Subyektif Obyektif Assestment Planning

Diagnosis Terapi
05/06/2015 05.00 Dispepsia SGOT/SGPT Infus Hydromal:PZ
-nyeri ulu hati dan perut Tensi 100/70 mmHg; Hepatitis virus Akut (1:2)
kanan atas suhu 36.0°C; Nadi 80 Inj. Tomid 3x1 amp
-demam (-) x/mnt; RR 24 x/mnt; GCS Braxidin 3x 1 tab
-mual (+) muntah (-) 456 Antacid 3x1 C
12.00 Pantoprazole 2x1
Tensi 110/70 mmHg; amp
suhu 36.0°C; Nadi 86
x/mnt
17.00
Tensi 120/70 mmHg;
suhu 36.0°C; Nadi 84
x/mnt

06/06/2015 05.00 Dispepsia - Infus Hydromal:PZ

-nyeri ulu hati Tensi 110/80 mmHg; Hepatitis virus akut (1:2)
-demam (-) suhu 36.0°C; Nadi 82 Inj. Tomid 3x1 amp
-mual (+) muntah (-) x/mnt Braxidin 3x 1 tab
12.00 Antacid 3x1 C
Tensi 100/70 mmHg; Pantoprazole 2x1
suhu 36.7°C; Nadi 82 amp
x/mnt
Lab:
SGOT 158
SGPT 327

07/06/2015 05.00 Dispepsia IgM anti HAV Infus Hydromal:PZ

- nyeri ulu hati Tensi 120/80 mmHg; Hepatitis Virus Akut (1:2)
-demam (-) suhu 36.0°C; Nadi 84 Inj. Tomid 3x1 amp
-mual (+) muntah (-) x/mnt Braxidin 3x 1 tab
12.00 Antacid 3x1 C
Tensi 110/70 mmHg; Pantoprazole 2x1
suhu 36.0°C; Nadi 80 amp
x/mnt Buscopan 1x1 amp
17.00
Tensi 140/80 mmHg;
suhu 36.7°C; Nadi 80
x/mnt

08/06/2015 05.00 Hepatitis virus akut - Infus Hydromal:PZ

- nyeri ulu hati Tensi 120/80 mmHg; (1:2)
-demam (-) suhu 36.0°C; Nadi 84 Inj. Tomid 3x1 amp
-mual (+) muntah (3x) isi x/mnt Braxidin 3x 1 tab
makanan Antacid 3x1 C
 12.00 Pantoprazole 2x1
Tensi 120/70 mmHg; amp
suhu 36.2°C; Nadi 80 Buscopan 1x1 amp
x/mnt
Lab:
IgM anti HAV (-) titer
0,01

09/06/2015 05.00 Hepatitis virus akut - -

-nyeri ulu hati (-) Tensi 110/80 mmHg;
-mual (-) muntah (-) suhu 34.1°C; Nadi 100 ACC KRS
-BAK lancar warna x/mnt; RR 26 x/mnt
kuning