I.

Follow Up Tanggal Sesak (+) Demam (+) S Nyeri perut (-) Ma/mi (</+) Mual/muntah (+/-) BAB/BAK (+/+) TD = 140/80 mmHg RR = 32 x/ Tindak Lanjut

20-2-2013

N = 85 x/ T = 38,1 A ARF + HF + HT grade I + ulkus manus IVFD D10 10 tpm IVFD Metronidazol 3 x 500gram Inj. Ceftriaxon 2 x 1gram Ranitidin 2 x 1 amp P Antrain 3 x 1 amp Lasix 1 x1 (1-0-0) Po. Asam folat 3 x 1 CaCO3 3 x 1 Curcuma 3 x 1 Dressing luka dgn Nacl + betadin 2x sehari Sesak (+) Demam (-) S Nyeri perut (+) Ma/mi (</+) Mual/muntah (+/-) TD = 130/70 mmHg RR = 28 x/

21-2-2013

N = 80 x/ T = 36,1C A ARF + HF + ulkus manus P IVFD RL:D5 (1:1) 20 tpm IVFD Metronidazol 3 x 500gram Inj. Ceftriaxon 2 x 1gram
31

Ranitidin 2 x 1 amp Antrain 3 x 1 amp Lasix 2 x1 (1-1-0) Po. Asam folat 3 x 1 CaCO3 3 x 1 Curcuma 3 x 1 Dressing luka dgn Nacl + betadin 2x sehari Sesak (+) Demam (-) S Nyeri perut (+) Ma/mi (</+) Mual/muntah (+/-) Tangan bengkak (+) TD = 100/60 mmHg O N = 79 x/ GDP = 89 RR = 24 x/ T = 36,7C

22-2-2013

G2PP = 119 A ARF + HF + ulkus manus IVFD RL:D5 (1:1) 20 tpm IVFD Metronidazol 3 x 500gram Inj. Ceftriaxon 2 x 1gram Ranitidin 2 x 1 amp P Antrain 3 x 1 amp Lasix 1 x1 (1-0-0) Po. Asam folat 3 x 1 CaCO3 3 x 1 Curcuma 3 x 1 Dressing luka dgn Nacl + betadin 2x sehari Sesak (-) Demam (-) S Nyeri perut (<) Mual/muntah (+/-) RR = 22 x/
32

23-2-2013

Ma/mi (</+)

Tangan bengkak (+) O TD = 120/80 mmHg

N = 82 x/ SGOT = 72

T = 36,5C GDS = 98

SGPT = 38 A ARF + HF + ulkus manus + Peningkatan enzim transaminase IVFD RL:D5 (1:1) 20 tpm IVFD Metronidazol 3 x 500gram Inj. Ceftriaxon 2 x 1gram Ranitidin 2 x 1 amp P Antrain 3 x 1 amp Lasix 1 x1 (1-0-0) Po. Asam folat 3 x 1 Hepa Q 2 x 1 Aminefron 3 x 1 Dressing luka dgn Nacl + betadin 2x sehari Sesak (-) Demam (+) S Nyeri perut (<) Mual/muntah (+/-) Tangan bengkak (+) TD = 90/60 mmHg O N = 76 x/ RR = 22 x/ T = 37,8C Ma/mi (</+)

GDS = 89 A ARF + HF + ulkus manus + Peningkatan enzim transaminase IVFD RL:D5 (1:1) 20 tpm 24-2-2013 IVFD Metronidazol 3 x 500gram Inj. Ceftriaxon 2 x 1gram Ranitidin 2 x 1 amp P Antrain 3 x 1 amp Lasix 1 x1 (1-0-0) Po. Asam folat 3 x 1 Hepa Q 2 x 1 Aminefron 3 x 1 25-2-2013 S Dressing luka dgn Nacl + betadin 2x sehari Sesak (+) Demam (-)
33

Nyeri perut (<) Mual/muntah (+/-) Tangan bengkak (<) TD = 100/70 mmHg

Ma/mi (</+)

RR = 20 x/

N = 76 x/ T = 36,8C A ARF + HF + ulkus manus + Peningkatan enzim transaminase IVFD RL:D5 (1:1) 20 tpm IVFD Metronidazol 3 x 500gram Inj. Ceftriaxon 2 x 1gram Ranitidin 2 x 1 amp P Antrain 3 x 1 amp Lasix 1 x1 (1-0-0) Po. Asam folat 3 x 1 Hepa Q 2 x 1 Aminefron 3 x 1 Dressing luka dgn Nacl + betadin 2x sehari Sesak (<) Demam (-) S Nyeri perut (<) Mual/muntah (+/-) Tangan bengkak (<) TD = 100/70 mmHg RR = 20 x/ Ma/mi (</+)

