Orchid 020219.doc

ORCHID 2 Februari 2019 NO MRS Pasien Dokter Diagnosis 602 1/2 An. Shafira Yustinah Rhinofaringitis, Azkia Firdaus, Demam dengue 9th, 223861 (H5)

603

1/2

An. Zahira Yasmi Anemia pada Ramadhaningru thalassemia mayor m, 13th, 127904

605 31/1 An. Rayyanka Yustinah Rhinofaringitis mauza, 1 thn . DCA 400761

606 28/1 An. Qistan Alif Yustinah DHF grade 2 (7) Santana An. 10 Faringitis thn 10 bln, 275899

Masalah

Terapi/Rencana RL 80cc/jam sanmol 250mg kp Omeprazole 2x20mg Praxion 5 ml kp, Puyer batuk (meptin 20mcg, vestein ½, rhinofed ½) 3x1

Ket Lab 01/02: Hb 14 Leu 2310 Ht 40.7 Tro 86000

R/ Cek DPL 2/2 Periproc 3x1

Lab 01/02: Hb 9 Leu 5320 Ht 25.2 R/ Tr Prc 2 kantong dengan Tro 124000 premed lasix 20mg IV dan dexamethason 5mg IV 1/2 RL 12 tpm Lab 31/1: Hb 13,1 Ht 38,4 puyer bapil 3x1 di ot Leu 4710 praxion 5 ml Tro 240000 sanmol drip 150 mg/30 menit B/E/N/L/M jika suhu diatas 38,5 0,4/0,0/49,3/43,1/7,2 cefotaxim 3x300mg ranitidin 2x15 mg lacto-B 2x1 p.o Zink 1x5 cc p.o RL 30cc/jam Lab 28/1: Hb: 15,2 Nebu combivent : Ns 2 leu:5,300 ht:45 cc/8jam trom:119.000 sanmol 300 mg/ 30 menit jika B/E/N/L/M 0,2 suhu 38,5 atau sakit kepala Omeprazole 2x30 mg iv Lab 29/1 : Hb 14.5 Tempra F 7,5 ml, Leu 4970 Ht 42 orezink 1x 5 ml, Tro 67000 liprolac 2x1 sac (HOS) (ketrin 3 mg, vestein 1/2 kaps, Lab 30/1 : Hb 16.2 meptin 20 ugr) 3x1 kaps Leu 7840 Ht 48.4 Tro 28000 R/ Cek DPL (2/2) IgG dan IgM anti Dengue positif

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Lab 31/1: Hb 13,3 Ht 38,9 Leu 8530 Tro 30000

609

1/2

An. Farras Aufa Yustinah Febris hr ke 5 ec Permana. 5 Th . Parotitis dextra, 299118 Dengan dehidrasi ringan sedang

610

1/2

An. Ayyub Adnan Esya Ardiansyah, 9bln, 434530

Cece Anemia ec susp Leukimia akut dd/ Thalassemia

611 30/1 An. M Gading Yustinah Rhinofaringitis 8 Th 2 Bln akut 283730

RL 12 tpm Makro Cefixime 2x3,5 ml Sanmol 3x 5 ml PO, Jika Suhu > 38,5 Propyretic 160 mg Supp R/ Tr PRC 3x (2x40ml, 1x100ml) 1/2

Rl 15 tpm Cefotaxime 3x 600mg Sanmol drip 300mg selama 30 menit bila suhu >38.5

Lab 01/02 : HB 13.1 Leu 7760 Ht 38.3 Tro 53000 Lab 1/2/19: Hb 10.2 Leu 13610 Ht 29.0 Trom 409.000 B/E/N/L/M 0.2/0.7/88.3/6.5/4.3 Lab 01/02: Hb 5.5 Leu 7760 Ht 24.3 Tro 296000 B/E/N/L/M 0.3/5.2/2/77.2/15.3 Lab 28/1: Hb 14.3 Leu 4030 Ht 41.3 Trom 338000 B/E/N/L/M 0.5/0/47.1/39.1/13.2

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615 30/1 An. Raffasya Yustin, Rhinobronkitis Akbar, 5 bln 11 Kobal hari, 441738

615

1/2

An. Syakira Ramdhani, 8bl, 453601

616 29/1 An. Farel, 11 thn . 414634

617

1/2

618 31/1

Ismet Febris ec viral infection, Obs seizure ec epilepsi? Yustinah Viral infection

An. Raesa Yustinah Hiperpireksia Lutfah Kamila, pada febris H-2 ec 1th, 415369 Rhinofaringitis akut An Muhammad Ismet Hiperpireksia e.c Fatih Marzuki, farngitis 2 th 10 bln, tapp off terapi 394317 epilepsi

