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    Progress Note

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    Ardanti Putri
    This document contains 9 progress notes summarizing the 9 day hospitalization of a child. Key details include: - The child presented with cough, fever, diarrhea, and decreased activity. Exams showed tachycardia, tachypnea, and fever. - Over the course of treatment, cough and fever improved while appetite increased. The child was given IV antibiotics, vitamins, oral medications and increased oral feeding amounts. - By day 9, cough was ongoing but improved, appetite was good, and vital signs had normalized. The child was discharged in stable condition.

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    Progress Note

    Uploaded by

    Ardanti Putri
    34 views5 pages
    This document contains 9 progress notes summarizing the 9 day hospitalization of a child. Key details include: - The child presented with cough, fever, diarrhea, and decreased activity. Exams showed tachycardia, tachypnea, and fever. - Over the course of treatment, cough and fever improved while appetite increased. The child was given IV antibiotics, vitamins, oral medications and increased oral feeding amounts. - By day 9, cough was ongoing but improved, appetite was good, and vital signs had normalized. The child was discharged in stable condition.

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    This document contains 9 progress notes summarizing the 9 day hospitalization of a child. Key details include: - The child presented with cough, fever, diarrhea, and decreased activity. Exams showed tachycardia, tachypnea, and fever. - Over the course of treatment, cough and fever improved while appetite increased. The child was given IV antibiotics, vitamins, oral medications and increased oral feeding amounts. - By day 9, cough was ongoing but improved, appetite was good, and vital signs had normalized. The child was discharged in stable condition.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    34 views5 pages

    Progress Note

    Uploaded by

    Ardanti Putri
    This document contains 9 progress notes summarizing the 9 day hospitalization of a child. Key details include: - The child presented with cough, fever, diarrhea, and decreased activity. Exams showed tachycardia, tachypnea, and fever. - Over the course of treatment, cough and fever improved while appetite increased. The child was given IV antibiotics, vitamins, oral medications and increased oral feeding amounts. - By day 9, cough was ongoing but improved, appetite was good, and vital signs had normalized. The child was discharged in stable condition.

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    of 5

    X.

    PROGRESS NOTE

    Perawatan Hari 1
    (3/3/15) FASE STABILISASI I
    Batuk (+)

    Demam (+)

    BAB (+) BAK (+) N

    Kurang aktif, CM
    HR : 72x/mnt
    RR : 36x/mnt
    t : 36,9 C (peraxiler)
    Kepala : mesocephal
    Mata : Cekung (-/-), CA (-/-), SI (-/-)
    Hidung : sekret (-/-), nafas cuping hidung (-)
    Telinga : serumen (-/-), bengkak (-/-), nyeri (-/-)
    Mulut : sianosis (-), bibir kering (-)
    Leher : simetris, pembesaran KGB (+)
    Thorax : simetris, retraksi (+)
    o Pulmo : vesiculer, ronki basah (-), wheezing (-),
    expirasi memanjang (-)
    o Cor
    : BJ I-II reguler, bising(-)
    Abd
    : datar, supel, peristaltik(+), nyeri tekan
    (-), turgor baik
    Ekst : akral dingin (-)
    Hb 11.4
    Leko 9500
    Trombosit 310.000
    Ht 33
    GDS 121
    Inf D5% 8tpm
    Inj amox 3x200mg IV
    Po.Ambroxol 3x cth
    Po. Vit A 1x200.000
    Po. As folat 1x5mg

    Perawatan Hari 2
    (4/3/15) FASE STABILISASI I
    Batuk (+)

    Demam (-)

    BAB (+) BAK (+) N

    Kurang aktif, CM
    HR : 90x/mnt
    RR : 32x/mnt
    t : 38,6 C (peraxiler)
    Kepala : mesocephal
    Mata : Cekung (-/-), CA (-/-), SI (-/-)
    Hidung : sekret (-/-), nafas cuping hidung (-)
    Telinga : serumen (-/-), bengkak (-/-), nyeri (-/-)
    Mulut : sianosis (-), bibir kering (-)
    Leher : simetris, pembesaran KGB (+)
    Thorax : simetris, retraksi (+)
    o Pulmo : vesiculer, ronki basah (-), wheezing (-),
    expirasi memanjang (-)
    o Cor
    : BJ I-II reguler, bising(-)
    Abd
    : datar, supel, peristaltik(+), nyeri tekan
    (-), turgor baik
    Ekst : akral dingin (-)
    X-foto rontgen thorax : infiltrate minimal pada
    perihiler kanan dan kiri
    DD : BRPN proses spesifik

