1. Tn.

B;24th;160cm;65kg
Tidak bias BAK, keluar darah,
Abdomen :
Nyeri tekan suprapubik +
Nyeri ketok CVA +/+

Kes:cm
Td:143/94mmhg
Hr:96x/i
Rr:20x/i
T:36,8
Spo2:99%

Lab
Hb:15,2
Ht:42,9
Leukosit:11,8
Trombosit:427
Gds:109
UR:0,60
CR:14,9

Urtin rutin :
lekosit +3
blood +2

Dx: ISK DD INTOKSIKASI ASAM JENGKOLAT

Th.
Ivfd rl 20 tpm
Inj. Ketorolac 1amp/24jam
Inj.esola 1amp/24jam
Natrium bicarbonate 3x2tab

2. Ny.K;56th;150cm;63kg
BAB cair 3 hari smrs, air > ampas, frekuensi > 15x/ hari, warna hijau, mual , muntah,
penurunan nafsu makan, bak normal

Abdomen:
Nyeri tekan epigastrium +
BU meningkat , NTE +
 Kes:cm
Td:148/100mmhg
Hr:110x/i
Rr:22x/i
T:36,7
Spo2:100%

Lab
Hb:13,0
Ht:39,5
Leukosit:13,4
Trombosit:250
Gds:162

Dx: GEA

Th.
Ivfd rl 20 tpm
Inj. Ondan 1amp/12jam kp
Inj. Topazol 1amp/24jam
Zink 1x20mg
Inj.ceftriaxon 1gr/12jam
L-bio 1x1 sachet

3. Ny.L;22th;155cm;58kg
Pusing, demam, nyeri pinggang , nyeri BAK sejak 4 hari smrs

Abdomen:
Nyeri tekan suprapubik +
Nyeri ketok CVA +/+

Kes:cm
Td:128/90mmhg
Hr:100x/i
Rr:23x/i
T:37,6
Spo2:100%

Lab
Hb:13,8
Ht:38,5
 Leukosit:26,0
Trombosit:240
Gds:158

Urin rutin
Lekosit +3

Dx: ISK pregnancy

Th.
Ivfd rl 20 tpm
Inj.ceftriaxon 1gr/12jam
Pct tab 3x500mg po
Asmet 3x500mg po
Pct infus 500mg/8jam
O2 3lpm kp

4. Ny.P;37th;156cm;62kg
Keluar darah dari jalan lahir sejak 4 hari, sehari 2-3x ganti pembalut

Abdomen:
Nyeri tekan epigastrium +

Kes:cm
Td:131/79mmhg
Hr:113x/i
Rr:21x/i
T:36,1
Spo2:100%

Lab
Hb:7,6
Ht:23,1
Leukosit:15,2
Trombosit:37
Gds:121

Urin rutin
Keton +2
Lekosit:11-13
Eritrosit:21-23
 Plano test (-)

Dx: PUA

Th.
Ivfd rl 20 tpm
Inj.ceftriaxon 1gr/12jam
Inj.ondan 1amp/12jam
Transfuse prc 1 kolf
Pil KB kombinasi
4x14hari
3x13hari
2x12hari
1x14hari

5. Ny.P;15th;152cm;53kg
G1P0 gr 14-15 mgg , Mual muntah sejak 3 mgg, frekuensi mua > 12x/hari , muntah
air

Kes:cm
Td:118/81mmhg
Hr:80x/i
Rr:22x/i
T:36,7
Spo2:98%

Lab
Hb:13,0
Ht:37,3
Leukosit:9,6
Trombosit:294
Gds:87
Plano test +

Dx: HEG

Th.
Ivfd rl 20 tpm
Inj. Ondan 1amp/12jam
 Inj. Ranitidine 1amp/12jam

6. Ny.S;37th;151cm;55kg
BAB cair 2 hari smrs, air > ampas, frekuensi > 5 x/, mual , muntah, nyeri uluhati

Abdomen:
Nyeri tekan epigastrium +
BU normal , NTE +

Kes:cm
Td:140/91mmhg
Hr:114x/i
Rr:22x/i
T:36,3
Spo2:97%

Lab
Hb:14,0
Ht:43,0
Leukosit:13,7
Trombosit:293
Gds:132

Dx: GEA + dispepsia

Th.
Ivfd rl 30 tpm
Inj. metoclopramid 1amp/12jam kp
Inj. Topazol 1amp/24jam
Zink 1x20mg
Inj.ceftriaxon 1gr/12jam
L-bio 1x1 sachet
Sucralfat syr 3x1 c

7. Ny.E;36th;156cm;57kg
Demam, batuk, pilek, pusing, mual sejak 4 hari smrs , bab dan bak normal

Thorak: vesicular +/+

Abdomen: BU normal , NTE +
 Kes:cm
Td:116/76mmhg
Hr:92x/i
Rr:20x/i
T:37,8
Spo2:97%

