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. 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