Follow Up Pasien Ruangan Tulip Mim

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  FOLLOW UP PASIEN RUANGAN TULIP (5 NOVEMBER 2018) No NAMA PASIEN/UMUR TANGGAL MRS DIAGNOSIS MASALAH TERAPI 1. Mr. Guido Nesi /30 th 31/01/2019 Lung TB relaps + Hemoptoe recovery S : patient treated day 5. Patient referral from Soe , with abdominal pain, nausea and vomiting. Coughing and abdominal pain are felt approximately 4 months ago. Cough with white phlegm. Coughing is especially felt at night. Approximately 1 month ago, coughing was accompanied by blood The history of OAT drug consumption in 2016 and 2018 was declared complete, did not break up the drug. TB in the family was denied O: TTV: TD: N:101x/menit S:36,1  ̊ C RR:20x/menit SPO2:98% tanpa Oksigen Pulmo Inspection: symmetrical when static (+ / +) and dynamic (+ / +), widening ribs (- / -), breathing aid muscles (- / -), Palpation: Pain Relief (-) Percussion: sonor in both lung fields Auscultation: vesicular breath sounds, Rhonkhi -/-, Wheezing -/- LAB 31/10/2018 Albumin:2,9 mmol/L P: -OAT Kategori 2 (2HRZES/HRZE/SHR3E3) -NaCl 0,9 % 20 tpm Sp.PD -Glimiperid 2x1 mg -Metformin 3x500  LAB 03/01/2010 HB : 10,6 g/dl RBC : 4,22 ribu/ul HCT : 38,7 % WBC: 7,30 ribu/ul GDS : 268 mg/dl (01) GDP : 234 mg/dl GD2PP : 280 mg/dl HbA1c : 13,4 Hbs Ag : non reaktif HIV : Non reaktif MTB : detected Low Rifampisin : Resistence 2. Mr. Salmun Tanau/65 yo 29/01/2019 Lung TB on OAT + anemia + Hypocalemia, hyponatremi corrected S: patient treated day 6. weakness , vomiting (-), shortness of breath, occasional cough, O: TTV: TD: 90/60 mmHg N: 87X/menit S:36 derajat celcius RR: 18x/menit SPO2: 97% Lila : 18 cm Tb : 162 cm IMT : 58,63 % Eye : Conjungtiva naemis (+/+) Pulmo Inspection: symmetrical when static (+ / +) and dynamic (+ / +), widening ribs (- / -), breathing aid muscles (- / -), Palpation: Pain Relief (-) Percussion: sonor in both lung fields Auscultation: vesicular breath sounds, Rhonkhi +/+-, Wheezing -/- LAB 29/01/2019 Hb: 7,8 g/dl RBC : 3,05 ribu/ ul P: -NaCl 0.9 : D5% 2:1 -  Hct : 20,9% MCV : 68,5 fL MCH : 25,6 fL WBC: 2,24 ribu/ul Plt : 40 Na: 118 (30/01) 126 mmol/L (03/02) K: 1,8 (29/01) 3,5 mmol/L (03/02) Albumin:2,3 mmol/l Ca : 2,1 3. Mrs. Dolorosa Sila/ 26 yo 30/01/2019 Lung TB BTA (+) + Anemia S: patient treated day 5 . Cough and fever reduced. Cough with white phlegm. O: TD: 100/60 mmHg N: 74 x/menit S:36,1 ˚ C RR: 24x/Menit SPO2: 96% Pulmo Inspection: symmetrical when static (+ / +) and dynamic (+ / +), widening ribs (- / -), breathing aid muscles (- / -), Palpation: Pain Relief (-) Percussion: sonor in both lung fields Auscultation: vesicular breath sounds, Rhonkhi +/+-, Wheezing -/- LAB 30/10/18 Hb:7,7 g/dl RBC : 3,9 Hct 25,9 % MCV : 66,2 fl MCH : 19,7 fl MCHC 29,7 fl WBC: 15,26 ribu/ul Eosinophil : 0,3 P: -OAT categorie 1 ( 2HRZE+ 4HR3) -Transfusi PRC -PCT 3x500  Basophil : 0,1 Neutrophil 77,1 Lhymphosit 11,7 Plt : 620 GDS:101 mg/dl BUN : 5,0 Kreatinin : 0,5 Albumin 2,1 BTA (+) 4. Ms.Nefi Banoet/22 yo 2/2/2019 Lung Tb + dyspnea +anemia + hipoalbuminemia S: patient treated day 5 . Cough and fever reduced. Cough with white phlegm. O: TD: 100/60 mmHg N: 74 x/menit S:36,1 ˚ C RR: 24x/Menit SPO2: 96% Eye ; Conjungtiva anemis Pulmo Inspection: symmetrical when static (+ / +) and dynamic (+ / +), widening ribs (- / -), breathing aid muscles (- / -), Palpation: Pain Relief (-) Percussion: sonor in both lung fields Auscultation: vesicular breath sounds, Rhonkhi +/+-, Wheezing -/- LAB 2/2/19 Hb:7,2 g/dl RBC : 3,62 Hct 24,9 % MCV : 68,8 fl MCH : 19,9 fl MCHC 28,9 fl WBC: 12,80 ribu/ul Eosinophil : 0,01 P: -sputum S-P-S -PRC transfusion 1 bag/day -Paracetamol 3 x 500 mg -O2 mask 10 tpm
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