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    Follow Up Pasien: Tanggal/ Hari Rawatan Keluhan Utama Vital Sign Diagnosa Therapy

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    AfDal Daal
    This document records the follow up treatment of a patient over 5 days from September 1st to September 5th. The patient presented with slurred speech, weakness on the left side of the body, and seizures. Vital signs and complaints were recorded each day. The diagnosis remained non-hemorrhagic stroke, hypertension, and grand mal epilepsy. Intravenous fluids and medications including antibiotics, antihypertensives, anticonvulsants, and vitamins were administered daily to treat the conditions. The patient's vital signs and complaints improved over the 5 day period.

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    Follow Up Pasien: Tanggal/ Hari Rawatan Keluhan Utama Vital Sign Diagnosa Therapy

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    AfDal Daal
    5 views2 pages
    This document records the follow up treatment of a patient over 5 days from September 1st to September 5th. The patient presented with slurred speech, weakness on the left side of the body, and seizures. Vital signs and complaints were recorded each day. The diagnosis remained non-hemorrhagic stroke, hypertension, and grand mal epilepsy. Intravenous fluids and medications including antibiotics, antihypertensives, anticonvulsants, and vitamins were administered daily to treat the conditions. The patient's vital signs and complaints improved over the 5 day period.

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    Follow Up Pasien

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    This document records the follow up treatment of a patient over 5 days from September 1st to September 5th. The patient presented with slurred speech, weakness on the left side of the body, and seizures. Vital signs and complaints were recorded each day. The diagnosis remained non-hemorrhagic stroke, hypertension, and grand mal epilepsy. Intravenous fluids and medications including antibiotics, antihypertensives, anticonvulsants, and vitamins were administered daily to treat the conditions. The patient's vital signs and complaints improved over the 5 day period.

    Copyright:

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    5 views2 pages

    Follow Up Pasien: Tanggal/ Hari Rawatan Keluhan Utama Vital Sign Diagnosa Therapy

    Uploaded by

    AfDal Daal
    This document records the follow up treatment of a patient over 5 days from September 1st to September 5th. The patient presented with slurred speech, weakness on the left side of the body, and seizures. Vital signs and complaints were recorded each day. The diagnosis remained non-hemorrhagic stroke, hypertension, and grand mal epilepsy. Intravenous fluids and medications including antibiotics, antihypertensives, anticonvulsants, and vitamins were administered daily to treat the conditions. The patient's vital signs and complaints improved over the 5 day period.

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    of 2

    FOLLOW UP PASIEN

    TANGGAL/
    HARI
    RAWATAN
    01/09/2015
    (I)

    02/09/2015
    (II)

    KELUHAN
    UTAMA
    Bicara Pelo,
    kelemahan anggota
    gerak tubuh sebelah
    kiri, kejang.

    Bicara Pelo,
    kelemahan anggota
    gerak tubuh sebelah
    kiri

    VITAL SIGN

    DIAGNOSA

    Sens: Compos
    Mentis
    TD : 110/80
    mmHg
    HR : 100x/ menit
    RR : 20x/ menit
    T : 37,6oC

    DD/
    -

    Sens: Compos
    Mentis
    TD : 140/100
    mmHg
    HR : 84x/ menit
    RR : 28x/ menit
    T : 37,1oC

    DD/
    -

    Stroke non
    Haemorrhagic +
    Hipertensi +
    epilepsi Grandmall
    Stroke
    Haemorrhagic +
    Hipertensi +
    epilepsi Grandmall
    Stroke non
    Haemorrhagic +
    Hipertensi +
    epilepsi Grandmall
    Stroke
    Haemorrhagic +
    Hipertensi +
    epilepsi Grandmall

    THERAPY

    IVFD RL 20 gtt/menit
    Inj. Ranitidine 1 amp/12 jam
    Inj. Ceftazidine 1gr /12 jam
    Inj. Citicholine 500 mg/12 jam
    Inj. Ketorolac 1 amp/8 jam
    Tab. B.Complex 2x1
    Tab. Aptor 1x1
    Cap. Phenytoin 100 mg 3x1

    IVFD RL 20 gtt/menit
    Inj. Ranitidine 1 amp/12 jam
    Inj. Ceftazidine 1gr /12 jam
    Inj. Citicholine 500 mg/12 jam
    Inj. Ketorolac 1 amp/8 jam
    Tab. B.Complex 2x1
    Tab. Aptor 1x1
    Cap. Phenytoin 100 mg 3x1

    03/09/2015
    (III)

    Bicara Pelo,
    kelemahan anggota
    gerak tubuh sebelah
    kiri, batuk

    Sens: Compos
    mentis
    TD : 150/90
    mmHg
    HR : 64x/ menit
    RR : 28x/ menit
    T : 36,7oC

    DD/
    - Stroke non
    Haemorrhagic +
    Hipertensi + epilepsi
    Grandmall
    - Stroke Haemorrhagic +
    Hipertensi + epilepsi
    Grandmall

    04/09/2015
    (IV)

    Bicara Pelo,
    kelemahan anggota
    gerak tubuh sebelah
    kiri, batuk

    Sens: Compos
    mentis
    TD : 130/80
    mmHg
    HR : 100x/ menit
    RR : 28x/ menit
    T : 36,7oC

    DD/
    - Stroke non
    Haemorrhagic +
    Hipertensi + epilepsi
    Grandmall
    - Stroke Haemorrhagic +
    Hipertensi + epilepsi
    Grandmall

    05/09/2015
    (V)

    Bicara Pelo,
    kelemahan anggota
    gerak tubuh sebelah
    kiri, batuk

    Sens: Compos
    mentis
    TD : 130/80
    mmHg
    HR : 88x/ menit
    RR : 24x/ menit
    T : 36,8 oC

    DD/
    - Stroke non
    Haemorrhagic +
    Hipertensi + epilepsi
    Grandmall
    - Stroke Haemorrhagic +
    Hipertensi + epilepsi
    Grandmall

    IVFD RL 20 gtt/menit
    Inj. Ranitidine 1 amp/12 jam
    Inj. Ceftazidine 1gr /12 jam
    Inj. Citicholine 500 mg/12 jam
    Inj. Ketorolac 1 amp/8 jam
    Tab. B.Complex 2x1
    Tab. Cilostazol 2x1
    Tab Clopidogrel 75 mg 1x1
    Cap. Phenytoin 100 mg 3x1
    Syrp. Ambroxol 1x1
    IVFD RL 20 gtt/menit
    Inj. Ranitidine 1 amp/12 jam
    Inj. Ceftazidine 1gr /12 jam
    Inj. Citicholine 500 mg/12 jam
    Inj. Ketorolac 1 amp/8 jam
    Tab. B.Complex 2x1
    Tab. Cilostazol 2x1
    Tab Clopidogrel 75 mg 1x1
    Cap. Phenytoin 100 mg 3x1
    Syrp. Ambroxol 1x1
    Tab. B.Complex 2x1
    Tab. Cilostazol 2x1
    Tab. Ciprofloxaxin 2x1
    Tab. Ranitidin 2x1
    Tab Clopidogrel 75 mg 1x1
    Cap. Phenytoin 100 mg 3x1
    Syrp. Ambroxol 1x1

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