    Inf D5% 8tpm


    Inj amox 3x200mg IV
    Po.Ambroxol 3x cth
    Po. Vit A 1x200.000
    Po. As folat 1x5mg
    Po. Zinc 20mg

    Perawatan Hari 3
    (5/3/15) FASE STABILISASI II
    Batuk (+)
    Muntah 1x setelah minum susu, susu tdk habis
    BAB (+) BAK (+) N
    Kurang aktif, CM
    HR : 96x/mnt
    RR : 30x/mnt
    t : 37.8 C (peraxiler)
    Kepala : mesocephal
    Mata : Cekung (-/-), CA (-/-), SI (-/-)
    Hidung : sekret (-/-), nafas cuping hidung (-)
    Telinga : serumen (-/-), bengkak (-/-), nyeri (-/-)
    Mulut : sianosis (-), bibir kering (-)
    Leher : simetris, pembesaran KGB (+)
    Thorax : simetris, retraksi (+)
    o Pulmo : vesiculer, ronki basah (-), wheezing (-),
    expirasi memanjang (-)
    o Cor
    : BJ I-II reguler, bising(-)
    Abd
    : datar, supel, peristaltik(+), nyeri tekan
    (-), turgor baik
    Ekst : akral dingin (-)

    Inf D5% 8tpm


    Inj amox 3x200mg IV
    Po.Ambroxol 3x cth
    Po. Vit A 1x200.000
    Po. As folat 1x5mg
    Po. Zinc 20mg
    Diit : F75 12x 75cc, air gula 50cc

    Perawatan Hari 4
    (6/3/15) FASE STABILISASI II
    Batuk (+)

    Susu habis

    BAB (+) BAK (+) N

    Kurang aktif, CM
    HR : 96x/mnt
    RR : 30x/mnt
    t : 37.8 C (peraxiler)
    Kepala : mesocephal
    Mata : Cekung (-/-), CA (-/-), SI (-/-)
    Hidung : sekret (-/-), nafas cuping hidung (-)
    Telinga : serumen (-/-), bengkak (-/-), nyeri (-/-)
    Mulut : sianosis (-), bibir kering (-)
    Leher : simetris, pembesaran KGB (+)
    Thorax : simetris, retraksi (+)
    o Pulmo : vesiculer, ronki basah (-), wheezing (-),
    expirasi memanjang (-)
    o Cor
    : BJ I-II reguler, bising(-)
    Abd
    : datar, supel, peristaltik(+), nyeri tekan
    (-), turgor baik
    Ekst : akral dingin (-)

    Inf D5% 8tpm


    Inj amox 3x200mg IV
    Po.Ambroxol 3x cth
    Po. Vit A 1x200.000
    Po. As folat 1x5mg
    Po. Zinc 20mg
    Diit : F75 8x 110cc, air gula

    Perawatan Hari 5
    (7/3/15) FASE STABILISASI II
    Batuk (+)

    Susu habis (+) muntah 1x

    BAB (+) BAK (+) N

    Kurang aktif, CM
    HR : 96x/mnt
    RR : 30x/mnt
    t : 37.8 C (peraxiler)
    Kepala : mesocephal
    Mata : Cekung (-/-), CA (-/-), SI (-/-)
    Hidung : sekret (-/-), nafas cuping hidung (-)
    Telinga : serumen (-/-), bengkak (-/-), nyeri (-/-)
    Mulut : sianosis (-), bibir kering (-)
    Leher : simetris, pembesaran KGB (+)
    Thorax : simetris, retraksi (+)
    o Pulmo : vesiculer, ronki basah (-), wheezing (-),
    expirasi memanjang (-)
    o Cor
    : BJ I-II reguler, bising(-)
    Abd
    : datar, supel, peristaltik(+), nyeri tekan
    (-), turgor baik
    Ekst : akral dingin (-)
    Mantoux tes (-)
    Scoring TB : 6

    Inf D5% 8tpm


    Inj amox 3x200mg IV
    Po.Ambroxol 3x cth
    Po. Vit A 1x200.000
    Po. As folat 1x5mg
    Po. Zinc 20mg
    Po. FDC

