Follow Up Pasien

Tanggal 28/07/2017:
Subjective Objective Assesment Planning
Mual (+) KU: Cukup Intoksikasi IVFD RL 20 tpm
Muntah (+)
GCS: 456 Paracetamol Inj.Omeprazole 1 x 1
sedikit o
Tax: 36,4 C amp
Nyeri perut (-)
RR 20x/menit PO. N-Acetylcysteine
Nadi: 88x/menit Maintenance dose:
TD: 100/60 mmHg 14 caps/4jam
K/L: Konjungtiva Anemis (-), OT/PT Serial / 24 jam
Sclera Icteric (-)
suara nafas vesikuler di semua area
Ronkhi - | - wheezing - | -
-|- -|-
-|- -|-
Abd: flat, soefl, BU (+) N
Extrimitas: akral hangat, edema - |
-, anemia - | -, maculopapular
rash (-), turgor normal, vulnus
ekskoriatum antebrachii sinistra

Tanggal 29/07/2017:
Subjective Objective Assesment Planning
Mual (+) KU: Cukup Post- IVFD RL 20 tpm
Muntah (-)
GCS: 456 intoksikasi Inj.Omeprazole 1 x 1
Nyeri perut (-)
Tax: 36,3oC Parasetamol amp
RR 20x/menit PO. N-Acetylcysteine
Nadi: 82x/menit Maintenance dose:
Kimia Klinik
TD: 100/60 mmHg 14 caps/4jam
SGOT: 27 u/l
SGPT: 33 u/l
K/L: Konjungtiva Anemis (-), OT/PT Serial / 24 jam
Sclera Icteric (-)
suara nafas vesikuler di semua area
Ronkhi - | - wheezing - | -
-|- -|-
-|- -|-

1
Abd: flat, soefl, BU (+) N
Extrimitas: akral hangat, edema - |
-, anemia - | -, maculopapular rash
(-), turgor normal, vulnus
ekskoriatum antebrachii sinistra