HASIL FOLLOW UP PASIEN

14-12-2019

Follow up tanggal 14-12-2019

SUBJECTIVE OBJECTIVE ASSESMENT THERAPY PLANNING

 Lemas +  KU : lemah  Post coma  Infus dextrose  Memeriksa

 Nyeri  Kesadaran : hipoglikemi 10% lmp GDA stick
 Luka kaki sopor  Sekunder 1:  Dextrose 40 %  Memasang
kanan  GCS:222 Gangren pedis IV infus
 Tensi: 120/80 dextra  Ketoprofen 1mg  Mengambil
mmHg  Sekunder 2: CKD  Omeprazol 40mg darah untuk
 HR :90 x/menit + sepsis  Ondancetron 8 peeriksaan
 RR : 18x/menit mg lab
 Temp : 34ᵒC  Vicilline 1,5 gram  Memberikan
 K/L : A/I/C/D drop dalam PZ injeksi
-/-/-/- 100 ml  GCS 456
 Thorax :
Vesi: +/+
Wh -/-
Rh -/-
 Abdomen :
BU +
Met –
Dist –
 Eks : akral basah
hangat dingin
 15-12-2019

Follow up tanggal 15-12-19

SUBJECTIVE OBJECTIVE ASSESMENT THERAPY PLANNING

 Lemas +  KU : lemah  Post coma  Infus dextrose  Observasi

 Nyeri  Kesadaran : hipoglikemi 10% 14 lmp
 Luka kaki CM  Sekunder 1:  Inj. Dextrose 40
kanan  GCS:456 Gangren pedis %
 Tensi: 120/80 dextra  Ketoprofen 1mg
mmHg  Sekunder 2: 3x1
 HR :80 x/menit CKD + sepsis  Omeprazol
 RR : 20x/menit 40mg
 Temp : 36,5ᵒC 2x1
 K/L : A/I/C/D  Ondancetron 8
-/-/-/- mg 3x1
 Thorax :  Vicilline 15 mg
Cor: s1 s2 TR 3x1
Pulmo:
Vesi: +/+
Wh -/-
Rh -/-
 Abdomen :
BU +
Met –
Dist –
 Eks : akral
hangat kering
merah
 16-12-2019

Follow up tanggal 16-12-2019

SUBJECTIVE OBJECTIVE ASSESMENT THERAPY PLANNING

 Lemas +  KU : lemah  Post coma  Infus dextrose  Observasi

 Nafsu makan  Kesadaran : hipoglikemi 10% 14 tpm
menurun CM  Sekunder 1: D5 1000cc
 GCS: - Gangren pedis /24jam
 Tensi: 120/80 dextra  Inj.
mmHg  Sekunder 2: Metronidazole
 HR :80 x/menit CKD + sepsis 3x500mg
 RR : 20x/menit
 Temp : 36,5ᵒC PO:
 K/L : A/I/C/D
-/-/-/-  Omeprazol
 Thorax : 40mg
Cor: s1 s2 TR 3x1
Pulmo:  Ondancetron 8
Vesi: +/+ mg 3x1
Wh -/-  Vicilline sx 1,5 g
Rh -/- 3x1/ 1,5 g /12
 Abdomen : jam
BU +  PCR 3x
Met –  Asam folat 1x1
Dist –  CaCO3 1x1
 Eks : akral
hangat kering
merah
Hasil pemeriksaan penunjang tgl 16-12-2019

