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  • Tanggal/ Hari Rawatan Catatan Instruksi

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    nurul
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    This medical record documents a patient's treatment from Wednesday to Friday for suspected ileus obstruktif or blocked intestines. Over the three days, the patient's condition did not improve and their vital signs declined. Treatments included IV fluids, antibiotics, pain medication and consultations, but the family declined surgery on Wednesday. By Friday night, the patient's blood pressure dropped severely and they went into cardiac arrest, passing away early Saturday morning.

    Original Description:

    follow up paien

    Original Title

    follow up

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    This medical record documents a patient's treatment from Wednesday to Friday for suspected ileus obstruktif or blocked intestines. Over the three days, the patient's condition did not improve and their vital signs declined. Treatments included IV fluids, antibiotics, pain medication and consultations, but the family declined surgery on Wednesday. By Friday night, the patient's blood pressure dropped severely and they went into cardiac arrest, passing away early Saturday morning.

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    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
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    3 views3 pages

    Tanggal/ Hari Rawatan Catatan Instruksi

    Uploaded by

    nurul
    This medical record documents a patient's treatment from Wednesday to Friday for suspected ileus obstruktif or blocked intestines. Over the three days, the patient's condition did not improve and their vital signs declined. Treatments included IV fluids, antibiotics, pain medication and consultations, but the family declined surgery on Wednesday. By Friday night, the patient's blood pressure dropped severely and they went into cardiac arrest, passing away early Saturday morning.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as doc, pdf, or txt
    of 3

    Tanggal/

    hari Catatan Instruksi


    rawatan

    Rabu S/ perut terasa sakit, BAB dan Th/


    flatus (-)
    22/3/19 - IVFD RL 500 cc + D10% +
    O/ VS: Aminofluid 200cc
    H1
    TD : 120/80 mmHg - Ceftriaxon 1x2gr

    N : 88 x/menit - Metronidazol 3x500mg


    - Alinamin f 3x1
    RR : 23 x/menit
    - Ranitidine 2x40mg
    T : 37.0 °C - Ketorolac 3x30mg
    Abd - Rencana laparotomi

    I: cembung - Jam 16.00 keluarga


    menolak untuk operasi
    P: nyeri tekan +

    P: timpani

    A: bising usus kesan meningkat,


    meta;ic sound +

    Ass/

    ileus obstruktif

    Kamis S/ perut terasa sakit, BAB dan Th/


    flatus (-)
    23/3/201 - IVFD RL 500 cc + D10% +
    9 O/ VS: Aminofluid 200cc
    H2 TD : 110/60 mmHg - Ceftriaxon 1x2gr

    N : 88 x/menit - Metronidazol 3x500mg


    - Alinamin f 3x1
    RR : 23 x/menit
    - Ketorolac 3x30mg
    T : 36.0 °C - Omeprazol 2x40mg
    Abd - Sucralfat syr 3xcI

    3
    I: cembung - Dulcolax tab 2x1

    P: nyeri tekan +

    P: timpani

    A: bising usus kesan meningkat,


    meta;ic sound +

    Ass/

    ileus obstruktif

    Jumat S/ perut terasa sakit, BAB dan Th/


    flatus (-)
    24/3/19 - IVFD RL 500 cc + D10% +
    O/ VS: Aminofluid 200cc
    H3
    TD : 90/60 mmHg - Ceftriaxon 1x2gr

    N : 88 x/menit - Metronidazol 3x500mg


    - Alinamin f 3x1
    RR : 23 x/menit
    - Ketorolac 3x30mg
    T : 36.0 °C - Omeprazol 2x40mg
    Abd - Sucralfat syr 3xcI

    I: cembung - Dulcolax tab 2x1


    - Konsul penyalit dalam
    P: nyeri tekan +
    - KSR 3X1
    P: timpani - Cek elektrolit ulang
    A: bising usus kesan meningkat,
    meta;ic sound + Jam 23.50 TD 60/40 mmhg
    Loading RL 500 cc TD 60/40

    Lab Drip dobutamin 0.5mcg pantau


    TD
    Na/K/Cl : 145/2.8/108
    Tanggal 25/06/19 pukul 04.48
    Ass/ EKG asystol paien dinyatakann
    ileus obstruktif meninggal dunia

    4
    5

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