1 Agustus 2015
IDENTITAS
DIAGNOSIS
TATA LAKSANA
PEMERIKSAAN LANJUTAN
Penurunan
kesadaran ec.
Hipoksia DD/
Meningitis,
Meningoensefalitis,
Ensefalitis +
edema paru
31-7-15 LCS :
O2 nasal 1L/menit
D5 NS gtt 8x(makro)/menit
Aminofusin 1g/kgBB/hr kec.
8cc/jam
Ceftriaxone 1 x 1g (9)
Fenitoin 2x50mg
Paracetamol 4x 10ml
Dexametasone 3x3mg STOP
Nebu ventolin +NS/8jam
Asetazolamid 3x150mg
R/H/Z/E 150/100/350/200
O2 nasal 1 l/m
Ceftriaxone 1x 850 mg (13)
Ampisilin 4 x 850 mg (13)
Ca glukonas 5 cc dalam D5 50 cc
(1jam)/8jam hari kedua
21-7-15: Hb 11,6 WBC 19900 Ht 35 Plt 450.000 MCV 74,8 MCH 25 MCHC 33 LED 25
DC 0/0/84/8 ret: 1,0 BSS 124 Ureum 9 Cr 0,31 Ca 9,0 Na 144 K 4,1 CRP 6
22-7-15: LCS: tidak bewarna, agak keruh, tidak berbau, BJ 1.020 bekuan (-) LEUKOSIT
192 pmn 38 mn 63 nonne + pandy + protein 0,3 Glukosa 41,3 LDH 218 Cl
108
26-7-15: Mantoux test: (-)
27-7-15: Hb 15,1 Ht 42 WBC 12.200 Plt 179.000 DC: 0/0/89/7/4 SGOT 142 SGPT 170
Alb 3,4 Protein Total 6,4 ur 5 Cr 0,18 As. Urat 3,4 Ca 8,5 Na 136 K 3,3 Cl 102
Keterangan
RABER RESPIRO
1
3
.
6
Aden S/Lk/17-112011
BB: 10kg PB: 50 cm
BB/U <-3 PB/U -2 s/d
0 SD
BB/PB : <-3 SD
15013462/903139
MRS 21-7-15
Satria N A/ Lk/9-1114
BB: 7,1kg PB 84cm
BB/U: PB/U:
BB/PB:
LK: 47 cm
15018935/903080
MRS:
Penurunan Kesadaran
ec. Meningitis TB
BP + Meningitis
O2 nasal 1 l/m
Ceftriaxone 1x 850 mg (10)
Ampisilin 4 x 850 mg (10)
Fenitoin 2 x 45 mg
Zinc 1 x 20 mg via ngt
Ca glukonas 5 cc dalam D5 50 cc
(1jam)/8jam
LK: 51 cm
LK: 44 cm
4
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2
4
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3
p
i
c
u
4
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4
Ratih Amalia/Pr/26-22015
BB: 6 kg PB:66 cm
BB/U: -1,07 PB/U +1
BB/PB:-2,25
Lk: 43 cm
(normocephali)
903885/15019424
MRS: 24-7-15
Penurunan Kesadaran
ec. Meningitis
bakterialis +
Hemangioma R.
frontalis
M. Sulton Attamami/
Lk/21-12-2013
BB: 9,5 kg
PB: 79 cm
BB/U: -1,47 PB/U:
-1,62
BB/PB: -0,94
LK: 46cm
901093/
MRS: 04-07-2015
Meningitis
Bakterialis + BP
O2 sungkup 5L/m
D12,5 kec 30cc/jam
F100 8x 100cc
Gliserol 3x20cc
Meropenem 3x200mg
(20)STOP
Nebu Ventolin + NS/8 jam
Abbotic (claritromycin)
Meningitis
Bakterialis
24-7-15: Hb 11,4 WBC 5.500 Ht 33 Plt 66.000 MCV 73,4 MCH 25 MCHC 34 LED 2 DC
0/4/66/20/10 SGOT 2275 SGPT 2737 Protein total 4,9 Alb 3,1 BSS 81 Ur 25 As.
