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    Yorim Sora Pasila
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    12 views3 pages

    Follow Up BP

    Uploaded by

    Yorim Sora Pasila

    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 3

    FOLLOW UP

    Tangga 18 Juli 2018 (ICU) 19 Juli 2018 (Pinru Biasa) 20 Juli 2018
    l
    S Sesak, tidak berkurang Sesak berkurang, demam Sesak (-), demam (-),
    dengan posisi duduk, demam, turun, batuk batuk (+)
    batuk berdahak
    O KU: TSS/CM KU: TSS/CM KU: TSS/CM
    TD: 143/80 TD: 110/70 TD: 170/90
    Nadi: 110x/m Nadi: 86x/m Nadi: 76x/m
    hitung manual RR: 26x/m RR: 22x/m
    RR: 42x/m hitung Suhu: 37,60C Suhu: 36,50C
    manual Mata: kontak (+), pupil bulat, Mata: kontak (+),
    Suhu: 380C isokor, diameter 3 mm, reflex pupil bulat, isokor,
    Mata: kontak (+), pupil bulat, cahaya +/+, konjungtiva diameter 3 mm, reflex
    isokor, diameter 3 mm, reflex anemis -/-, sclera ikteric -/- cahaya +/+,
    cahaya +/+, konjungtiva Thorax: Cor: BJ I/II regular, konjungtiva anemis -/-
    anemis -/-, sclera ikteric -/- murmur (-), gallop (-) , sclera ikteric -/-
    Thorax: Cor: BJ I/II regular, Pulmo: suara nafas Thorax: Cor: BJ I/II
    murmur (-), gallop (-) vesikuler +/+, ronki -/-, regular, murmur (-),
    Pulmo: suara nafas wheezing -/- gallop (-)
    vesikuler +/+, ronki +/+, Abdomen: flat, supel, BU (+) Pulmo: suara
    wheezing -/- N, NT (-), timpani nafas vesikuler +/+,
    Abdomen: flat, supel, BU (+) Ekstremitas: akral hangat, ronki -/-, wheezing -/-
    N, NT (-), timpani edema (-) Abdomen: flat, supel,
    Ekstremitas: akral hangat, Status Neurologis: Motorik: BU (+) N, NT (-),
    edema (-) 5/5/5/5 timpani
    Status Neurologis: Motorik: Ekstremitas: akral
    5/5/5/5 hangat, edema (-)
    Status Neurologis:
    Motorik: 5/5/5/4
    A Bronkopneumonia Bronkopneumonia ISPA
    Perawatan hari ke-1 Perawatan hari ke-2
    P  IVFD Futrolit 4  IVFD Futrolit 4 BLPL
    cc/jam (infuse cc/jam (infuse Resep pulang:
    pump) pump)  Cefixime
     02 8 lpm NRM  02 3 lpm nc 2x100 mg po
     Co. dr. Budi Sp. A  Nebu NaCl 3% 5 cc  Paracetamol
     Nebu NaCl 3% 5 cc + Pulmicort 1 amp 3x250 mg po
    + Pulmicort 1 amp + Farbivent 1/12 k/p
    + Farbivent 1/8 jam jam  Vestein syr
     Dexa 3X10 mg iv  Dexa 3X10 mg iv 3x1 cth
     Aminofilin 10 cc +  Merophenenm  Kontrol poli
    NaCl 0.9% 10 cc 3x1,5 gr iv + nacl Anak RSBI,
    dalam spuit 20 cc 100 cc drip dlm 15 Selasa 24 Juli
    habis dalam 30 menit pakai infuse 2018
    menit pump
    lanjut:  Sagestam 3x50 mg
     Aminofilin 18 cc + iv
    NaCl 0.9% 32 cc  Paracetamol
    dalam 50 CC habis 500mg/6jam iv k/p
    dalam 24 jam (infus  Meixam 3x1 gr dlm
    pump) 100 cc Nacl 0.9%
     Merophenenm drip dlm 15 menit
    3x1,5 gr iv + nacl pakai infuse pump
    100 cc drip dlm 15  Vestein 3x1 cth
    menit pakai infuse  Diet Lunak 3x/Susu
    pump 2x
     Sagestam 3x50 mg
    iv
     Paracetamol
    500mg/4jam iv
     Meixam 3x1 gr dlm
    100 cc Nacl 0.9%
    drip dlm 15 menit
    pakai infuse pump
     Vestein 3x1 cth
     Diet Lunak 3x/Susu
    2x
     Rawat ICU

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