27 febuari 2015

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LAPORAN HARIAN RESPIROLOGI Periode : Febuari 2015 Jumat , 27/02/2015 Madya : dr. Gita/ Senior : dr. Yasmien/dr. Livi/dr. Zakaria No Identitas Diagnosis Tatalaksana Laboratorium Masalah 1 Lt 3 Km11 Adrian Almughini/Lk/9 tahun BB : 23.5 kg PB : 129 cm 476464/15005079 MRS 21/02/2015 R : 7 Asma episodik sering serangain berat + faringitis akut + Gizi kurang 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 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 Ampicillin 3 x 300 mg iv (4) Kloramfenikol 3 x 250 mg iv (4) Paracetamol 3 x 100 mg (bila T > 38.5˚C) Diet NB 3x 1 porsi + FC (F100) 3 x 200 cc 24/02/2015 Hb : 10.5 Leu 6000 Tr 215000 LED 70 DC 0/0/48/41/11 CRP (+) 41 Ekspertise Ro Thorax : Air bronchogram (+) Infiltrat di perihiler kanan dan kiri Kesan : bronkhopneumoni a dd/ TB paru Menunggu hasil mantoux 3 Lt 1 Km 3 Meysha Novianti/Pr/1th 9bln BB : 10 kg PB 85 cm 870856/15005495 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 4 Lt 1 Km 3 Solahudin Al Ayubi/Lk/5 bln BB : 6.2 kg PB : 72 cm 878479/15005574 MRS 26/02/2015 Bronkhopneumonia + Motorc delayed + Susp Hipotiroid kongenital IVFD D5 ¼ NS gtt 6 makro Ampicillin 3 x 250 mg (2) Klormfenikol 3 x 125 mg (2) O2 nasal 1L/mnt Diet Asi on demand 26/02/2015

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Page 1: 27 febuari 2015

LAPORAN HARIAN RESPIROLOGI Periode : Febuari 2015 Jumat , 27/02/2015 Madya : dr. Gita/ Senior : dr. Yasmien/dr. Livi/dr. ZakariaNo Identitas Diagnosis Tatalaksana Laboratorium Masalah1

Lt 3Km11

Adrian Almughini/Lk/9 tahunBB : 23.5 kg PB : 129 cm476464/15005079MRS 21/02/2015R : 7

Asma episodik sering serangain berat + faringitis akut + Gizi kurang

Ceftazidime 3 x 600 mg (7) ivDexamethason 3 x 7 mg iv STOPSalbutamol 3 x 2 mg poNebulasi dengan ventolin /12 jamO2 nasal 1L/mnt Diet NB 3 x 1 porsi + FC (F100) 4 x 200 cc

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

2Lt 3

Km 8

Fitri Ramadani/Pr/1 th 6 blnBB : 9 kg PB : 77 cm877814/15005274MRS 24/02/2014R : 4

Bronkhopneumonia + Gizi Kurang

Ampicillin 3 x 300 mg iv (4)Kloramfenikol 3 x 250 mg iv (4)Paracetamol 3 x 100 mg (bila T > 38.5˚C)Diet NB 3x 1 porsi + FC (F100) 3 x 200 cc

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

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

3Lt 1

Km 3

Meysha Novianti/Pr/1th 9blnBB : 10 kg PB 85 cm 870856/15005495MRS 26/02/2015R : 2

Asma episodik jarang serangan berat + Gizi Kurang

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

26/02/2015

4Lt 1

Km 3

Solahudin Al Ayubi/Lk/5 blnBB : 6.2 kg PB : 72 cm878479/15005574MRS 26/02/2015R : 2

Bronkhopneumonia + Motorc delayed + Susp Hipotiroid kongenital

IVFD D5 ¼ NS gtt 6 makro Ampicillin 3 x 250 mg (2)Klormfenikol 3 x 125 mg (2)O2 nasal 1L/mnt Diet Asi on demand

26/02/2015

5Lt 1 Km3

Syifa Ramadani/Pr/3 tahunBB : 11 kg PB : 88 cm878485/15005587MRS 26/02/2015R : 2

Asma Episodik jarang serangan berat + TDBD grade I + Gizi kurang

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