Lab
Hb:11,2
Ht:34,8
Leukosit:5,8
Trombosit:184
Gds:105

Dx: obs. febris

Th.
Ivfd rl 20 tpm
Inj. Ondan 1amp/12jam kp
Inj. Topazol 1amp/24jam
Inj.ceftriaxon 1gr/12jam
Pct infus 500mg/8jam
Imunos 2x1 tab

8. An.F;1th 11 bln;90cm;10kg
Kejang dirumah 2x durasi 5 menit, setelah kejang anak sadar, demam, batuk sejak 3
hari smrs, bab & bak normal.
Rpd: riw. Kejang
Thorak : vesicular +/+

Kes:cm
Hr:134x/i
Rr:30x/i
T:37,8
Spo2:100%

Lab
Hb:9,0
Ht:29,4
Leukosit:13,7
 Trombosit:322
Gds:103

Dx: KDK +ISPA

Th.
Ivfd kaen 1B 20tpm mikro
Pct drops 4x1ml
Pct infus 10cc iv
Diazepam puyer 3x1mg
Inj. Ceftriaxone 2x500mg iv drip D5% 25 cc TS
Inj. Ondan 3x1 mg kp
Erdostein syr 2x1/2cth
Diet ML 1000K + ES 2x

9. Tn.K;70th;170cm;73kg
BAB cair 1 hari smrs, air > ampas, frekuensi > 10x/ hari, , mual , muntah.

Abdomen:
Nyeri tekan epigastrium +
BU meningkat , soepel, NTE +
Kes:cm
Td:104/67mmhg
Hr:95x/i
Rr:20x/i
T:36,4
Spo2:100%

Lab
Hb:13,5
Ht:40,4
Leukosit:12,7
Trombosit:211
Gds:144
Ur:58,3
Cr:1,62

Dx: GEA + AKI

Th.
Ivfd rl 20 tpm
 Inj. Ondan 1amp/12jam kp
Inj. Ranitidine 1amp/12jam
Zink 1x20mg
Metronidazole 500mg iv/8jam
L-bio 1x1 sachet
Antasida syr 3x1 c
Loperamide 2x1 tab

10. Ny.M;51th;150cm;58kg
Nyeri tengkuk 3 hari smrs,
Rpd: HT tidak terkontrol

Kes:cm
Td:225/127mmhg
Hr:110x/i
Rr:22x/i
T:36,7
Spo2:100%

Lab
Hb:13,8
Ht:38,5
Leukosit:8,7
Trombosit:270
Gds:162

Dx: HT

Th.
Ivfd nacl 0,9 % 20 tpm
Inj. Esola 1amp/24jam
Amlodipine 1x5 mg po
Captopril 3x25mg po

11. Tn.S;66th;167cm;70kg
Sesak napas 1 jam smrs, batuk, pilek 1 mgg

Thorak : vesicular +/+, wheezing +/+

 Kes:cm
Td:156/106mmhg
Hr:117x/i
Rr:22x/i
T:36,6
Spo2:100% O2 3lpm nasal kanul

Lab
Hb:14,0
Ht:44,6
Leukosit:16,7
Trombosit:363

Dx: asma bronkial

Th.
Ivfd rl 20 tpm
Inj. Ceftriaxone 2x1gr
n.acetysilstein 3x1tab
nebu ventolin /12jam

12. An.N;1th;100cm;12,8kg
Demam, batuk berdahak, pilek, sejak 3 hari smrs, mual muntah > 5x/hari
Imunisasi lengkap
Thorak : vesicular +/+

Kes:cm
Hr:135x/i
Rr:40x/i
T:38,2
Spo2:100%

Lab
Hb:13,5
Ht:39,0
Leukosit:8,1
Trombosit:160
Gds:144
 Dx: vomitus drs+ ispa

Th.
Ivfd kaen 1B 12tpm
Diet ML 1000K +ES 2X
Pct syr 4x1 cth
Pct infus 20cc iv
Inj.ondan 3x1mg kp
l-bio 1x1 sachet
erdostein syr 2x1/2 cth

13. An.F;11th;143cm;41,3kg
Demam, batuk , sejak 4 hari smrs, mual muntah > 5x/hari
Badan sakit semua

Thorak : vesicular +/+

Kes:cm
Hr:116x/i
Rr:22x/i
T:39,3
Spo2:100%

Lab
Hb:12,9
Ht:38,0
Leukosit:6,3
Trombosit:147

Dx: dhf

Th.
Ivfd kaen 1B 20 tpm
Diet ML 1800K +ES 2X
Pct syr 4x2 1/2 cth
Pct infus 30cc iv
Inj.ondan 3x3mg kp
erdostein syr 2x1 cth
14. An.A;5th;120cm;19,5kg
Demam, batuk berdahak, pilek, sejak 1 mgg smrs,
Thorak : vesicular +/+

