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    28 April 2019: Bab Iv Follow Up

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    preveenna
    The document details the follow up of a patient presenting with right lower abdominal pain. Initial examination found the patient to have compos mentis sensorium and stable hemodynamics, with an assessment of acute appendicitis. Treatment included IV fluids, NGT, urinary catheter, antibiotics including ceftriaxone and ketorolac, and a planned appendectomy. Follow up notes on subsequent days show the patient's pain reducing after the appendectomy, with stable vital signs and continuing antibiotic treatment until discharge on May 1st.

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    Download as DOC, PDF, TXT or read online from Scribd

    28 April 2019: Bab Iv Follow Up

    Uploaded by

    preveenna
    18 views3 pages
    The document details the follow up of a patient presenting with right lower abdominal pain. Initial examination found the patient to have compos mentis sensorium and stable hemodynamics, with an assessment of acute appendicitis. Treatment included IV fluids, NGT, urinary catheter, antibiotics including ceftriaxone and ketorolac, and a planned appendectomy. Follow up notes on subsequent days show the patient's pain reducing after the appendectomy, with stable vital signs and continuing antibiotic treatment until discharge on May 1st.

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    Follow up

    Original Title

    Follow up

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    The document details the follow up of a patient presenting with right lower abdominal pain. Initial examination found the patient to have compos mentis sensorium and stable hemodynamics, with an assessment of acute appendicitis. Treatment included IV fluids, NGT, urinary catheter, antibiotics including ceftriaxone and ketorolac, and a planned appendectomy. Follow up notes on subsequent days show the patient's pain reducing after the appendectomy, with stable vital signs and continuing antibiotic treatment until discharge on May 1st.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    18 views3 pages

    28 April 2019: Bab Iv Follow Up

    Uploaded by

    preveenna
    The document details the follow up of a patient presenting with right lower abdominal pain. Initial examination found the patient to have compos mentis sensorium and stable hemodynamics, with an assessment of acute appendicitis. Treatment included IV fluids, NGT, urinary catheter, antibiotics including ceftriaxone and ketorolac, and a planned appendectomy. Follow up notes on subsequent days show the patient's pain reducing after the appendectomy, with stable vital signs and continuing antibiotic treatment until discharge on May 1st.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    of 3

    BAB IV

    FOLLOW UP

    28 April 2019

    S Nyeri perut kanan bawah

    O Sensorium : Compos Mentis


    Hemodinamik : Stabil

    A Appendisitis akut

    P IVFD RL 30 gtt/i
    Pasang NGT  keluar cairan jernih 30 cc
    Pasang kateter urin  keluar inisial urin 300cc, UOP 60
    cc/jam (180 cc/3jam)
    Inj. Ceftriaxone 1g/12 jam/IV
    Inj. Ketorolac 1 amp/8 jam/IV
    Rencana : Appendectomy

    Hasil lab 28/04/2019

    Hasil Rujukan

    Hematologi

    Hemoglobin 15,4 13-18

    Hematokrit 44,50 39-54

    Leukosit 16,80 4,000-11,000

    Trombosit 316,000 150,000-450,000


    Neutrofil Segmen 85,3 50-70

    Elektrolit

    Natrium 136 135-155


    Hasil lab 28/04/2019

    Kalium 3,80 3.6-5.5

    Chlorida 97 96-106

    KGDs 103 <200

    29 April 2019

    S Nyeri post operasi

    O Sensorium : Compos Mentis


    Hemodinamik : Stabil

    A Post Appendectomy

    P IVFD RL 30 gtt/i
    Inj. Ceftriaxone 1g/12 jam/IV
    Inj. Ketorolac 1 amp/8 jam/IV
    Inj. Metronidazol 500 mg /8 jam
    Gentamisin 80 mg /12 jam

    30 April 2019

    S Nyeri berkurang , demam (-)

    O Sensorium : Compos Mentis


    Hemodinamik : Stabil

    A Post appendectomy

    P IVFD RL 30 gtt/i
    Inj. Ceftriaxone 1g/12 jam/IV
    Inj. Ketorolac 1 amp/8 jam/IV
    30 April 2019

    Inj. Metronidazol 500 mg /8 jam


    Gentamisin 80 mg /12 jam

    01 Mei 2019

    S Nyeri berkurang

    O Sensorium : Compos Mentis


    Hemodinamik : Stabil

    A Post appendectomy

    P IVFD RL 30 gtt/i
    Inj. Ceftriaxone 1g/12 jam/IV
    Inj. Ketorolac 1 amp/8 jam/IV
    Inj. Metronidazol 500 mg /8 jam
    Gentamisin 80 mg /12 jam

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