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  • Follow Up

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    Fakhrur Razi
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    The patient was admitted to the hospital from September 11-19, 2016 due to shortness of breath and cough. During this time, the patient was treated for suspected pericardial effusion and tuberculosis of the lungs. The patient's condition improved with bed rest, oxygen supplementation, IV fluids, antibiotics and steroids. Echocardiography was recommended to further evaluate the suspected pericardial effusion.

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    The patient was admitted to the hospital from September 11-19, 2016 due to shortness of breath and cough. During this time, the patient was treated for suspected pericardial effusion and tuberculosis of the lungs. The patient's condition improved with bed rest, oxygen supplementation, IV fluids, antibiotics and steroids. Echocardiography was recommended to further evaluate the suspected pericardial effusion.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    17 views5 pages

    Follow Up

    Uploaded by

    Fakhrur Razi
    The patient was admitted to the hospital from September 11-19, 2016 due to shortness of breath and cough. During this time, the patient was treated for suspected pericardial effusion and tuberculosis of the lungs. The patient's condition improved with bed rest, oxygen supplementation, IV fluids, antibiotics and steroids. Echocardiography was recommended to further evaluate the suspected pericardial effusion.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    of 5

    Tanggal S O A P

    11-9-
    2016

    12-09- Sesak Nafas Sens: CM  Efusi  Bed rest


    2016 (+), batuk TD: 100/60 perikard ec  O2 2-4 L/i
    (+) mmHg susp TB  IVFD NaCl
    HR: 60x/i paru 0,9% 10 gtt/i
    RR: 36x/i mikro
     PCT 3x500 mg
    Mata: anemis  Nebule Ventolin
    (+/+), ikterik (- 2,5 mg/8 jam
    /-)  Metilprednisolon
    Leher: TVJ e 4x8 mg
    R+2 cmH2O
     Kombinasi OAT
    Thorax:
    7 tab ac pagi
    -Cor: S1, S2
     B6 2x1
    (+), gallop (-),
    murmur (-)  Domperidone
    3x10 mg
    -Pulmo:
    SP:Vesikuler,  Inj. Transamine
    ST: ronki (+/+) 1 amp/hari
    Abdomen:  Inj. Vit. K 1
    soepel, BU (+) amp/hari
    Extremitas:  Levofloxacin
    edema pretibial 1x500 mg tab
    (-/-)  Tapping cairan
    pericard/12 jam
    13-9- Sesak Nafas Sens: CM  Efusi  Bed rest
    2016 (+), batuk TD: 100/60 perikard ec  O2 2-4 L/i
    (+) mmHg susp TB  IVFD NaCl
    HR: 60x/i paru 0,9% 10 gtt/i
    RR: 36x/i mikro
     PCT 3x500 mg
    Mata: anemis  Nebule Ventolin
    (+/+), ikterik (- 2,5 mg/8 jam
    /-)  Metilprednisolon
    Leher: TVJ e 4x8 mg
    R+2 cmH2O
     Kombinasi OAT
    Thorax: 7 tab ac pagi
    -Cor: S1, S2
     B6 2x1
    (+), gallop (-),
     Domperidone
    murmur (-)
    3x10 mg
    -Pulmo:
    SP:Vesikuler,  Inj. Transamine
    ST: ronki (+/+) 1 amp/hari
    Abdomen:  Inj. Vit. K 1
    soepel, BU (+) amp/hari
    Extremitas:  Levofloxacin
    edema pretibial 1x500 mg tab
    (-/-)  Tapping cairan
    pericard/12 jam
    14-9- Sesak Nafas Sens: CM  Efusi  Bed rest
    2016 (+), batuk TD: 105/55 perikard ec  O2 2-4 L/i
    (+) mmHg susp TB  IVFD NaCl
    HR: 88x/i paru 0,9% 10 gtt/i
    RR: 24x/i mikro
     Metilprednisolon
    Mata: anemis e 3x8 mg
    (+/+), ikterik (-  Kombinasi OAT
    /-) 7 tab ac pagi
    Leher: TVJ  B6 2x1
    R+2 cmH2O
     Domperidone
    Thorax: 3x10 mg
    -Cor: S1, S2
     Transamine
    (+), gallop (-),
    3x500 mg tab
    murmur (-)
     Levofloxacin
    -Pulmo:
    1x500 mg tab
    SP:Vesikuler,
    ST: ronki (+/+)  Tapping cairan
    Abdomen: pericard/12 jam
    soepel, BU (+)
    Extremitas: R/ Konsul HOM
    edema pretibial dan PTI
    (-/-)
    15-9- Sesak Nafas Sens: CM  Efusi  Bed rest
    2016 (+), batuk TD: 110/60 perikard ec  O2 2-4 L/i
    (+) mmHg susp TB  IVFD NaCl
    HR: 88x/i paru 0,9% 10 gtt/i
    RR: 24x/i mikro
     Metilprednisolon
    Mata: anemis e 3x8 mg
    (+/+), ikterik (-  Kombinasi OAT
    /-) 7 tab ac pagi
    Leher: TVJ  B6 2x1
    R+2 cmH2O
     Domperidone
    Thorax: 3x10 mg
    -Cor: S1, S2
     Transamine
    (+), gallop (-),
    3x500 mg tab
    murmur (-)
     Levofloxacin
    1x500 mg tab
    -Pulmo:  Tapping cairan
    SP:Vesikuler, pericard/12 jam
    ST: ronki (+/+)  Koreksi 2 fls
    Abdomen: NaCl 3% habis
    soepel, BU (+) dalam 48 jam
    Extremitas:  Koreksi albumin
    edema pretibial 3 fls, 1 fls /hari
    (-/-)
    16-9- Sesak Nafas Sens: CM  Efusi  Bed rest
    2016 (+), batuk TD: 90/60 perikard ec  O2 2-4 L/i
    (+) mmHg susp TB  IVFD NaCl
    HR: 88x/i paru 0,9% 10 gtt/i
    RR: 24x/i mikro
     Metilprednisolon
    Mata: anemis e 3x8 mg
    (+/+), ikterik (-  Kombinasi OAT
    /-) 7 tab ac pagi
    Leher: TVJ  B6 2x1
    R+2 cmH2O
     Domperidone
    Thorax: 3x10 mg
    -Cor: S1, S2
     Transamine
    (+), gallop (-),
    3x500 mg tab
    murmur (-)
    -Pulmo:  Levofloxacin
    1x500 mg tab
    SP:Vesikuler,
    ST: ronki (+/+)  Tapping cairan
    Abdomen: pericard/12 jam
    soepel, BU (+)  Koreksi 2 fls
    Extremitas: NaCl 3% habis
    edema pretibial dalam 48 jam
    (-/-)  Koreksi albumin
    3 fls, 1 fls /hari

