LAPORAN HARIAN RESPIROLOGI

Periode : Febuari 2015

Jumat , 27/02/2015
No
Identitas
1
Adrian Almughini/Lk/9 tahun
Lt 3
BB : 23.5 kg PB : 129 cm
Km11 476464/15005079
MRS 21/02/2015
R:7

Diagnosis
Asma episodik sering
serangain berat + faringitis
akut + Gizi kurang

Tatalaksana
Ceftazidime 3 x 600 mg (7) iv
Dexamethason 3 x 7 mg iv STOP
Salbutamol 3 x 2 mg po
Nebulasi dengan ventolin /12 jam
O2 nasal 1L/mnt
Diet NB 3 x 1 porsi + FC (F100) 4 x 200 cc
Ampicillin 3 x 300 mg iv (4)
Kloramfenikol 3 x 250 mg iv (4)
Paracetamol 3 x 100 mg (bila T > 38.5C)
Diet NB 3x 1 porsi + FC (F100) 3 x 200 cc

Madya : dr. Gita/ Senior : dr. Yasmien/dr. Livi/dr. Zakaria

Laboratorium
Masalah
21/02/2015
Hb 14.3 Leu 27300 LED 17 Tr 464000
DC 0/0/86/9/5 CRP < 5

2
Lt 3
Km 8

Fitri Ramadani/Pr/1 th 6 bln

BB : 9 kg PB : 77 cm
877814/15005274
MRS 24/02/2014
R:4

Bronkhopneumonia + Gizi
Kurang

3
Lt 1
Km 3

Meysha Novianti/Pr/1th 9bln

BB : 10 kg PB 85 cm
870856/15005495
MRS 26/02/2015
R:2
Solahudin Al Ayubi/Lk/5 bln
BB : 6.2 kg PB : 72 cm
878479/15005574
MRS 26/02/2015
R:2
Syifa Ramadani/Pr/3 tahun
BB : 11 kg PB : 88 cm
878485/15005587
MRS 26/02/2015
R:2

Asma episodik jarang

serangan berat + Gizi Kurang

Dexamethason 3 x 3 mg iv (2)
Nebulisasi ventolin/ 8 jam
O2 nasal 1L/mnt
Diet NB 3 x 1 porsi + F100 (FC) 3 x 200 cc

26/02/2015

Bronkhopneumonia + Motorc
delayed + Susp Hipotiroid
kongenital

IVFD D5 NS gtt 6 makro

Ampicillin 3 x 250 mg (2)
Klormfenikol 3 x 125 mg (2)
O2 nasal 1L/mnt
Diet Asi on demand
IVFD D5 + Aminofilin 55 mg gtt 10 makro
(hingga pk 23.00)
Dexamethason 3 x 4 mg iv (2)
Nebulisasi dengan ventolin/ 8 jam
O2 nasal 1L/mnt

26/02/2015

4
Lt 1
Km 3
5
Lt 1
Km3

Asma Episodik jarang

serangan berat + TDBD grade
I + Gizi kurang

24/02/2015
Hb : 10.5 Leu 6000 Tr 215000 LED 70
DC 0/0/48/41/11
CRP (+) 41

26/02/2015

Ekspertise Ro Thorax :
Air bronchogram (+)
Infiltrat di perihiler
kanan dan kiri
Kesan :
bronkhopneumonia dd/
TB paru
Menunggu hasil
mantoux