Urat 6,4 Cr 0,35 Ca 7,9 Na 143 K 4,4 Cl 119 CRP <5
LCS: kekuningan, jernih, tidak berbau, BJ 1.020 pH 9 leu 305 PMN 82 MN18
Nonne pandy + prot 0,1 LDH 530 Gluk 67,6 Cl 113
EEG brain
monitoring
(7-8-15)
LK: 42 cm
4-7-15: Hb 10,5 WBC 9700 Ht 32 PLT 117.000 MCV 75,5 MCHC 33 LED 35
DC 0/0/68/24/8 BSS 66 Na 140 K 40 Cl 113 Ca 66 CRP 44 LCS tidak
berwarna, jernih, tidak berbau, BJ 1020 bekuan pH 9 leukosit 96
PMN 76 MN 24 sel blast nonne pandy + protein 0,1 LDH 40
Glukosa 71,7 Cl 132
7-7-15: : Hb 10,5 WBC 7000 Ht 32 PLT 258.000 MCV 75,5 MCHC 33 LED 35
DC 0/0/76/18/6 SGOT 197 SGPT 157 Alb 3,6 Bss 108 102 Ur 35 Cr
0,29 Ca 9,1 Phosfor 3,5 Na 143 K 5,1 Cl 113
26-7-15: Hb 13,3 Ht 40 WBC 13,3 Plt 565.000 MCV 81,1 MCH 27 MCHC 34
LED 18 DC 0/0/50/35/15 Ca 10,0 Na 144 K 4,1 Cl 113
Hb 11,0 WBC 5.000 Ht 32 Plt 144.000 LED 2 DC 0/0/60/30/10 GDS 120 Ca
8,3 Na 138 K 2,624-6-15 Ca 7,7 Na 139 K 4,0 LCS tidak berwarna, jernih, BJ
1,020 bekuan (-) pH 8 Leu 65 PMN 88 MN 12 Nonne (-) Pandy (+) Prot 0,1
LDH 33 Gluk 94,6 Cl 127
25-6-15 Na: 136 K: 4 Cl: 103 Ca:7,9
27-6-15 Ca 8,8 Na 136 K 3,6 Cl 107
8-7-15: Hb: 9,8 Leukosit 8.000 Ht 30 LED 22 DC: 0/5/68/20/7
Kultur darah : Steril
9-7-15: kultur urine: candidiasis albicans (yeast(+)pseudohypa(+))
>100.000/ml
9-7-15: bilasan lambung BTA I (-)
10-7-15: LCS: tidak berwarna, jernih, tidak berbau, BJ 1.020 Bekuan (-) pH
8,0 lekosit 71 PMN 82 MN 18 Sel blast (-) nonne (-) pandy (+)
protein 0,1 Glukosa 75,9 LDH 50 Cl 131
LCS: BTA (-) bilasan lambung BTA II (-)
10-7-15: kultur LCS: S. Epidermidis, Sensitif (vankomycin,
Amikacin)
13-7-15: bilasan lambung III (-)
14-7-15: Hb 8,6 WBC 9.700 Ht 25 Plt 438.000 MCV 78 MCH 27 MCHC 35
LED 32 DC 0/1/66/24/7 Ret 1,4 SGOT 64 SGPT 53 Ureum 9
LK: 47 cm
O2 nasal 2L/menit
Ampisilin 3x500mg (6)
Ceftriaxone 3x 60mg (6)
Dexametasone 3 x 2 mg (6)
Ranitidine 2 x 10mg
Diazepam bila kejang
LK: 45 cm
4
.
6
Herli bin
Asmawi/Lk/11-022015
BB: 6 kg PB: 64 cm
BB/U -2,19 PB/U
-1,90
BB/PB: -1,97
LK: 46 cm
(normocephali)
15019468/903905
Mrs: 24-7-15
5
.
1
Aiko Alvaro/Lk/30-122014
BB: 6,9 kg PB: 64
cm
BB/U: -1,62
PB/U:
-2,29
Penurunan
kesadaran ec. Susp.
Peningkatan TIK ec.
SAH + hidrocephalus
(ventrikulomegali) +
anemia ec. Susp.
Perdarahan DD/ def.
Fe
Kejang demam ec.