    Perawatan Hari 6
    (8/3/15) FASE STABILISASI II
    Batuk (+) berkurang
    Susu habis
    BAB (+) BAK (+) N
    Kurang aktif, CM
    HR : 96x/mnt
    RR : 30x/mnt
    t : 37.8 C (peraxiler)
    Kepala : mesocephal
    Mata : Cekung (-/-), CA (-/-), SI (-/-)
    Hidung : sekret (-/-), nafas cuping hidung (-)
    Telinga : serumen (-/-), bengkak (-/-), nyeri (-/-)
    Mulut : sianosis (-), bibir kering (-)
    Leher : simetris, pembesaran KGB (+)
    Thorax : simetris, retraksi (+)
    o Pulmo : vesiculer, ronki basah (-), wheezing (-),
    expirasi memanjang (-)
    o Cor
    : BJ I-II reguler, bising(-)
    Abd
    : datar, supel, peristaltik(+), nyeri tekan
    (-), turgor baik
    Ekst : akral dingin (-)

    Po. FDC
    Diit : F100 6x 150cc

    Perawatan Hari 7
    (9/3/15) FASE STABILISASI II
    Batuk (+) berkurang

    Susu habis, bubur tdk habis

    BAB (+) BAK (+) N

    Kurang aktif, CM
    HR : 72x/mnt
    RR : 36x/mnt
    t : 36,9 C (peraxiler)
    Kepala : mesocephal
    Mata : Cekung (-/-), CA (-/-), SI (-/-)
    Hidung : sekret (-/-), nafas cuping hidung (-)
    Telinga : serumen (-/-), bengkak (-/-), nyeri (-/-)
    Mulut : sianosis (-), bibir kering (-)
    Leher : simetris, pembesaran KGB (+)
    Thorax : simetris, retraksi (+)
    o Pulmo : vesiculer, ronki basah (-), wheezing (-),
    expirasi memanjang (-)
    o Cor
    : BJ I-II reguler, bising(-)
    Abd
    : datar, supel, peristaltik(+), nyeri tekan
    (-), turgor baik
    Ekst : akral dingin (-)
    Hb 11.4
    Leko 9500
    Trombosit 310.000
    Ht 33
    GDS 121

    Diit : F75 6x 150cc, air gula

    Perawatan Hari 8
    (10/3/15) FASE TRANSISI
    Batuk (+)

    Susu habis, bubur habis

    BAB (+) BAK (+) N

    Kurang aktif, CM
    HR : 72x/mnt
    RR : 36x/mnt
    t : 36,9 C (peraxiler)
    Kepala : mesocephal
    Mata : Cekung (-/-), CA (-/-), SI (-/-)
    Hidung : sekret (-/-), nafas cuping hidung (-)
    Telinga : serumen (-/-), bengkak (-/-), nyeri (-/-)
    Mulut : sianosis (-), bibir kering (-)
    Leher : simetris, pembesaran KGB (+)
    Thorax : simetris, retraksi (+)
    o Pulmo : vesiculer, ronki basah (-), wheezing (-),
    expirasi memanjang (-)
    o Cor
    : BJ I-II reguler, bising(-)
    Abd
    : datar, supel, peristaltik(+), nyeri tekan
    (-), turgor baik
    Ekst : akral dingin (-)
    Hb 11.4
    Leko 9500
    Trombosit 310.000
    Ht 33
    GDS 121

    Perawatan Hari 9
    (11/3/15) FASE TRANSISI
    Batuk (+)
    Susu habis, bubur habis
    BAB (+) BAK (+) N
    Kurang aktif, CM
    HR : 72x/mnt
    RR : 36x/mnt
    t : 36,9 C (peraxiler)
    Kepala : mesocephal
    Mata : Cekung (-/-), CA (-/-), SI (-/-)
    Hidung : sekret (-/-), nafas cuping hidung (-)
    Telinga : serumen (-/-), bengkak (-/-), nyeri (-/-)
    Mulut : sianosis (-), bibir kering (-)
    Leher : simetris, pembesaran KGB (+)
    Thorax : simetris, retraksi (+)
    o Pulmo : vesiculer, ronki basah (-), wheezing (-),
    expirasi memanjang (-)
    o Cor
    : BJ I-II reguler, bising(-)
    Abd
    : datar, supel, peristaltik(+), nyeri tekan
    (-), turgor baik
    Ekst : akral dingin (-)
    Hb 11.4
    Leko 9500
    Trombosit 310.000
    Ht 33
    GDS 121

    Po. FDC
    Diit: F100 6x 150cc, bubur lauk cacah 1x

    Po. FDC
    Diit: F100 6x 150cc, bubur lauk cacah 2x

    Po. FDC
    Diit: F100 6x 150cc, ubur lauk cacah 2x

    PULANG

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