Follow Up

Hari/ Tanggal S O A P
HP-1 Nyeri dada TD : 92/71 CHF IVFD RL 12
13/03/2019 menjalar hingga mmHg RBBB tpm
tangan kiri N : 80 x/menit MS Inj Furosemid
Keringat dingin RR : 22 x/menit MR 3x1 A
Mual T : 36 Susp. Inj Ranitidin
Pneumonia 2x1 A
Inj Ceftriaxone
2x1 gr
PO ISDN 3x5
mg
PO Aspilet 1x1
tab
PO NAC 3x1
caps
PO PCT 4x1
tab
PO
Spironolacton
1x12,5 mg
HP-2 Masih nyeri TD : 90/70 CHF IVFD RL 12
14/03/2019 dada mmHg RBBB tpm
Keringat dingin N : 76 x/menit MS Inj Furosemid
Mual (-) RR : 22 x/menit MR 3x1 A
T : 36 Susp. Inj Ranitidin
Pneumonia 2x1 A
Inj Ceftriaxone
2x1 gr
PO ISDN 3x5
mg
PO Aspilet 1x1
tab
PO NAC 3x1
caps
PO PCT 4x1
tab
PO
Spironolacton
1x12,5 mg
HP-3 Nyeri dada TD : 90/68 CHF IVFD RL 12
15/03/2019 menjalar hingga mmHg RBBB tpm
tangan kiri N : 86 x/menit MS Inj Furosemid
berkurang RR : 22 x/menit MR 3x1 A
Keringat dingin T : 36 Susp. Inj Ranitidin
(-) Pneumonia 2x1 A
Mual (-) Inj Ceftriaxone
Batuk jarang 2x1 gr
 PO ISDN 3x5
mg
PO Aspilet 1x1
tab
PO NAC 3x1
caps
PO PCT 4x1
tab
PO
Spironolacton
1x12,5 mg
HP-4 Nyeri dada TD : 100/60 CHF IVFD RL 12
16/03/2019 menjalar hingga mmHg RBBB tpm
tangan kiri N : 55 x/menit MS Inj Furosemid
berkurang RR : 20 x/menit MR 3x1 A
Keringat dingin T : 36,7 Susp. Inj Ranitidin
(-) Pneumonia 2x1 A
Mual (-) Inj Ceftriaxone
Batuk jarang 2x1 gr
PO ISDN 3x5
mg
PO Aspilet 1x1
tab
PO NAC 3x1
caps
PO PCT 4x1
tab
PO
Spironolacton
1x12,5 mg
BLPL