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  • Tanggal Subject Object Assessment Planning

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    Emma Nuro
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    The document contains daily medical records for a patient over 3 days (11/11/15 to 13/11/15). On the first day, the patient presented with cough, dyspnea, nausea, and abdominal pain. Examinations found moderate general condition and vital signs within normal limits. Diagnoses included possible TB, community-acquired pneumonia, chronic diarrhea, and malnutrition. Treatment plans included IV fluids, antibiotics, antacids, and supplements. On subsequent days, cough and dyspnea improved while vital signs remained stable. By the third day, symptoms further improved and the patient was deemed able to be discharged.

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    The document contains daily medical records for a patient over 3 days (11/11/15 to 13/11/15). On the first day, the patient presented with cough, dyspnea, nausea, and abdominal pain. Examinations found moderate general condition and vital signs within normal limits. Diagnoses included possible TB, community-acquired pneumonia, chronic diarrhea, and malnutrition. Treatment plans included IV fluids, antibiotics, antacids, and supplements. On subsequent days, cough and dyspnea improved while vital signs remained stable. By the third day, symptoms further improved and the patient was deemed able to be discharged.

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    7 views2 pages

    Tanggal Subject Object Assessment Planning

    Uploaded by

    Emma Nuro
    The document contains daily medical records for a patient over 3 days (11/11/15 to 13/11/15). On the first day, the patient presented with cough, dyspnea, nausea, and abdominal pain. Examinations found moderate general condition and vital signs within normal limits. Diagnoses included possible TB, community-acquired pneumonia, chronic diarrhea, and malnutrition. Treatment plans included IV fluids, antibiotics, antacids, and supplements. On subsequent days, cough and dyspnea improved while vital signs remained stable. By the third day, symptoms further improved and the patient was deemed able to be discharged.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    of 2

    Tanggal Subject Object Assessment Planning

    11/11/15 Batuk(+)berkurang dahak (+), Keadaan umum sakit sedang, compos Mentis -TB paru BTA (?) Kasus Baru Infus Ringer Laktat 20 tpm
    Sesak(+)berkurang Vital Sign -Pneumonia komunitas Inj.iv. Pantoprazole 1 x 1g
    Mual (+) T:110/70 mmHg CURB-65 (1) PSI (52) Inj. Iv. Ceftriaxone 2 x 1g
    nyeri ulu hati (+) N:110x/menit - Diare kronis Fluconazol 1 x 150mg
    BAB mencret 2 x. R:25x/menit - Malnutrisi, Hipoalbumin Cotrimoxazol 2 x 960mg
    Suhu: 36,4oC Sohobion 1 x 1 tablet
    SpO2:97 % VIP albumin 2 x 1 capsul
    Status generalis OAT FDC 3-0-0
    Mata: CA -/-, SI -/-
    THT: DBN
    Thoraks
    Cor: BJ I-II murni reguler
    Paru (anterior)
    Inspeksi statis: kanan = kiri
    Inspeksi dinamis: kanan = kiri
    Palpasi: Vocal fremitus kanan = kiri
    Perkusi:Sonor kanan = kiri
    Auskultasi:VBS kanan = kiri
    Suara tambahan: RBK (+/+)
    Abdomen: Soepel, BU (+) N, NT (+) epigastrium
    Ekstremitas: CRT < 2

    Pemeriksaan laboratorium
    B-20 test 3 : non reaktif

    12/11/15 Batuk(+) dahak (-), Keadaan umum sakit sedang, compos Mentis -TB paru BTA (?) Kasus Baru Infus Ringer Laktat 20 tpm
    Sesak(+)berkurang Vital Sign -Pneumonia komunitas Inj.iv. Pantoprazole 1 x 1g
    Mual (+) T:100/60 mmHg CURB-65 (1) PSI (52) Inj. Iv. Ceftriaxone 2 x 1g
    nyeri ulu hati (-) N:102x/menit - Malnutrisi, Hipoalbumin Fluconazol 1 x 150mg
    BAB dbn. R:28x/menit Cotrimoxazol 2 x 960mg
    Suhu: 36,1oC Sohobion 1 x 1 tablet
    SpO2:96 % VIP albumin 2 x 1 capsul
    Status generalis OAT FDC 3-0-0
    Mata: CA -/-, SI -/-
    THT: DBN
    Thoraks
    Cor: BJ I-II murni reguler
    Paru (anterior)
    Inspeksi statis: kanan = kiri
    Inspeksi dinamis: kanan = kiri
    Palpasi: Vocal fremitus kanan = kiri
    Perkusi:Sonor kanan = kiri
    Auskultasi:VBS kanan = kiri
    Suara tambahan: RBK (+/+)
    Abdomen: Soepel, BU (+) N, NT (-)
    Ekstremitas: CRT < 2
    13/11/15 Batuk(+) dahak (-), Keadaan umum sakit sedang, compos Mentis -TB paru BTA (?) Kasus Baru Boleh Pulang
    Sesak(+)berkurang Vital Sign -Pneumonia komunitas Fluconazol 1 x 150mg
    Mual (+) berkurang T:110/70 mmHg CURB-65 (1) PSI (52) Sohobion 1 x 1 tablet
    nyeri ulu hati (-) N:110x/menit - Malnutrisi, Hipoalbumin As. Mefenamat 3 x 1 tablet
    BAB dbn. R:25x/menit VIP albumin 2 x 1 capsul
    Suhu: 36,4oC OAT FDC 3-0-0
    SpO2:97 %
    Status generalis
    Mata: CA -/-, SI -/-
    THT: DBN
    Thoraks
    Cor: BJ I-II murni reguler
    Paru (anterior)
    Inspeksi statis: kanan = kiri
    Inspeksi dinamis: kanan = kiri
    Palpasi: Vocal fremitus kanan = kiri
    Perkusi:Sonor kanan = kiri
    Auskultasi:VBS kanan = kiri
    Suara tambahan: RBK (+/+)
    Abdomen: Soepel, BU (+) N, NT (-)
    Ekstremitas: CRT < 2

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