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Follow Up Pasien 5 Februari 2015 18 Februari 2015TanggalFollow Up
5/2/2015S : Demam(+) Nyeri (+)
O: Compos Mentis. TD 130/80, HR: 80x/i, RR: 20x/i, Temp: 37,1 Drain : 800 cc/ 24jam LO ; Basah FC, Irigasi (+) merah
A: Tumor Buli Post Open Biopsy + Hidronefrosis Moderate Bilateral + Anemia
P: IVFD NaCl 0,9% 20gtt/i Inj Ceftriaxone 1gr/12jam Inj Ranitidine 50mg/12jam Inj Ketorolac 30mg/8jam 1amp Vit K 10mg/8jam Inj Transamin 500mg/8jam Captopril 2x12g Diet Makanan Biasa
6/2/2015S : Demam(-)
O: Compos Mentis. TD 130/80, HR: 80x/i, RR: 20x/i, Temp: 37,1 LO : kuning FC, Irigasi (+) merah
A: Tumor Buli Post Open Biopsy + Anemia
P: IVFD NaCL 0.9% 20gtt/i Inj Ceftriaxone 1gr/12jam Inj Ranitidine 50mg/12jam Inj Ketorolac 30mg/8jam 1amp Vit K 10mg/8jam Inj Transamin 500mg/8jam Transfusi PRC 350cc Diet Makanan Biasa
R: Spirometri CT Scan Upper Lower Abdomen tanpa Contrast
7/2/2015S : Demam(-) Nyeri (+)
O: Compos Mentis. TD 130/80, HR: 80x/i, RR: 20x/i, Temp: 37,1 LO tertutup kassa, rembes (-) FC, Irigasi (+) merah
A: Tumor Buli Post Open Biopsy + Anemia
P: IVFD NaCl 0.9% 20gtt/i Inj Ceftriaxone 1gr/12jam Inj Ranitidine 50mg/12jam Inj Ketorolac 30mg/8jam 1amp Vit K 10mg/8jam Inj Transamin 500mg/8jam Diet Makanan Biasa Lanjut Transfusi PRC
8/2/2015S : Demam(-) Nyeri (-)
O: Compos Mentis. TD 130/80, HR: 80x/i, RR: 20x/i, Temp: 37,1 LO tertutup kassa, rembes (-) FC, Irigasi (+) merah
A: Tumor Buli Post Open Biopsy + Anemia
P: IVFD RL 20gtt/i Inj Ceftriaxone 1gr/12jam Inj Ranitidine 50mg/12jam Inj Ketorolac 30mg/8jam 1amp Vit K 10mg/8jam Inj Transamin 500mg/8jam Diet Makanan Biasa
R: Cek Lab Post Transfusi
9/2/2015S : Demam(-) Nyeri (-)
O: Compos Mentis. TD 130/80, HR: 80x/i, RR: 20x/i, Temp: 37,1 LO tertutup kassa, rembes (-) FC, Irigasi (+) merah
A: Tumor Buli Post Open Biopsy + Anemia
P: IVFD RL 20gtt/i Inj Ceftriaxone 1gr/12jam Inj Ranitidine 50mg/12jam Inj Ketorolac 30mg/8jam 1amp Vit K 10mg/8jam Inj Transamin 500mg/8jam Diet Makanan Biasa
10/2/2015S : Demam(+)O: Compos Mentis. TD 130/80, HR: 80x/i, RR: 20x/i, Temp: 37,1 LO tertutup kassa, rembes (-) FC, Irigasi (+) merah Drain : 50cc/ 24jam
A: Tumor Buli Post Open Biopsy + Hidronefrosis Moderate Bilateral + Anemia + Hiperkalemia
P: IVFD RL 20gtt/i Inj Ceftriaxone 1gr/12jam Inj Ranitidine 50mg/12jam Inj Ketorolac 30mg/8jam 1amp Vit K 10mg/8jam Inj Transamin 500mg/8jam Paracetamol 3x 500mg Transfusi PRC 2 bag @ 175cc Diet Makanan Biasa
R: KOnsul pra Toleransi OP
11/2/2015S : Demam(-) Nyeri (-)
O: Compos Mentis. TD 130/80, HR: 80x/i, RR: 20x/i, Temp: 37,1 LO tertutup kassa, rembes (-) FC, Irigasi (+) merah
A: Tumor Buli Post Open Biopsy + Anemia