Meningitis bakterialis
+ anemia + hidrocele
+ hernia umbilicalis
IVFD D5 NS 20xmikro
R/ Operasi elektif
R/ transfusi PRC 1X80mg
24-7-15: LCS: tidak bewarna, agak keruh, tidak berbau, BJ 1.020 bekuan (+) pH 8.0
Lekosit 482 PMN 42 MN 58 Nonne (-) Pandy (+) Protein0,1 LDH 0,22 Glukosa 39,5 Cl
135
27-7-15: Hb 11 WBC 14.400 Ht 35 Plt 344.000 DC 0/0/86/13/1
LK: 42 cm
Meningitis Bakterialis
O2 nasal 1L/menit
IVFD
Ampisilin 3 x 700 mg (4)
Ceftriaxone 1 x 700 mg(4)
Dexametasone 3 x 2mg(4)
Diazepam 2mg bila kejang
27-7-15: Hb 11,7 Ht 33 WBC 7.200 Plt 58.000 DC 0/1/33/60/6 GDS 167 SGOT 1068
SGPT 190 Ureum 19 Creatinin 0,26 Ca 7,8 Na 113 K 4,8 Cl 100
LCS:kekuningan, agak keruh, tidak berbau, BJ 1.020 bekuan (-) pH 9,0 Lekosit
103 PMN 69 MN 31 nonne (+) pandy (+) Protein 0,1 LDH 28 Glukosa 107,5 Cl
114
28-7-15: Hb 9,4 Ht 27 Plt 23.000 WBC 4.500
LK: 41 cm
BB/PB: -0,22
LK: 42
cm(normocephali)
15019602/904047
MRS: 27-7-2015
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5
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4
5
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5
M. Fransisko/Lk/ 2010-13
BB: 11kg PB: 80 cm
LK: 45 cm
15014152/905183
MRS: 31-1-2015
M. Novriansyah/
Lk/16-11-08
BB: 18 kg PB 112 cm
LK: 51,5 cm
905212/15020191
MRS: 1-8-2015
Mixdal Reder/
Pr/ 27-12-13
BB : 7,2 kg PB: 82
cm
LK: 48cm 44cm
BB/U=-2,14
PB/U=-0.72
BB/PB=-2,47
15015304/ 897124
MRS 09-6-15
Kejang tanpa
demam ec. Susp. SOL
dd/ Epilepsi
KDK +
tonsilofaringitis Akut
Meningitis TB + BP
Pneumonia lobaris
(D)
31-7-15: Hb 12,4 WBC 16,8 Ht 38 Plt 398.000 DC 0/1/64/32/3 BSS 135 Ca 8,8 Na
147 K 4,1
O2 nasal 1 L/ menit
Fluconazole 1x120mg
Baclofen 3x2mg p.o
Ventolin+NS Nebu 3x 1amp
Dexametasone 3x3 mg(stop)
Claritromicyn 2x100mg
R/H/Z/E : 150/80/300/160 (10)
BSB 3X100
F100 8X60ml
O2 nasal 1 L/ menit
Fluconazole 1x120mg
Baclofen 3x2mg p.o
Ventolin+NS Nebu 3x 1amp
Dexametasone 3x3 mg(stop)
Azitromisin 1 x150 mg
R/H/Z/E : 150/80/300/160 (7)
LK: 44 cm
5
.
6
I
.
2
LANTAI 3
Abiyyu danial
Ghaisan/
Lk/8-5-2014
BB: 5,4 kg PB: 63,5
cm
LK: 42,5 cm
905196/15014162
MRS: 31-7-15
Panji Naufal Al
Bhadrika/Lk/22-08-13
BB: 8,5kg PB: 78cm
BB/U: -3,01 PB/U:
-2,99
BB/PB: -2,12
LK: 38 cm
(mikrosefali)
15019447/903895
Penurunan
Kesadaran ec.
Meningitis Bakterialis
31-7-15: Hb 12,4 WBC 9.300 Ht 36 Plt 162.000 LED 8 DC 0/1/47/39/13 Na 137 K 4,4
Cl 104 CRP 11
LCS: tidak bewarna jernih, tidak berbau BJ 1.020 pH 8 bekuan (-) lekosit 217
PMN 79 MN 21 sel blast (-) nonne (-) pandy (+) protein 30 LDH 83 Glukosa
64,8 Cl 120
STOPPER
Depakene 2 x 2,5 cc
Urdafalk 3x80mg
Clonazepam 2x0,05 mg (3)
R/ fisioterapi
24-7-15: Hb 13,1 WBC 11.300 Ht 37 Plt 94.000 MCV 87,3 MCH 31 MCHC 35 Led 6 DC
0/2/11/73/14 SGOT 69 SGPT 18 Ca 9,4 Na 148 K 4,3
MRS: 24-7-2015
M. Fariz Azhari/ lk/
10bln
15016417/ 854529
8,3kg/ 70cm/ 51cm
MRS 21-6-15
Hidrosefalus Post
VP shunt + CP +
susp. Epilepsi +
keratitis eksposure
ODS + atropi papil
bilateral
LK: 52 cm