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  • Follow Up Simple

    Загружено:

    Annisa Putri
    8 просмотров1 страница
    The patient presented with fever, rash, and shortness of breath on the first day, and experienced improved symptoms on subsequent days. On examination, the patient appeared ill but alert, with a temperature of 37.9°C, pulse of 124 beats/min, respiratory rate of 32 breaths/min, and oxygen saturation of 99% on 2L nasal cannula. Physical exam found no abnormalities of the head, eyes, nose, mouth, ears, neck, chest, or heart. The patient's condition improved over the next two days with decreasing fever and symptoms.

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    The patient presented with fever, rash, and shortness of breath on the first day, and experienced improved symptoms on subsequent days. On examination, the patient appeared ill but alert, with a temperature of 37.9°C, pulse of 124 beats/min, respiratory rate of 32 breaths/min, and oxygen saturation of 99% on 2L nasal cannula. Physical exam found no abnormalities of the head, eyes, nose, mouth, ears, neck, chest, or heart. The patient's condition improved over the next two days with decreasing fever and symptoms.

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    8 просмотров1 страница

    Follow Up Simple

    Загружено:

    Annisa Putri
    The patient presented with fever, rash, and shortness of breath on the first day, and experienced improved symptoms on subsequent days. On examination, the patient appeared ill but alert, with a temperature of 37.9°C, pulse of 124 beats/min, respiratory rate of 32 breaths/min, and oxygen saturation of 99% on 2L nasal cannula. Physical exam found no abnormalities of the head, eyes, nose, mouth, ears, neck, chest, or heart. The patient's condition improved over the next two days with decreasing fever and symptoms.

    Авторское право:

    © All Rights Reserved
    Скачайте в формате DOCX, PDF, TXT или читайте онлайн в Scribd
    Отметить как неприемлемый контент
    из 1

    Keluhan (S)

    Sabtu, 08-10-2016
    Minggu. 09-10-2016
    Hari ke-1 :
    Hari ke-2:
    - Demam (+)
    - Sesak (+)
    - Ruam merah (+) - Batuk (+)
    - Demam (-)
    di wajah,dada,
    - Tidur nyenyak
    kaki

    KeadaanUmu KU: gelisah, tampak


    m (KU)
    sakit sedang
    Kesadaran : Compos
    Kesadaran
    mentis
    Tanda Vital
    Tanda Vital
    Suhu: 37,9 0C
    Nadi:
    124
    kali/menit,
    RR : 32 kali/menit
    SpO2:
    99
    %terpasang O2 2
    lpm nasal kanul
    (NK)

    Senin, 10-10-2016
    Hari ke 3:
    - Batuk (+) jarang
    - Sesak (-)
    - Demam (-)
    - Tidur nyenyak

    KU: menangis, tampak skit KU: tampak skit ringan


    Kesadaran : CM
    sedang
    Tanda vital :
    Kesadaran : CM
    - Suhu :37,1 0C
    Tanda vital :
    - Nadi : 110 x/mnit
    06.00 WIB:
    0
    - RR : 28 x/mnit
    - Suhu :36,7 C
    - SpO2: 98 % tanpa nasal
    - Nadi : 115 x/menit
    - RR : 24 x/ mnt
    kanul
    SpO2: 99 %terpasang

    FOLLOW
    UP

    O2 2 lpm nasal kanul


    (NK)

    PemeriksaanF Kepala : normocephal Kepala


    : Kepala
    :
    isik
    rambut
    tidak
    normocephalrambuttidak
    normocephalrambuttidakmudah
    mudah dicabut
    mudahdicabut
    dicabut
    - Mata :
    - Mata :
    matacekung - Mata :
    matacekung
    (+/
    matacekung (-/-),
    (+/
    +),konjungtivaanemis
    (-/-),
    konjungtiva
    +),konjungtivaanemis
    skleraikhterik (-/-)
    Hidung
    : NCH (-/-), sekret
    anemis (-/-),sclera
    (-/-), skleraikhterik (-/-)
    - Hidung : NCH (-/-),
    (-/-)
    ikhterik (-/-)
    - Mulut : Mukosabasah (-),
    - Hidung : NCH
    sekret (-/-)
    - Mulut : Mukosabasah
    Bibirsianosis (-)
    (-/-), sekret (-/-)
    Telinga
    : Normotia, sekret (-/-)
    - Mulut : Mukosa
    (-), Bibirsianosis (-)
    basah (-), Bibir - Telinga : Normotia, Leher: KGB takmembesar
    Thorax : retraksi(-)
    sekret (-/-)
    sianosis (-)
    Pulmo:
    KGB
    - Telinga
    : Leher:
    Suaradasarvesikuler
    (+/+),
    takmembesar
    Normotia, sekret
    ronkhi(-/-) wheezing (-/-)
    Thorax : retraksi(-)
    (-/-)
    Cor :
    Pulmo:
    Leher:
    KGB
    BunyiJantung I-II normal,
    - Suaradasarvesikuler (+/
    takmembesar
    murmur(-), gallop (-)
    +), ronkhi(-/-) wheezing
    Thorax : retraksi(+)

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