P: IVFD RL 20gtt/i Inj Ceftriaxone 1gr/12jam Inj Ranitidine 50mg/12jam Inj Ketorolac 30mg/8jam 1amp Vit K 10mg/8jam Inj Transamin 500mg/8jam Diet Makanan Biasa
12/2/2015S : Demam(+) Nyeri (-)
O: Compos Mentis. TD 160/80, HR: 80x/i, RR: 20x/i, Temp: 37,8 LO tertutup kassa, rembes (-) FC, Irigasi (+) merah Drain : 600cc/ 24 jam kuning pekat
A: Tumor Buli Post Open Biopsy + Hidronefrosis Moderate Bilateral +Anemia
P: IVFD RL 20gtt/i Inj Ceftriaxone 1gr/12jam Inj Ranitidine 50mg/12jam Inj Ketorolac 30mg/8jam 1amp Vit K 10mg/8jam Inj Transamin 500mg/8jam Captopril 2x 12,5mg Diet Makanan Biasa
13/2/ 2015S : Demam(-) Nyeri (-)
O: Compos Mentis. TD 130/80, HR: 80x/i, RR: 20x/i, Temp: 37,1 LO tertutup kassa, rembes (-) FC, Irigasi (+) merah
A: Tumor Buli Post Open Biopsy + Anemia
P: IVFD RL 20gtt/i Inj Ceftriaxone 1gr/12jam Inj Ranitidine 50mg/12jam Inj Ketorolac 30mg/8jam 1amp Vit K 10mg/8jam Inj Transamin 500mg/8jam Diet Makanan Biasa
14/2/2015S : Demam(-) Nyeri (-)
O: Compos Mentis. TD 130/80, HR: 80x/i, RR: 20x/i, Temp: 37,1 LO tertutup kassa, rembes (-) FC, Irigasi (+) merah
A: Tumor Buli Post Open Biopsy + Anemia
P: IVFD RL 20gtt/i Inj Ceftriaxone 1gr/12jam Inj Ranitidine 50mg/12jam Inj Ketorolac 30mg/8jam 1amp Vit K 10mg/8jam Inj Transamin 500mg/8jam Diet Makanan Biasa
R: Cek Darah Lengkap, Elektrolit & Albumin
15/2/2015S : Demam(-) Nyeri (-)
O: Compos Mentis. TD 130/80, HR: 80x/i, RR: 20x/i, Temp: 37,1 LO tertutup kassa, rembes (+) FC, 1500cc/24jam merah kehitaman
A: Tumor Buli Post Open Biopsy Hidronefrosis Moderate Bilateral
P: IVFD RL 20gtt/i Inj Ceftriaxone 1gr/12jam Inj Ranitidine 50mg/12jam Inj Ketorolac 30mg/8jam 1amp Vit K 10mg/8jam Inj Transamin 500mg/8jam Captopril 2x 12,5mg Diet Makanan Biasa
16/2/2015S : Demam(-) Nyeri (-)
O: Compos Mentis. TD 130/80, HR: 80x/i, RR: 20x/i, Temp: 37,1 LO tertutup kassa, rembes (-) FC, Irigasi (+) merah
A: Tumor Buli Post Open Biopsy + Anemia
P: IVFD RL 20gtt/i Inj Ceftriaxone 1gr/12jam Inj Ranitidine 50mg/12jam Inj Ketorolac 30mg/8jam 1amp Vit K 10mg/8jam Inj Transamin 500mg/8jam Diet Makanan Biasa
17/2/2015S : Demam(-) Nyeri (-)
O: Compos Mentis. TD 130/80, HR: 80x/i, RR: 20x/i, Temp: 37,1 LO tertutup kassa, rembes (-) FC, Irigasi (+) merah
A: Tumor Buli Post Open Biopsy + Anemia
P: IVFD RL 20gtt/i Inj Ceftriaxone 1gr/12jam Inj Ranitidine 50mg/12jam Inj Ketorolac 30mg/8jam 1amp Vit K 10mg/8jam Inj Transamin 500mg/8jam Diet Makanan Biasa
18/2/2015S : Demam(-) Nyeri (-)
O: Compos Mentis. TD 130/80, HR: 80x/i, RR: 20x/i, Temp: 37,1 LO tertutup kassa, rembes (-) FC, Irigasi (+) merah
A: Tumor Buli Post Open Biopsy + Anemia
P: IVFD RL 20gtt/i Inj Ceftriaxone 1gr/12jam Inj Ranitidine 50mg/12jam Inj Ketorolac 30mg/8jam 1amp Vit K 10mg/8jam Inj Transamin 500mg/8jam Diet Makanan Biasa