp. ISK

    IVFD RL XVgtt/mnt
    (makro)
    Hasil konsul :
    1. Pasien boleh pulang bila
    tidak ada demam dan
    perdarahan besok.
    2. Furosemide stop

    12

    Ilmu Kesehatan Anak


    Paru
    I
    P
    A
    Jantung
    I
    P
    A

    : Simetris, retraksi (-)


    : Ekspansi Simetris
    : Vesikuler +/+, Ronkhi
    -/-Wheezing -/: Ictus cordis tidak terlihat
    : Ictus cordis teraba
    : BJ I/II Reguler, Murmur (-)

    Abdomen
    I
    : Datar
    A
    : Bising usus (+) 8x/ menit
    P
    : Organomegali (-), turgor
    kulit normal, nyeri tekan (-)
    P
    : Timpani (+)
    Ekstremitas :
    Edema superior -/-Edema inferior -/-,
    Sianosis superior -/- Sianosis
    inferior -/-, Ptekie superior -/Ptekie inferior -/Hb
    Ht
    Trombosit

    10,8
    23%
    210000/L

    Ht : (27-23)/23 x100%
    : 0,1739x100% = 17%
    12/11/2015

    KU
    KS
    TD
    HR
    RR
    T

    :
    :
    :
    :
    :
    :

    Kulit

    : Ptekie (-)

    Paru
    I
    P
    A
    Jantung
    I
    P
    A

    Tampak Sakit Sedang


    Compos Mentis
    110/70 mmHg
    124 x/menit
    28 x/menit
    37,1C

    DBD tanpa syok +


    susp. ISK

    Cefadroxyl 125mg
    syrup 3 x 1 cth
    Ambroxol syrup 3 x
    1/2 cth
    Parasetamol syrup 3 x

    11/2 cth
    Pasien boleh pulang

    : Simetris, retraksi (-)


    : Ekspansi Simetris
    : Vesikuler +/+, Ronkhi
    -/-Wheezing -/: Ictus cordis tidak terlihat
    : Ictus cordis teraba
    : BJ I/II Reguler, Murmur (-)

    Abdomen
    I
    : Datar
    A
    : Bising usus (+) 10x/ menit
    P
    : Organomegali (-), turgor
    kulit normal, nyeri tekan (-)
    P
    : Timpani (+)
    Ekstremitas :

    13

    Ilmu Kesehatan Anak


    Edema superior -/-Edema inferior
    Sianosis superior -/- Sianosis
    inferior -/-, Ptekie superior -/Ptekie inferior -/-

    14

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