    R/
    Echocardiography
    19-9- Sesak Nafas Sens: CM  Efusi  Bed rest
    2016 (+), batuk TD: 110/60 perikard ec  O2 2-4 L/i
    (+) mmHg susp TB  IVFD NaCl
    HR: 120x/i paru 0,9% 10 gtt/i
    RR: 30x/i  Anemia ec mikro
    penyakit  Metilprednisolon
    Mata: anemis kronis e 3x8 mg
    (+/+), ikterik (-  OAT RHZE
    /-) 600/400/1500/10
    Leher: TVJ 00
    R+2 cmH2O
    Thorax:
    -Cor: S1, S2  Inj. Amikacin
    (+), gallop (-), 500 mg/8 jam IV
    murmur (-)  Levofloxacin
    -Pulmo: 1x500 mg tab
    SP:Vesikuler,  B6 2x1
    ST: ronki (+/+)  Domperidone
    Abdomen: 3x10 mg
    soepel, BU (+)
    Extremitas: R/ cek lab ulang
    edema pretibial Darah Rutin, SI,
    (-/-) TIBC, Ferritin,
    Coomb test, Hb
    elektroforesis,
    RFT, LFT
    20-9- Sesak Nafas Sens: CM  Efusi  Bed rest
    2016 (+), batuk TD: 110/70 perikard ec  O2 2-4 L/i
    (+) mmHg susp TB  IVFD NaCl
    HR: 60x/i paru 0,9% 10 gtt/i
    RR: 18x/i  Anemia ec mikro
    penyakit  Metilprednisolon
    Mata: anemis kronis e 3x8 mg
    (+/+), ikterik (-  OAT RHZE
    /-) 600/400/1500/10
    Leher: TVJ 00
    R+2 cmH2O  Inj Amikacin
    Thorax: 500 mg/ 8 jam
    -Cor: S1, S2 IV
    (+), gallop (-),
     Levofloxacin
    murmur (-) 1x500 mg tab
    -Pulmo:
     B6 2x1
    SP:Vesikuler,
     Domperidone
    ST: ronki (+/+)
    3x10 mg
    Abdomen:
    soepel, BU (+)  Transamine
    Extremitas: 3x500 mg tab
    edema pretibial
    (-/-) R/ pemberian
    Eritropoietin 1000
    IU/minggu selama
    4 minggu
    21-9- Sesak Nafas Sens: CM  Efusi  Bed rest
    2016 (+), batuk TD: 110/70 perikard ec  O2 2-4 L/i
    (+) mmHg susp TB  IVFD NaCl
    HR: 68x/i paru 0,9% 10 gtt/i
    RR: 20x/i mikro
    Mata: anemis  Anemia ec  Metilprednisolon
    (+/+), ikterik (- penyakit e 3x8 mg
    /-) kronis  OAT RHZE
    Leher: TVJ 600/400/1500/10
    R+2 cmH2O 00
    Thorax:  Inj Amikacin
    -Cor: S1,S2 (+), 500 mg/ 8 jam
    gallop (-), IV
    murmur (-)  Levofloxacin
    -Pulmo: 1x500 mg tab
    SP:Vesikuler,  Transamine
    ST: ronki (+/+) 3x500 mg tab
    Abdomen:  Codein 3x10 mg
    soepel, BU(+)
     B6 1x1
    Extremitas:
     Domperidone
    edema pretibial
    3x10 mg
    (-/-)

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