Kes:cm
Hr:125x/i
Rr:24x/i
T:37,8
Spo2:100%

Lab
Hb:14,8
Ht:39,8
Leukosit:8,7
Trombosit:245
Widal +

Dx: demam typoid+ ispa

Th.
Ivfd kaen 1B 15tpm
Pct syr 4x2 cth
Pct infus 20cc iv
Inj.ondan 3x2mg kp
Eventolin 1 respul / 8jam
erdostein syr 2x1/2 cth
ceftriaxone 2x750 mg iv drip d5% 50cc tanpa ST

15. An.Mk;6th;122cm;16,7kg
Demam sejak 4 hari smrs, mual, muntah >2x/hari
Thorak : vesicular +/+

Kes:cm
Hr:135x/i
Rr:24x/i
T:37,4
Spo2:100%

Lab
Hb:13,8
Ht:40,1
 Leukosit:8,6
Trombosit:275
Widal +

Dx: demam typoid+ ispa

Th.
Ivfd kaen 1B 15tpm
Pct syr 4x 1 1/2 cth
Pct infus 16cc iv
Inj.ondan 3x2mg kp
Eventolin 1 respul / 8jam
erdostein syr 2x1/2 cth
ceftriaxone 2x750 mg iv drip d5% 50cc tanpa ST
ranitidine 2x20mg iv
diet ML 1500K + ES 2X

16. An.S;10 bln ;97cm;10,5kg

Bab cair >4x/ hari, air > ampas, Demam, batuk kering 2 hari smrs mual muntah setiap
makan

Thorak : vesicular +/+

Kes:cm
Hr:145x/i
Rr:24x/i
T:38,9
Spo2:100%

Lab
Hb:12,5
Ht:37,9
Leukosit:9,1
Trombosit:321

Dx: gea

Th.
Ivfd rl 200cc 15tpm
Pct syr 4x1 cth
Pct infus 10cc iv
 Inj.ondan 3x1mg kp
erdostein syr 2x1/2 cth
cefxim syr 2x1/2 cth
lbio 1x1 sachet
zink 1x20mg

17. Tn.A;21th;167cm;68kg
Nyeri BAK, demam, mual muntah sejak 4 hari smrs

Abdomen:

Nyeri tekan suprapubik +

Kes:cm
Td:116/96mmhg
Hr:87x/i
Rr:22x/i
T:36,9
Spo2:98%

Lab
Hb:13,7
Ht:39,2
Leukosit:9,3
Trombosit:359
Gds:143
Urin rutin: lekosit +1

Dx: isk

Th.
Ivfd rl 20 tpm
Inj. Ceftriaxone 2x1gr
Pct tab 3x500mg po
Inj. Ondan 2x1 amp
Inj. Ranitidine 2x1 amp

18. Ny .N;57th;158cm;68kg
Lemas sejak 2 hari smrs, luka terbuka pada kaki kanan
Rpd: DM
 Kes:cm
Td:156/96mmhg
Hr:77x/i
Rr:21x/i
T:36,7
Spo2:98%

Lab
Hb:11,7
Ht:34,2
Leukosit:24,6
Trombosit:491
Gds:592
Cr:1.35
Ur:53.3
Urin rutin: lekosit +1

Dx: dm
Th.
Ivfd nacl 20 tpm
Inj. Ceftriaxone 2x1gr
Inj. Ondan 2x1 amp
Inj. Ranitidine 2x1 amp

19. Ny.S;60th;155cm;65kg
mual muntah , nyeri uluhati, pusing, sejak 4hari smrs
rpd: HT tidak terkontrol

Abdomen: Nyeri tekan epigastrium +

Kes:cm
Td:211/ 106mmhg
Hr:89x/i
Rr:20x/i
T:36,2
Spo2:98%

Lab
Hb:11,1
Ht:31,2
Leukosit:13,3
 Trombosit:294
Gds:143

Dx: dyspepsia + ht

Th.
Ivfd rl 20 tpm
Inj. Ceftriaxone 2x1gr
Inj. Ondan 2x1 amp
Inj. Ranitidine 2x1 amp
Candersatan 1x16mg po
Sucralfat syr 3x1 c

20. Ny.S;36th;154cm;60kg
G3P2A0 gr 27-28 mgg dengan keluhan Demam , batuk sejak 4 hari smrs
Hpht:18-6-2021
Tp:25-3-2022

Thorak: vesikular

Kes:cm
Td:106/76mmhg
Hr:128x/i
Rr:20x/i
T:37,9
Spo2:98%
Djj : 157x/i

Lab
Hb:10,0
Ht:30,0
Leukosit:11,2
Trombosit:301
Dx: obs. febris

Th.
Ivfd rl 20 tpm
Inj. Ceftriaxone 2x1gr
Pct tab 3x500mg po
Vit c 2x1 tab