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  • 6H05 - Bpk. Saminan - 80 Tahun-602768 TGL Msuk Rs 26/09/18

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    zaskia
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    1. Bpk. Saminan, 80 years old, was admitted on 26/09/18 for EKG abnormalities, Hb 7, and other lab results. He is on drip lansoprazole and IV fluids. His thorax is clear and he is tolerating a diet. Further follow up and labs are needed. 2. Ibu Linur sigalingging, 63 years old, was admitted on 26/09/18. She appears sick and her vital signs and exams will be documented. Her labs, urine output and fluid balance are pending. She is being treated for dehydration, vomiting, and CAD with IV antibiotics, antacids and IV fluids for rehydration.

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    contoh follow up

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    follow up

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    1. Bpk. Saminan, 80 years old, was admitted on 26/09/18 for EKG abnormalities, Hb 7, and other lab results. He is on drip lansoprazole and IV fluids. His thorax is clear and he is tolerating a diet. Further follow up and labs are needed. 2. Ibu Linur sigalingging, 63 years old, was admitted on 26/09/18. She appears sick and her vital signs and exams will be documented. Her labs, urine output and fluid balance are pending. She is being treated for dehydration, vomiting, and CAD with IV antibiotics, antacids and IV fluids for rehydration.

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    11 views2 pages

    6H05 - Bpk. Saminan - 80 Tahun-602768 TGL Msuk Rs 26/09/18

    Uploaded by

    zaskia
    1. Bpk. Saminan, 80 years old, was admitted on 26/09/18 for EKG abnormalities, Hb 7, and other lab results. He is on drip lansoprazole and IV fluids. His thorax is clear and he is tolerating a diet. Further follow up and labs are needed. 2. Ibu Linur sigalingging, 63 years old, was admitted on 26/09/18. She appears sick and her vital signs and exams will be documented. Her labs, urine output and fluid balance are pending. She is being treated for dehydration, vomiting, and CAD with IV antibiotics, antacids and IV fluids for rehydration.

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    of 2

    FOLLOW UP PASIEN : JUMAT 28 SEPTEMBER 2018

    1. 6H05 – Bpk. Saminan – 80 tahun- 602768 tgl msuk rs 26/09/18


    - EKG (+) Lab 26/9
    - Hb 7, ht 21, rbu 2.4 wbc 16, ur 135, cr 2.2 trop T 39, K 5.1
    - Thorax dbn
    - LINE 1 : drip lansoprazole 6mg / jam
    - Line 2 : NS 500/12 jam, NGT no 16 (26/09)
    - Post PRC 1 bag 26/9
    - Th/ lansoprazole 6mg/jam mem0 (+) BO acc 2 hari 26-27/9/18
    - Spuling NG jk jernih aff NGT diet nasi tim
    - F/U lab
    S:

    O: KU tampak sakit ____, GCS E_ M_ V_


    TD: ______ mmHg, HR: ___ x/ mnt, RR:__ x/mnt , temp: ____ C
    Mata : KP ___, SI ____
    Mulut: sianosis ___, mukosa lembab __, lidah kering__
    Hidung:
    Leher: meningkat JVP ____, pembesaran KGB
    Thorax : VBS ___ , Rh ____ , Whz ___ , s1s2 reg , mitral (-) gallop (-)
    Abd: datar , supel, distensi (-) asites (-) nyeri tekan __ pada light/deep palpation di region
    kuadran______
    eks: akral hangat, edema (-) , CRT <2 dtk
    Hasil FBC, bil, op/pt ur cr ada/blm ada hasil
    Urin output ____ml/ ___ kam
    Balance : ____ / 24 jam

    Others:

    A: hemel ec ulkus peptikum ec susp NSAID

    P: lansoprazole IV 6mg / jam


    Sucralfate PO 3x1
    Ceftriaxone IV 2gr 1x1
    FOLLOW UP PASIEN : JUMAT 28 SEPTEMBER 2018
    2. 6H01 – ibu Linur sigalingging – 63 thn – 825735  tgl masuk 26/09

    S:

    O: KU tampak sakit ____, GCS E_ M_ V_


    TD: ______ mmHg, HR: ___ x/ mnt, RR:__ x/mnt , temp: ____ C
    Mata : KP ___, SI ____
    Mulut: sianosis ___, mukosa lembab __, lidah kering__
    Hidung:
    Leher: meningkat JVP ____, pembesaran KGB
    Thorax : VBS ___ , Rh ____ , Whz ___ , s1s2 reg , mitral (-) gallop (-)
    Abd: datar , supel, distensi (-) asites (-) nyeri tekan __ pada light/deep palpation di region
    kuadran______
    eks: akral hangat, edema (-) , CRT <2 dtk
    Hasil FBC, bil, op/pt ur cr ada/blm ada hasil
    Urin output ____ml/ ___ kam
    Balance : ____ / 24 jam

    Others:

    A: dehidrasi, vomitus, CAD

    P: metoclopramide IV 10mg 3x1


    Omeprazole IV 40 mg 2x1
    Ceftriaxone IV 2gr 1x1
    PCT PO 500 mg 3x1
    Rehidrasi  NS

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