FOLLOW UP PASIEN RUANGAN TULIP (5 NOVEMBER 2018)

No NAMA PASIEN/UMUR TANGGAL DIAGNOSIS MASALAH TERAPI

MRS
1. Mr. Guido Nesi /30 th 31/01/20 Lung TB S : patient treated day 5. P:
19 relaps + Patient referral from Soe -OAT Kategori
Hemoptoe , with abdominal pain, 2
recovery nausea and vomiting. (2HRZES/HRZE
Coughing and abdominal /SHR3E3)
pain are felt -NaCl 0,9 % 20
approximately 4 months tpm
ago. Cough with white
phlegm. Coughing is Sp.PD
especially felt at night. -Glimiperid
Approximately 1 month 2x1 mg
ago, coughing was -Metformin
accompanied by blood 3x500
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
 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. Tn. Salmun Tanau/65 29/01/20 Lung TB on S: patient treated day 6. P:

th 19 OAT weakness , vomiting (-), -NaCl 0.9 :
+ anemia + shortness of breath, D5%
Hypocalemi occasional cough, 2:1
a, O:
hyponatre TTV: -
mi TD: 90/60 mmHg
corrected 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
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. Ny. Dolorosa Sila/ 26 30/01/20 Lung TB S: patient treated day 5 . P:

th 19 BTA (+) Cough and fever -OAT
+ Anemia reduced. Cough with categorie 1 (
white phlegm. 2HRZE+ 4HR3)
-Transfusi PRC
O: -PCT 3x500
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
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. Nn.Nefi Banoet/22 th 2/2/2019 Lung Tb + S: patient treated day 5 . P:

dyspnea Cough and fever -sputum S-P-S
+anemia + reduced. Cough with -PRC
hipoalbumi white phlegm. transfusion 1
nemia bag/day
O: -Paracetamol
TD: 100/60 mmHg 3 x 500 mg
N: 74 x/menit -O2 mask 10
S:36,1 ˚ C tpm
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 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
 Basophil : 0,02
Neutrophil : 11,87
Lhymphosit : 0,6
Monosit : 0,30
Plt : 228
GDS:106 mg/dl
BUN : 16,0
Kreatinin : 0,51
Natrium : 129 mmol/dL
Kalium : 3,1 mmol/dL
Calcium : 1,01 mmol/dL

Lab 3/2/19
HbSag non reaktif
HIV non reaktif
SGPT : 37
SGOT : 56
Albumin 1,4

5. Tn.Plaudius/33th 27/10/20 Pneumonia S: Keluhan batuk P:

18 +TB Paru+ berdahak kuning masih -Aminofluid
B20 dirasakan namun sudah 1000cc/hari
berkurang -Ceftriaxone:
O: 2x2g IV
TD:100/60 mmHg -Levofloxacin
N:104x/menit 1x750mg IV
SPO2:99% -OMZ 2x40 mg
RR:20X/menit IV
S:36,8˚C -Nebu
combiven/8
Lab 27/10/2018 jam
K:2,9 mmol/L -NAC 3X200
29/10/2018 mg
HIV: Reaktif -ASPAR K 3X1
02/11/2018
Albumin :2,4 mmol/L
6. Tn.Amir Asor/20th 26/10/20 TB S: Keluhan batuk kering P:
18 Paru+Limfa masih dirasakan, -Aminofluid
denitis TB bengkak pada kaki 1000cc/24jam
berkurang sedikit, nyeri -ceftriaxone
perut seluruh perut. 2x2g IV
-Kalnex
O: 2x250mg IV
TTV: PCT 3X1 gr IV
TD:90/60 mmhg OAT KAT I
N:104x/menit RHZE
SPO2:95% 450/300/1000
RR: 22X/menit /75-
S:36,9˚C B6 1X10mgIV
Mata: SI (+/+)
Leher : Pembesaran KGB
colli S&D, konsistensi
keras, ukuran 2x3cm
Abdomen: NT(+) Seluruh
regio

LAB 26/10/2018
Hb: 9,3 g/dl
27/10/2018
HbsAg:
LAB 3/11/2018
Albumin:2,5 mmol/L