N = 68 x/ T = 37,5C A ARF + HF + ulkus manus + Peningkatan enzim transaminase IVFD RL:D5 (1:1) 20 tpm IVFD Metronidazol 3 x 500gram 26-2-2013 P Inj. Ceftriaxon 2 x 1gram Ranitidin 2 x 1 amp Antrain 1 x 1 amp (k/p) Lasix 1 x1 (1-0-0) Po. Asam folat 3 x 1 Hepa Q 2 x 1 Aminefron 3 x 1 Dressing luka dgn Nacl + betadin 2x sehari
34

Sesak (-) S Nyeri perut (<) Mual/muntah (+/-) Tangan nyeri (+) TD = 100/70 mmHg

Demam (-) Ma/mi (</+)

RR = 18 x/

N = 72 x/ T = 37,1C A ARF + HF + ulkus manus + Peningkatan enzim transaminase IVFD RL:D5 (1:1) 20 tpm IVFD Metronidazol 3 x 500gram 27-2-2013 Inj. Ceftriaxon 2 x 1gram Ranitidin 2 x 1 amp Antrain 1 x 1 amp (k/p) P Lasix 1 x1 (1-0-0) Po. Asam folat 3 x 1 Hepa Q 2 x 1 Aminefron 3 x 1 Dressing luka dgn Nacl + betadin 2x sehari Kultur pus Sesak (-) S Nyeri perut (<) Mual/muntah (+/-) Tangan nyeri (+) TD = 100/70 mmHg RR = 20 x/ Demam (-) Ma/mi (</+)

O 28-2-2013

N = 74 x/ T = 36,1C A ARF + HF + ulkus manus + Peningkatan enzim transaminase P IVFD RL:D5 (1:1) 20 tpm IVFD Metronidazol 3 x 500gram Inj. Ceftriaxon 2 x 1gram Ranitidin 2 x 1 amp Antrain 1 x 1 amp (k/p) Lasix 1 x1 (1-0-0) Po. Asam folat 3 x 1 Hepa Q 2 x 1
35

Aminefron 3 x 1 Dressing luka dgn Nacl + betadin 2x sehari Sesak (-) Demam (-) S Nyeri perut (<) Mual/muntah (+/-) Tangan nyeri (+) TD = 100/60 mmHg RR = 20 x/ Ma/mi (</+)

N = 76 x/ T = 36,5C A ARF + HF + ulkus manus + Peningkatan enzim transaminase IVFD RL:D5 (1:1) 20 tpm 29-2-2013 IVFD Metronidazol 3 x 500gram Inj. Ceftriaxon 2 x 1gram Ranitidin 2 x 1 amp P Antrain 1 x 1 amp (k/p) Lasix 1 x1 (1-0-0) Po. Asam folat 3 x 1 Hepa Q 2 x 1 Aminefron 3 x 1 2-3-2013 S Dressing luka dgn Nacl + betadin 2x sehari Sesak (-) Demam (-) Nyeri perut (<) Mual/muntah (+/-) Tangan nyeri (<) TD = 100/60 mmHg RR = 20 x/ Ma/mi (</+)

N = 76 x/ T = 36,5C A ARF + HF + ulkus manus + Peningkatan enzim transaminase P IVFD RL:D5 (1:1) 20 tpm IVFD Metronidazol 3 x 500gram Inj. Ceftriaxon 2 x 1gram Ranitidin 2 x 1 amp Antrain 1 x 1 amp (k/p) Lasix 1 x1 (1-0-0) Po. Asam folat 3 x 1
36

Hepa Q 2 x 1 Betahistin 3 x 1 Pletal 2 x 50mg Dressing luka dgn Nacl + betadin 2x sehari Sesak (-) Demam (-) S Nyeri perut (<) Mual/muntah (</-) Tangan nyeri (<) TD = 100/60 mmHg RR = 22 x/ Ma/mi (</+)

N = 70 x/ T = 36,6C A ARF + HF + ulkus manus + Peningkatan enzim transaminase IVFD RL:D5 (1:1) 20 tpm 3-3-2013 IVFD Metronidazol 3 x 500gram Inj. Ceftriaxon 2 x 1gram Ranitidin 2 x 1 amp P Lasix 1 x1 (1-0-0) Po. Asam folat 3 x 1 Hepa Q 2 x 1 Betahistin 3 x 1 Pletal 2 x 50mg 4-3-2013 S Dressing luka dgn Nacl + betadin 2x sehari Sesak (-) Demam (-) Nyeri perut (<) Mual/muntah (-/-) Tangan nyeri (<) TD = 120/80 mmHg Ma/mi (</+) pucat (+) RR = 20 x/

