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  • Tanggal S O A P 4 Juli 2016: Follow Up

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    efri
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    This document contains a medical follow up report for a patient from July 4th to July 8th. Each day, the patient's symptoms of coughing and difficulty swallowing are noted, along with vital signs and physical exam findings including reduced lung auscultation and submandibular lymph node swelling. The diagnosis of pulmonary TB and laryngitis is continued, and the same treatment regimen of antibiotics and supportive medications is continued over the 5 day period, with slight improvement in symptoms noted on the last day.

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    FOLLOW UP

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    This document contains a medical follow up report for a patient from July 4th to July 8th. Each day, the patient's symptoms of coughing and difficulty swallowing are noted, along with vital signs and physical exam findings including reduced lung auscultation and submandibular lymph node swelling. The diagnosis of pulmonary TB and laryngitis is continued, and the same treatment regimen of antibiotics and supportive medications is continued over the 5 day period, with slight improvement in symptoms noted on the last day.

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    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
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    6 views3 pages

    Tanggal S O A P 4 Juli 2016: Follow Up

    Uploaded by

    efri
    This document contains a medical follow up report for a patient from July 4th to July 8th. Each day, the patient's symptoms of coughing and difficulty swallowing are noted, along with vital signs and physical exam findings including reduced lung auscultation and submandibular lymph node swelling. The diagnosis of pulmonary TB and laryngitis is continued, and the same treatment regimen of antibiotics and supportive medications is continued over the 5 day period, with slight improvement in symptoms noted on the last day.

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    © All Rights Reserved
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    of 3

    FOLLOW UP

    Tanggal S O A P

    4 Juli 2016 Batuk (+) - TD : 110/70 mmHg, HR: 97x/ TB Paru + Laryngitis  IVFD RL gtt 20x/m
    menit, RR: 27x/menit, T: 37 C  Rifampisin 1x225 mg
    Sulit dan Nyeri  Isoniazid 1x450 mg
    menelan (+) - Kepala : -  Pirazinamid 1x1125 mg
    - Leher : Benjolan submandibulla  Etambutol 1x675 mg
     Ambroxol 3x40 mg
    - THT : Faring hiperemis (+), T2/T2
    - Thorax : auskultasi vesikuler (+)
    menurun
    - Cor : Ictus cordis tampak, Ictus
    cordis teraba, thrill teraba,
    - abdomen : dbn
    - ekstremitas : akral hangat

    5 Juli 2016 Batuk (+) - TD : 110/70 mmHg, HR: 97x/ TB Paru + Laryngitis  IVFD RL gtt 20x/m
    menit, RR: 27x/menit, T: 37 C  Rifampisin 1x225 mg
    Sulit dan Nyeri  Isoniazid 1x450 mg
    menelan (+) - Kepala : -  Pirazinamid 1x1125 mg
    - Leher : Benjolan submandibulla  Etambutol 1x675 mg
     Ambroxol 3x40 mg
    - THT : Faring hiperemis (+), T3/T3
    - Thorax : auskultasi vesikuler (+)
    menurun
    - Cor : Ictus cordis tampak, Ictus
    cordis teraba, thrill teraba,
    - abdomen : dbn
    - ekstremitas : akral hangat

    6 Juli 2016 Batuk (+) - TD : 110/70 mmHg, HR: 68x/ TB Paru + Laryngitis  IVFD RL gtt 20x/m
    menit, RR: 28x/menit, T: 36.5 C  Rifampisin 1x225 mg
    Sulit dan Nyeri  Isoniazid 1x450 mg
    menelan (+) - Kepala : -  Pirazinamid 1x1125 mg
    - Leher : Benjolan submandibulla  Etambutol 1x675 mg
     Ambroxol 3x40 mg
    - THT : Faring hiperemis (+), T2/T2
    - Thorax : auskultasi vesikuler (+)
    menurun
    - Cor : Ictus cordis tampak, Ictus
    cordis teraba, thrill teraba,
    - abdomen : dbn
    - ekstremitas : akral hangat

    7 Juli 2016 Batuk (+) - TD : 110/70 mmHg, HR: 68x/ TB Paru + Laryngitis  IVFD RL gtt 20x/m
    menit, RR: 28x/menit, T: 36.5 C  Rifampisin 1x225 mg
    Sulit dan Nyeri  Isoniazid 1x450 mg
    menelan (+) - Kepala : -  Pirazinamid 1x1125 mg
    - Leher : Benjolan submandibulla  Etambutol 1x675 mg
    - THT : Faring hiperemis (+), T2/T2  Ambroxol 3x40 mg
    - Thorax : auskultasi vesikuler (+)
    menurun
    - Cor : Ictus cordis tampak, Ictus
    cordis teraba, thrill teraba,
    - abdomen : dbn
    - ekstremitas : akral hangat

    8 Juli 2016 Batuk (+) - TD : 100/70 mmHg, HR: 69x/ TB Paru + Laryngitis  IVFD RL gtt 20x/m
    menit, RR: 24x/menit, T: 36.5 C  Rifampisin 1x225 mg
    Sulit dan Nyeri  Isoniazid 1x450 mg
    menelan (+) - Kepala : -  Pirazinamid 1x1125 mg
    berkurang  Etambutol 1x675 mg
    - Leher : Benjolan submandibulla
     Ambroxol 3x40 mg
    - THT : Faring hiperemis (+), T2/T2
    - Thorax : auskultasi vesikuler (+)
    menurun
    - Cor : Ictus cordis tampak, Ictus
    cordis teraba, thrill teraba,
    - abdomen : dbn
    - ekstremitas : akral hangat

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