618 10/1 An. Daffa Cece co Infeksi CMV ramadhan, 7bln, Ismet co kongenital, 0452010 Hessy Katarak Asmawa kongenital, ti co penyakit jantung Ramzi kongenital, co GDD, mikrosefali Chandra → Vebi Sherly

Praxion forte 5 ml bila T > 38 Puyer bartuk pilek 3x1 pulv Orezink 1x 5 ml Liprolac 2x 1 Sachet, combivent:NS/8jam Puyer 3x1 (ketricin 3mg, meptin 20 ugr, vestein ½ kaps, rhinofed ½ tab) IV Plug Lab 30/1: Hb 10 Leu 5980 Puyer batuk ( Triamcinolon Ht 31 Tro 268000 0.5mg, Salbutamol 0.7mg, Vestein ¼, rhinofed 1/3) 3x1 Cefotaxim 3x250mg Combivent1/2:NS/6jam Paracetamol 100 mg kp suhu>38,5 Sanmol drop 0,8cc kp demam Chest fisioterapi D5% ½ ns + Kcl 25meq 10cc/jamPhental 35 mg dalam NS 25cc/12jam, Sanmol 60mg kp Ceftriaxone 1x60mg Dexamethason 3x1 RL 15 tpm bila demam -> PCT tablet 3x500mg bila 38,5 C berikan PCT infus 500mg iv selama 30 menit cefotaxime 2x1gr Dexamethason 2x1 Erdostein 3x1 Omeprazole 2x1 R/ cek DPL 2/2 RL 12 tpm makro Cefotaxim 3x300mg Paracetamol 5 ml kp Proris 125mg kp R/ Cek UL 1/2 RL 6 tpm makro Cefotaxim 3x300 mg, paracetamol 3x100mg, kepra 1x90mg puyer 2x1 (salbutamol0,5 mg, cetirizin 0,5 mg, methyl prednisolon)

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Lab 01/02: Hb 10.2 Leu 4990 Ht 30 Tro 432000 Na/K/Cl 139/4.2/107

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Lab 29/1: Hb 12,6 Ht 35,1 Leu 9630 Tro 274000 B/E/N/L/M 0,1/0,0/87,5/5,4/7,0

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Lab 01/02 : Hb 13.5 Leu 2900 Ht 38.1 Tro 144000

Lab 01/02: Hb 11.4 Leu 24760 Ht 33.1 Tro 395000

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Lab 31/1 : Hb 10.8 Leu 9190 Ht 32 Tro 335000

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Lab 01/02 : Hb 11.4 Leu 6059 Ht 34.3 Tro 267000 malaria mikroskopik tidak ditemukan Operasi Kaen 1 B 4 cc/jam Lab 10/1: reticulosit 2. katarak Ceftriaxon 2x250mg (iv) Hb 11,1 leuko 16880 (cece tdk Cymevene 2x25mg (2minggu, HT 32 Tro 360000 acc) 28 kali pemberian) → 26/28) Alb 3,5 Bil tot 0,09, bil direk 0,05 bil ind 0,05 R/ Tes ASSR dan OAE → ot/pt 34/13 gamma GT 58 jadwal tunda tgu Cimeven Ur/Cr 8/0,25. selesai anti rubela IgG non reaktive. Anti rubella IgM negatif. R/Echo 28/1 jam 19.00 → Anti Toxo IgG/IgM

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Tunda sampai cymevene selesai

non reactive. GDT: anemia normositik normokrom, (hasil lab prodia by Phone anti CMV IgG + 59,2) CT head 11/1: Toxoplasmosis Tes BERA 14/1 : 70/80 Vena Seksi 16/1 vena sectie 28/1 jam 18.30

619 31/1 An. Khalis, 1 thn . 420001

Yasmi DD dd/ DBD

IVFD RL gtt 10 makro parasetamol drop 4 x 0,9 cc Ranitidin 2 x 10 mg

Lab 31/1: Alb 3,5 Ur/Cr 7/0,25 Egfr 238,7 Lab 31/1: Hb 10,7 Ht 32,6 Leu 5620 Tro 130000 B/E/N/L/M 0,2/1,1/30,8/61,7/6,2