N = 80 x/ T = 36,5C A ARF + HF + ulkus manus + Peningkatan enzim transaminase P IVFD RL:D5 (1:1) 20 tpm IVFD Metronidazol 3 x 500gram Inj. Ceftriaxon 2 x 1gram Ranitidin 2 x 1 amp Lasix 1 x1 (1-0-0)
37

Po. Asam folat 3 x 1 Hepa Q 2 x 1 Betahistin 3 x 1 Pletal 2 x 50mg Dressing luka dgn Nacl + betadin 2x sehari Sesak (-) Demam (-) S Nyeri perut (<) Mual/muntah (-/-) Tangan nyeri (<) TD = 110/80 mmHg Ma/mi (</+) pucat (-) RR = 20 x/

N = 80 x/ T = 36,5C A ARF + HF + ulkus manus IVFD RL:D5 (1:1) 20 tpm 5-3-2013 IVFD Metronidazol 3 x 500gram Inj. Ceftriaxon 2 x 1gram Lasix 1 x1 (1-0-0) P Po. Asam folat 3 x 1 Hepa Q 2 x 1 Betahistin 3 x 1 Pletal 2 x 50mg Analsik 3 x 1 6-3-2013 S Dressing luka dgn Nacl + betadin 2x sehari Sesak (-) Demam (-) Nyeri perut (<) Mual/muntah (-/-) Ma/mi (</+) pucat (+)

Tangan nyeri (<) sariawan (+) TD = 110/80 mmHg RR = 20 x/

N = 80 x/ T = 36C A ARF + HF + ulkus manus P IVFD RL:D5 (1:1) 20 tpm IVFD Metronidazol 3 x 500gram Inj. Ceftriaxon 2 x 1gram Po. Asam folat 3 x 1
38

Hepa Q 2 x 1 Pletal 2 x 50mg Analsik 3 x 1 Dressing luka dgn Nacl + betadin 2x sehari Sesak (-) Demam (-) sariawan (+) S Nyeri perut (<) Mual/muntah (+/-) Tangan nyeri (<) TD = 110/80 mmHg Ma/mi (</+) pucat (+) pusing (+) RR = 20 x/

N = 80 x/ T = 36C A ARF + HF + ulkus manus IVFD RL:D5 (1:1) 20 tpm 7-3-2013 IVFD Metronidazol 3 x 500gram Inj. Ceftriaxon 2 x 1gram Po. Asam folat 1 x 1 P Hepa Q 2 x 1 Pletal 2 x 50mg Analsik 3 x 1 Tetes mulut. Candistatin 4 gtt 2 8-3-2013 S Dressing luka dgn Nacl + betadin 2x sehari Sesak (-) Demam (-) sariawan (<) Nyeri perut (-) Mual/muntah (-/-) Tangan nyeri (<) TD = 100/60 mmHg Ma/mi (</+) pucat (-) pusing (<) RR = 21 x/

N = 75 x/ T = 36,5C A ARF + HF + ulkus manus P IVFD RL:D5 (1:1) 20 tpm IVFD Metronidazol 3 x 500gram Inj. Ceftriaxon 2 x 1gram Po. Asam folat 1 x 1 Hepa Q 2 x 1 Pletal 2 x 50mg
39

Analsik 3 x 1 Tetes mulut. Candistatin 4 gtt 2 Dressing luka dgn Nacl + betadin 2x sehari Sesak (-) Demam (-) sariawan (<) S Nyeri perut (-) Mual/muntah (-/-) Tangan nyeri (<) TD = 90/50 mmHg Ma/mi (</+) pucat (-) pusing (-) RR = 23 x/

N = 85 x/ T = 36,5C A ARF + HF + ulkus manus IVFD RL:D5 (1:1) 20 tpm IVFD Metronidazol 3 x 500gram sesuai kultur : inj. meropenem 2x1 Inj. Ceftriaxon 2 x 1gram Po. Asam folat 1 x 1 9-3-2013 P Hepa Q 2 x 1 Pletal 2 x 50mg Analsik 3 x 1 Tetes mulut. Candistatin 4 gtt 2 Dressing luka dgn Nacl + betadin 2x sehari Pasien pulang atas permintaan sendiri

40