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  • Daily Follow Up Notes for Bronchopneumonia Patient

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    Abdul Aziz Azhari Azizi
    12 views6 pages
    1. The document describes a 5-day follow up report for a patient being treated for bronchopneumonia. Over the 5 days, the patient's symptoms of coughing and wheezing improved while vital signs like heart rate and respiratory rate decreased. 2. The patient was given oxygen therapy, IV fluids, antibiotics including ampicillin and gentamicin, and cough medication including ambroxol syrup. 3. On the fifth day, the patient's cough had decreased and wheezing persisted while examination findings were otherwise unchanged from prior days. The treatment plan continued as before.

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    Follow Up Harian

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    1. The document describes a 5-day follow up report for a patient being treated for bronchopneumonia. Over the 5 days, the patient's symptoms of coughing and wheezing improved while vital signs like heart rate and respiratory rate decreased. 2. The patient was given oxygen therapy, IV fluids, antibiotics including ampicillin and gentamicin, and cough medication including ambroxol syrup. 3. On the fifth day, the patient's cough had decreased and wheezing persisted while examination findings were otherwise unchanged from prior days. The treatment plan continued as before.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    12 views6 pages

    Daily Follow Up Notes for Bronchopneumonia Patient

    Uploaded by

    Abdul Aziz Azhari Azizi
    1. The document describes a 5-day follow up report for a patient being treated for bronchopneumonia. Over the 5 days, the patient's symptoms of coughing and wheezing improved while vital signs like heart rate and respiratory rate decreased. 2. The patient was given oxygen therapy, IV fluids, antibiotics including ampicillin and gentamicin, and cough medication including ambroxol syrup. 3. On the fifth day, the patient's cough had decreased and wheezing persisted while examination findings were otherwise unchanged from prior days. The treatment plan continued as before.

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    © All Rights Reserved
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    of 6

    1

    2.10 FOLLOW UP HARIAN


    Tanggal/hari
    rawatan
    Catatan Instruksi
    22-04-2014
    H-1
    S/ sesak (+), batuk berdahak (+)
    O/ VS/HR = 138 x/menit
    RR = 48 x/menit
    T = 37,7
    o
    C
    Pf/
    Kepala : normocephali,
    Mata : konj.palp.inf pucat (-/-)
    Sklera ikterik (-/-)
    Telinga: normotia, sekret (-)
    Hidung: NCH (+), sekret (-)
    Mulut: mukosa basah, sianosis (-)
    Leher : pemb. KGB (-)
    Thoraks: simetris, retraksi (-), ves (+/+),
    Rh (+/+), Wh (-/-), stridor (+/+)
    Cor : BJ I>BJ II, reg, bising (-)
    Abdomen: soepel, H/L/R tidak teraba,
    timpani (+), peristaltik (+), bising usus
    (-)
    Ektremitas :
    Th /
    O
    2
    nasal 2 liter/i
    nebule NaCL 2cc/6jam

    2

    -Superior : pucat (-/-) edema (-/-)
    -Inferior : pucat (-/-) edema (-/-)

    Ass/ Bronkopneumonia
    02-03-2013
    H-2
    S/ sesak nafas (+), Batuk (+)
    O/ VS/HR = 125 x/menit
    RR = 49 x/menit
    T = 36,1
    o
    C
    Pf/
    Kepala : normocephali,
    Mata : konj.palp.inf pucat (-/-)
    Sklera ikterik (-/-)
    Telinga: normotia, sekret (-)
    Hidung: NCH (+), sekret (-)
    Mulut: mukosa basah, sianosi (-)
    Leher : pemb. KGB (-)
    Thoraks: simetris, retraksi (+), ves
    (+/+), Rh (+/+), Wh (-/-),stridor (+/+)
    Cor : BJ I>BJ II, reg, bising (-)
    Abdomen: soepel, H/L/R tidak teraba,
    timpani (+), peristaltik (+), bising usus
    (-)
    Th /
    O
    2
    1-3 liter/i
    Nebule NaCL 2cc/6jam
    Ambroxol syr 3dd 1/2cth
    Ampisilin 75mg/8jam
    Gentamicin 25mg/12jam

