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  • 2.1 Lembar Follow Up Tanggal S O A P

    Uploaded by

    Andreas Tedi Karo-Karo
    16 views2 pages
    This document contains a follow up report for a patient seen on multiple dates from March 7th to 14th. On initial presentation, the patient had a fever of 38.1 degrees Celsius, mild to moderate dehydration, and a heart murmur suspicious for a ventricular septal defect. Treatment included IV fluids, antibiotics, and zinc supplementation. A cardiologist evaluation was planned. By the final date, the fever had resolved and dehydration improved. Surgical closure of a patent ductus arteriosus was scheduled for March 18th, and the patient was approved for discharge with improving nutrition but some lingering failure to thrive.

    Original Description:

    Lembar Follow Up Rn

    Original Title

    Lembar Follow Up Rn

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    This document contains a follow up report for a patient seen on multiple dates from March 7th to 14th. On initial presentation, the patient had a fever of 38.1 degrees Celsius, mild to moderate dehydration, and a heart murmur suspicious for a ventricular septal defect. Treatment included IV fluids, antibiotics, and zinc supplementation. A cardiologist evaluation was planned. By the final date, the fever had resolved and dehydration improved. Surgical closure of a patent ductus arteriosus was scheduled for March 18th, and the patient was approved for discharge with improving nutrition but some lingering failure to thrive.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    16 views2 pages

    2.1 Lembar Follow Up Tanggal S O A P

    Uploaded by

    Andreas Tedi Karo-Karo
    This document contains a follow up report for a patient seen on multiple dates from March 7th to 14th. On initial presentation, the patient had a fever of 38.1 degrees Celsius, mild to moderate dehydration, and a heart murmur suspicious for a ventricular septal defect. Treatment included IV fluids, antibiotics, and zinc supplementation. A cardiologist evaluation was planned. By the final date, the fever had resolved and dehydration improved. Surgical closure of a patent ductus arteriosus was scheduled for March 18th, and the patient was approved for discharge with improving nutrition but some lingering failure to thrive.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    of 2

    2.

    1 Lembar Follow Up
    Tanggal

    Demam(+)

    T: 38.1

    GEA

    - IVFD D5 NS

    , BAB cair Nadi:


    (+)
    7/3/2016

    118 dehidrasi

    410cc / 24 jam

    x/menit

    ringan-

    - Inj. Cefotaxime 3 x

    RR: 26 x/menit

    sedang

    100mg

    ane(-/-) ikt (-/-)

    - PCT syr. 3 x cth

    Rho(-/-)

    - zink 20mg 1x

    whe

    (-/-)
    NT(-) BU (+) N
    BAB
    (-),

    Akral hangat
    cair T: 36,8
    batuk Nadi:

    (+).
    8/3/2016

    GEA

    - IVFD D5 NS

    110 dehidrasi

    410cc / 24 jam

    x/menit

    ringan-

    RR: 28 x/menit

    sedang

    ane(-/-) ikt (-/-)

    Susp. VSD

    Rho(-/-)

    - Inj. Cefotaxime 3 x
    + 100mg

    whe

    - zink 20mg 1x

    (-/-)
    Murmur
    Demam(-),
    BAB
    (-).
    10/3/201
    6

    - Co. Cardiologi
    (+),

    BU (+) N
    T: 36,7

    cair Nadi:

    GEA
    108 dehidrasi

    RR: 26 x/menit

    sedang

    ane(-/-) ikt (-/-)

    Susp. VSD

    Murmur

    BAB
    (-).

    410cc / 24 jam

    ringan-

    whe

    BU (+) N
    T: 36,5

    cair Nadi:
    x/menit

    - Inj. Cefotaxime 3 x
    + 100mg
    - PCT syr. 3 x cth
    - zink 20mg 1x

    (-/-)

    11/3/2016 Demam(-),

    - IVFD D5 NS

    x/menit

    Rho(-/-)

    - PCT syr. 3 x cth

    - alih rawat divisi


    (+),

    cardio
    Susp.

    - rencana echo
    PJB - IVFD D5 NS

    118 non sianotik 410cc / 24 jam


    +

    GEA - Inj. Cefotaxime 3 x

    RR: 28 x/menit

    dehidrasi

    100mg

    ane(-/-) ikt (-/-)

    ringan-

    - PCT syr. 3 x cth

    Rho(-/-)

    whe sedang

    (-/-)
    Murmur
    12/3/201
    6

    Demam(-),
    BAB

    PDA + GEA - IVFD D5 NS


    110 dehidrasi
    ringan-

    - Inj. Cefotaxime 3 x

    RR: 26 x/menit

    sedang

    100mg

    ane(-/-) ikt (-/-)

    (membaik)

    - PCT syr. 3 x cth

    whe

    - zink 20mg 1x

    (-/-)
    Murmur
    Demam

    (-),

    - Pro PDA closure tgl


    (+),

    BU (+) N
    T: 36.8

    BAB Nadi:

    18/3/16
    PDA + GEA Boleh pulang

    106 dehidrasi

    cair

    (-), x/menit

    ringan-

    Sesak

    (-), RR: 28 x/menit

    sedang

    Batuk (+).

    410cc / 24 jam

    x/menit

    Rho(-/-)

    14/3/201

    - rencana echo

    (+),

    BU (+) N
    T: 36.5

    cair Nadi:

    (-).

    (membaik)

    - zink 20mg 1x

    ane(-/-) ikt (-/-)


    Rho(-/-)

    whe Gizi

    (-/-)
    Murmur
    BU (+) N

    (membaik) +
    + FTT

    (+),

    kurang

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