SOAP

Subjective Objective Assessment Planning

Diagnosis Terapi
13/06/2015 TD : 120/60 mmHg Obs. Icterus DL - Infus PZ 14
Muntah > 7x, Ikterus (+) Susp. Hepatitis Faal Hati tetes/ menit
Badan lemas, Acute Faal Ginjal - Injeksi
gatal seluruh Pantoprazole 1
badan, Mata ampul
kuning selama ± 1 - Hepamax 3x1
minggu (p.o)

14/06/2015 05.00 Hepatitis Virus - HbSAg - Infus Hydromal

Mual, badan TD : 130/80; N: 80; T: Akut - Anti HAV dan D5 1:1
lemas, perut 37°C - Ig M - Teracef 3x1
tidak enak, gatal ampul
seluruh badan - Hb: 11,5g/dl - Braxcidin 3x1
- Lekosit: 10100mm3 tab
- PCV: 33,2% - Eloxicam 3x1 tab
- Trombosit:
657000mm3
- LED: 48mm/jam
- SGOT: 478U/L
- SGPT:442U/L
- Bilirubin Direk:
13.42mg/dl
- Bilirubin indirek:
15.14mg/dl
- Bilirubin
Total:28.56mg/dl
- BUN:20.4mg/dl
- Serum
Creatinin:0.76mg/dl

15/06/2015 05.00 Hepatitis Virus - Faal hati Terapi tetap

Badan masih TD: 110/70; N: 88; T: Akut
lemas, mual + 36,7°C
berkurang, gatal
seluruh badan 12.00
TD: 100/80; N: 73; T:
35,7°C

16/06/2015 05.00 Hepatitis Virus - Infus hidromal

Badan masih TD: 110/70; N: 88; T: Akut : D5 1:1
lemas, mual (-), 36°C - Inj Tomit 3x1
gatal seluruh ampul
badan (+) 12.00 - Prednisolon
TD: 120/80; N: 84; T: 3x1 ampul
36°C - Vit K 3x1
ampul
 SOAP
17/06/2015 05.00 Hepatitis Virus Terapi tetap
TD: 120/80; N: 78; T: Akut
36°C

12.00
TD: 110/80; N: 85; T:
36,2°C

17.00
TD : 110/70 ; N: 88; T
: 36,3°C