8/18/2019 rgb follow up 7-9 des.doc

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FOLLOW UP

Tanggal S O A P

7 Des 2015

Bedah

Orthopedi

HCU

Bedah

Bedah

TKV

Bedah

Saraf 

 Nyeri (-)

Sesak (-)

Keluhan

(-)

KU sedang, C!D"1#0$%0&&Hg

''" 20$&eni,

 Nadi" *0$&eni,

saurasi **+

'egi Clai.ula (S)

/ " skin inak,

selling (), skin

ening (-)

" N3D (-), N! ()

" '4 shulder 

eraas karena nyeri'4 el, ris,

digii 6ull

KU sedang, C

!D"1#0$%0&&Hg

''" 20$&eni,

 Nadi" *0$&eni,

saurasi **+

'egi !hraks

" 8enge&angan

dada kanan 9 kiri:" kre8iasi (-)

:" snr$snr 

;" SD3 ($)

KU sedang, C,

, 8u8il

iskr ? &&$? &&,

re6leks .ahaya $

!D"1#0$%0&&Hg

''" 20$&eni,

 Nadi" *0$&eni,

saurasi **+

- C .lai.ula (S);ll&an gru8

k&inui6 

- SDH regi e&8ral

(D) S;H CH

regi e&8ral (S)

- C .sae 3 @ 3

(S) 8serir si&8le

- C .sae 3 @ 3

(S) 8serir si&8le

- SDH 'A !e&8ral (D)

S;H 'A !e&8ral

(S) CH 'A

!e&8ral (S)

- :r 4' .lai.ula- !unggu a.. !S BA

Sara6 

- !era8i ineksi sesuai

!S BA Sara6 

- Knserai6 dari

B!K3

- NaCl 0,*+ "

;&in6luid$2# a& 9

2"1

- nA :ara.ea&l 1

gr$% a&

- nA 'aniidine 50

&g$12 a&

- nA :heniin 100

&g$% a&

- Ni&di8ine 10

&g$2# a&

- C! S.an ke8ala

- :indah angsal

1

8/18/2019 rgb follow up 7-9 des.doc

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% Des 2015

Bedah

Orthopedi

HCUBedah

Bedah

TKV

Bedah

Saraf 

 Nyeri (-)

Sesak (-)

Keluhan

(-)

KU sedang, C

!D"1?0$%0&&Hg

''" 20$&eni,

 Nadi" >%$&eni,

saurasi **+

'egi Clai.ula (S)/ " skin inak,

selling (), skin

ening (-)

" N3D (-), N! ()

" '4 shulder 

eraas karena nyeri

'4 el, ris,

digii 6ull

KU sedang, C

!D"1?0$%0&&Hg''" 20$&eni,

 Nadi" >%$&eni,

saurasi **+

'egi !hraks

" 8enge&angan

dada kanan 9 kiri

:" kre8iasi (-)

:" snr$snr 

;" SD3 ($)

KU sedang, C,

, 8u8il

iskr ? &&$? &&,

re6leks .ahaya $

!D"1?0$%0&&Hg

''" 20$&eni,

 Nadi" >%$&eni,

saurasi **+

- C .lai.ula (S)

;ll&an gru8

k&inui6 

- SDH regi e&8ral

(D) S;H CH

regi e&8ral (S)- C .sae 3 @ 3

(S) 8serir si&8le

- C .sae 3 @ 3

(S) 8serir si&8le

- SDH 'A !e&8ral (D)

S;H 'A !e&8ral

(S) CH 'A

!e&8ral (S)

- :r 4' .lai.ula

- !unggu a.. !S BA

Sara6 

- !era8i ineksi sesuai

!S BA Sara6 - Knserai6 dari

B!K3

- NaCl 0,*+ "

;&in6luid$2# a& 9

2"1

- nA :ara.ea&l 1

gr$% a&

- nA 'aniidine 50

&g$12 a&

- nA :heniin 100

&g$% a&

- Ni&di8ine 10

&g$2# a&

* Des 2015

Bedah

Orthopedi

HCU

Bedah

 Nyeri ()

di ahu

kiri

KU sedang, C

!D"120$70&&Hg

''" 20$&eni,

 Nadi" 70$&eni,

saurasi **+

'egi Clai.ula (S)

/ " skin inak,

selling (), skin

ening (-)

" N3D (-), N! () " '4 shulder 

- C .lai.ula (S)

;ll&an gru8

k&inui6 

- SDH regi e&8ral

(D) S;H CH

regi e&8ral (S)

- C .sae 3 @ 3

(S) 8serir si&8le

- :r 4' .lai.ula

- !unggu a.. !S BA

Sara6 

2

8/18/2019 rgb follow up 7-9 des.doc

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Bedah

TKV

BedahSaraf 

Sesak (-)

Keluhan(-)

eraas karena nyeri

'4 el, ris,

digii 6ull

KU sedang, C

!D"120$70&&Hg''" 20$&eni,

 Nadi" 70$&eni,

saurasi **+

'egi !hraks

" 8enge&angan

dada kanan 9 kiri

:" kre8iasi (-)

:" snr$snr 

;" SD3 ($)

KU sedang, C,, 8u8il

iskr ? &&$? &&,

re6leks .ahaya $

!D"120$70&&Hg

''" 20$&eni,

 Nadi" 70$&eni,

saurasi **+

- C .sae 3 @ 3

(S) 8serir si&8le

- SDH 'A !e&8ral (D) S;H 'A !e&8ral

(S) CH 'A

!e&8ral (S)

- !era8i ineksi sesuai

!S BA Sara6 - Knserai6 dari

B!K3

- NaCl 0,*+ ";&in6luid$2# a& 9

2"1

- nA :ara.ea&l 1

gr$% a&

- nA 'aniidine 50

&g$12 a&

- nA :heniin 100

&g$% a&

- Ni&di8ine 10

&g$2# a&

- ;.. 8erasi di

 idang 4rh8aedi

?