2

R/ Cek serial DPL

619 31/1 An. Ainiya Faida Azmi 1 th 5 buln, 422841,

Fakhrul, palatoschizis Co Bilateral Yasmi co rahmat

IVFD RL/24 jam Cefotaxime 2x200mg PCT 3x3/4 cth

Lab 01/02 : Hb 11.1 Leu 7110 Ht 32.7 Tro 146000 Lab 31/1: PT/APTT/INR 9,9/0,93/39,9 (K 9,1/0,85/30) OT/PT 39/13 Ur/Cre 22/0,25 eGFR 200

2

Ro Tho 31/1: Normal

621 13/1 An Dhavin Rezky Aulia, 7th 5bln, 452247 PICU 16*

Ismet, Anthar co Rahmat co Sulung co Kobal

Penurunan kesadaran ec meningoensefalitis TB perbaikan , Hidrocephalus Post VP shunt, Stress ulcer perbaikan, HT stg II

Binasal 3lpmRA 20cc/jam, Meropenem 3x500mg Omeprazole 1x30mg, Piracetam 3x500mg, Paracetamol 250mg/6jam kp Prednison 3x5mg , INH 1x300mg, Rifampicin 1x350mg, Pirazinamide 1x500mg, Ethambutol 1x500mg, Vit B6 1x10mg, Valepsy 3x5ml bila TD > 97/54 Captopril 3x25mg, bila TD < 97/54 Captopril 2x25mg MC 6x100ml

Post palatoplasty 01/02 jam 08.00) Lab 13/1: Hb 12 Leu 16120 Ht 34,8 Trom 564000 ur 30 cr 0.42 eGFR 183,6 Na 131 K 3,9 cl 96 Kultur darah steril ro thorax 14/1 : Pneumonia (Spesifik? Nacl 50ml+phental 250mg 13/1 CT Scan kepala dengan kontras 14/1: Meningo-encephalitis dg hydrocephalus derajaT Sedang Lab 15/1: HBsAg negatif Anti HIV non reaktif PT 9,9(10,3) INR 0,93(0,96) APTT 28,1(29,7)

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analisa cairan otak bekuan negatif, agak keruh, Pandy negatif, Nonne negatif, sel MN 84 sel PMN 16 sel abnormal negatif klorida LCS 112 glukosa cairan 55 VP Shunt 15/1 Lab 16/1: Hb 10,3 Leu 11810 Ht 19,8 Tro 375000 Ro Thorax 16/1 : Normal Lab 17/1: Hb 10.8 Leu 9240 Ht 31.4 Tro 378000 PT 9.4(10.5) INR 0.88(0.98) APTT 31.7(33.2) GDS 19/1: 88 Ekstubasi + Kultur ujung ett (23/1) Lab 24/1: AGD pH 7.394 PO2 48 PCO2 63.5 SaO2 81 HCO3 39.1 BE 14 (darah Vena?) kultur ujung ETT: Klebsiella pneumonia, sensitif ( Ertapenem, Amikasin, Piperacillin tazobactam, ciprofloxacin, Tygecillin, nitrofurantoin, meropenem) Aff hecting selang-seling (24/1)

621

2/2

An. Fadhlan Ahmad Imanulhaq . 9 Th . 453615

Ismet CKR GCS 15 dengan amnesia retrogade

622

1/2

An. Abiyyu Rifid Rafardhan, 3 thn 7 bln, 361353

Yustinah Rhinofaringitis Chelitis angularis

RL 8 tpm makro Ceftriaxone 2x1 gr Piracetam 3x 500 mg

RL 12 tpm makro Cefotaxime 3x400mg iv Paracetamol 5cc kp S>38, Proris 125 kp S>38,5 Kenalog oral (sama ortu) Puyer batuk (Salbutamol 1,4mg , vestein 1/3, rhinofed 1/3) 3x1

Lab 25/1: Na/ K/ Cl 128/ 4/ 83 Lab 2/2/2019: Hb 13.9 Leu 11.040 Ht 37.5 Trom 511.000

Lab 1/2 : Hb: 11,6 Leu: 891 HT: 34,4 Trom: 223.000 b/e/n/l/m 0,4/0,1/78,7/7,3/13,5 Lab 01/02 : Normal

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622

2/2

An. Muhammad Desi DCA dehidrasi Ar Rayyan . 4 ringan-sedang, Th . 434596 Observasi vomitus dengan dehidrasi ringan

RL 10 tpm makro Acran 2x15 mg Orezink 1x1cth, Lasidofil 1x1 sachet, Vometa 3x3/4cth kp muntah, Praxion 4x1cth R/ Cek Darah samar , Sampel -

Lab 2/2/2019: Hb 12.8 Leu 7730 Ht 35.5 Trom 293.000 B/E/N/L/M 0.3/0.1/77.1/14.1 Na/K/Cl 134/3.3/100

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