    3

    Ektremitas :
    -Superior : pucat (-/-) edema (-/-)
    -Inferior : pucat (-/-) edema (-/-)

    Ass/ Bronkopneumonia
    03-03-2013
    H-3
    S/batuk (+), beringus (+)
    O/ VS/HR = 128 x/menit
    RR = 47 x/menit
    T = 36,2
    o
    C
    Pf/
    Kepala : normocephali,
    Mata : konj.palp.inf pucat (-/-)
    Sklera ikterik (-/-)
    Telinga: normotia, sekret (-)
    Hidung: NCH (+), sekret (-)
    Mulut: mukosa basah, sianosi (-)
    Leher : pemb. KGB (-)
    Thoraks: simetris, retraksi (+), ves
    (+/+), Rh (+/+), Wh (-/-), Stridor (+/+)
    Cor : BJ I>BJ II, reg, bising (-)
    Abdomen: soepel, H/L/R tidak teraba,
    timpani (+), peristaltik (+), bising usus
    Th/
    O
    2
    1-3 liter/i
    Nebule NaCL 2cc/6jam
    Ambroxol syr 3dd 1/2cth
    Ampisilin 75mg/8jam
    Gentamicin 25mg/12jam




    P/


    4

    (+)
    Ektremitas :
    -Superior : pucat (-/-) edema (-/-)
    -Inferior : pucat (-/-) edema (-/-)

    Ass/ Bronkopneumonia
    04-03-2013
    H-4
    S/ batuk(+), beringus (+)
    O/ VS/HR = 130 x/menit
    RR = 43 x/menit
    T = 36,3
    o
    C
    Pf/
    Kepala : normocephali,
    Mata : konj.palp.inf pucat (-/-)
    Sklera ikterik (-/-)
    Telinga: normotia, sekret (-)
    Hidung: NCH (+), sekret (-)
    Mulut: mukosa basah, sianosi (-)
    Leher : pemb. KGB (-)
    Thoraks: simetris, retraksi (-), ves (+/+),
    Rh (+/+), Wh (-/-), stridor (+/+)
    Cor : BJ I>BJ II, reg, bising (-)
    Th/
    O
    2
    1-3 liter/i
    Nebule NaCL 2cc/6jam
    Ambroxol syr 3dd 1/2cth
    Ampisilin 75mg/8jam
    Gentamicin 25mg/12jam

    5

    Abdomen: soepel, H/L/R tidak teraba,
    timpani (+), peristaltik (+), bising usus
    (-)
    Ektremitas :
    -Superior : pucat (-/-) edema (-/-)
    -Inferior : pucat (-/-) edema (-/-)

    Ass/ Bronkopneumonia
    05-03- 2013
    H-5
    S/batuk berkurang, beringus (+)
    O/ VS/HR = 134 x/menit
    RR = 39 x/menit
    T = 36,4
    o
    C
    Pf/
    Kepala : normocephali,
    Mata : konj.palp.inf pucat (-/-)
    Sklera ikterik (-/-)
    Telinga: normotia, sekret (-)
    Hidung: NCH (-), sekret (-)
    Mulut: mukosa basah, sianosi (-)
    Leher : pemb. KGB (-)
    Thoraks: simetris, retraksi (-), ves (+/+),
    Rh (+/+), Wh (-/-),Stridor (+/+)
    Th /
    O
    2
    1-3 liter/i
    Nebule NaCL 2cc/6jam
    Ambroxol syr 3dd 1/2cth
    Ampisilin 75mg/8jam
    Gentamicin 25mg/12jam

    6

    Cor : BJ I>BJ II, reg, bising (-)
    Abdomen: soepel, H/L/R tidak teraba,
    timpani (+), peristaltik (+), bising usus
    (-)
    Ektremitas :
    -Superior : pucat (-/-) edema (-/-)
    -Inferior : pucat (-/-) edema (-/-)

    Ass/ Bronkopneumonia

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