Pemeriksaan Metode Hasil Nilai Rujukan Satuan

GDP Hexokinase 46 [ 74 – 106] Mg/dl

GD2PP Hexokinase 54 [ < 120 mg/dl ] Mg/dl

HBA1C Tina-quant 8.8 [ 4.8 – 5.9 ] %

Albumin BCG + 1.9 [ 3.4– 4.8 ] g/dl

Bilirubin direk Jendrasik 0.36 [ <0.20 mg/dl ] 10^3/uL

Bilirubin Total Jendrasik 0.50 [ <1.20 mg/dl ] fl

SGOT IFCC 17 [ 0 – 50 unit/ L] pg

SGPT IFCC 9 [ 0-50 ] Unit/L

 17-12-2019

Follow up tanggal 17-12-2019

SUBJECTIVE OBJECTIVE ASSESMENT THERAPY PLANNING

 Nafsu makan  KU : lemah  Post coma  Infus dextrose  Observasi

menurun  Kesadaran : hipoglikemi 10% 14 tpm
CM  Sekunder 1: D5 1000cc
 GCS: 456 Gangren pedis /24jam
 Tensi: 120/80 dextra  Inj.
mmHg  Sekunder 2: Metronidazole
 HR :80 x/menit CKD + sepsis 3x500mg
 RR : 20x/menit
PO:
 Temp : 36,5ᵒC
 K/L : A/I/C/D
-/-/-/-  Omeprazol
 Thorax : 40mg
Cor: s1 s2 TR 3x1
Pulmo:  Ondancetron 8
Vesi: +/+ mg 3x1
Wh -/-  Vicilline sx 1,5 g
Rh -/- 3x1/ 1,5 g /12
 Abdomen : jam
BU +  PCR 3x
Met –  Asam folat 1x1
Dist –  CaCO3 1x1
 Eks : akral
hangat kering
merah
 18-12-2019

Hasil Pemeriksaan Penunjang tgl 18-12-2019

Pemeriksaan Metode Hasil Nilai Rujukan Satuan

WBC Flowcymetri 2.6 [ 4.50 – 11.50] 10^3/uL

RBC 2.6 [ 4.2 – 6.1 ] 10^6/uL

HGB 8.7 [ 14.0 – 17.5 ] g/dL

HCT Cell Counter 22.0 [ 37.0 – 52.0 ] %

PLT Cell Counter 324 [ 150 – 403 ] 10^3/uL

MCV Cell Counter 83.7 [ 79.0 – 99.0 ] fl

MCH Cell Counter 33.1 [ 27.0 – 31.0 ] pg

MCHC Cell Counter 39.5 [ 33.0 – 37.0 ] g/dL

RDW-SD 41.9 [ 35.0 – 47.0 ] fl

RDW-CV 15.2 [ 11.5 – 14.5 ] %

PDW 10.3 [ 9.0 – 17.0 ] fl

NEUT % 7.1 [ 25.0 – 40.0 ] %

LYMPH % 4.4 [ 2.0 – 8.0 ] %

MONO % 0.81 [ 2.0 – 8.0 ] %

EO 0.00 10^3/uL

BASO 0.03 10^3/uL

MONO 0.87 10^3/uL

NEUT 15.9 [ 2.0 – 7.7 ] 10^3/uL

LYMPH 1.3 [ 0.8 – 4.0 ] 10^3/uL

Gula Darah Sewaktu Hexokinase 217 [ 45-140 ] mg/dL

BUN Kinetik UV 72.6 [ 8.0 – 18.0 ] mg/dL

Creatinin Jaffe 7.2 [ 0.6 – 1.1 ] mg/dL

Natrium ISE 123 [ 136– 145] mmol/I

Kalium ISE 5.4 3.5-5.1 mmol/I

 klorida ISE 96 98-107 mmol/I

Albumin ISE 2.3 3.4-4.8 mmol/I

Follow up tgl 18-12-2019

SUBJECTIVE OBJECTIVE ASSESMENT THERAPY PLANNING

 Nafsu makan  KU : lemah  Post coma  Infus dextrose  Observasi

menurun  Kesadaran : hipoglikemi 10% 14 tpm
 Lemas + CM  Sekunder 1: IUFD D5 1000cc
 GCS: 456 Gangren pedis /24jam
 Tensi: 120/80 dextra  Inj.
mmHg  Sekunder 2: Metronidazole
 HR :80 x/menit CKD + sepsis 3x500mg
 RR : 20x/menit  POST HD 1  Inj. Vicilline sx
 Temp : 36,5ᵒC bulan yll 1,5 g 2x1
 K/L : A/I/C/D  Edema paru
PO:
-/-/-/-
 Thorax :  Omeprazol
Cor: s1 s2 TR 40mg
Pulmo: 3x1
Vesi: +/+  Asam folat 1x1
Wh -/-  CaCO3 1x1
Rh -/-  PCT 3x500mg
 Abdomen :
BU +
Met –
Dist –
 Eks : akral
hangat kering
merah