TANGGAL : 2 AGUSTUS 2013

LAPORAN HARIAN GIZI ENDOKRIN

DR. ANDRA/DR. LIVI/ DR. FAJAR/DR. FAHMI/ DR. DESMAN

NO 1 lt.2

NAMA Devia/Pr/15th/125cm/19kg 13020548/092572 MRS: 20-7-13

DIAGNOSIS DM tipe 1 + short stature + delayed puberty + retensio urin ec sistitis dd/neurogenic bladder + hipokalemia + gangguan gait ec ? + kejang tanpa demam ec ?

TERAPI RB nefro D5 1/2NS Novorapid 3x4 iu levemir 1x10iu ceftriaxon 1x2gr (10) ampicillin 3x700mg(8) lynoral 1x1/4 tab calnic syr 1x1cth R/MRI lumbal IV s/d sacral V tanggal 19/8/13 konsul ulang neuropediatri mengenai kejang tanpa demam (interpretasi EEG)

LAB 20/7 hb 12,8 ht 35 L 8300 Tr 430000 LED 101 DC 0/2/1/45/45/7 PT 7,2 alb 3,8 SGOT 29 SGPT 23 BSS 301 Ur/Cr/as.ur 47/0,4/6 chol 205 CRP(+)7 Na 138 K 2,1 Ca 8,7 Cl 86 P 3,8 22/7 hb 11,8 ht 34 L 17200 Tr 355000 DC 0/0/0/77/14/9 USG TUG cystitis 23/7 UR glu +3 keton(-) bakteri+3 L 0-3 E 0-1 24/7 K.urin E.faecalis sens:penisilin G, ampisilin, vancomysin, amox clavulanat 26/7 BNO& lumbosacral TAK hb 11,1 ht 31 L 6400 Tr 322000 DC 0/30/54/29/14 Ur/Cr/As.ur 21/0,3/3,2 Na 138 K 2,4 Ca 8,2 Cl 95 P 32,3 AGD FiO2 97 pH 7,57 pCO2 55,8 pO2 90,5 HCO3 51,0 Beecf 28,7 30/7/13 hb 12,4 ht 36 L 13200 Tr 352000 LED 22 DC 0/2/0/32/59/10 SGOT 221 SGPT 158 PT/alb 6,7/4,3 BSS 75 Ur/Cr/as.ur 15/0,22/4,1 Na 142 K 4,7 Ca 10,1 Cl 112 P 5,1 CRP(-)

2 lt.1

Aprilia/Pr/3,5bln/55cm/3,5kg 13022146/750417 MRS: 30-7-13 med: 4,5 -1SD=4,2 -2SD=3,8 3SD=3,5

marasmus K.V + soft tissue tumor regio colli sinistra + tonsilitis kronis + gangguan fungsi hati

3 lt.1

by. Salimah/Pr/50cm/2,2kg 13021739/750894 MRS: 1-8-13 med: 3,4 -1SD=3,1 -2SD=2,8 -

marasmus K II + dehidrasi berat + bronkopneumonia + oral moniliasis + FTT + hiponatremia + hipokalemia

F75 12x40cc kotrimoxazol 2x48mg (3x1cc)(4) ambroxol 3x3mg (3x1cc) PCT 3x2cc bila T>38,5C vit B/vit C/as.folat 1x1tab menunggu hasil K.darah&urin R/USG colli Sx menunggu hasil biopsi benjolan colli Sx F75 12x25cc (cek residu) rehidrasi lambat dengan RLG mulai pukul 11.00 tgl 2-8-13 4jam I220cc 55cc/jam

1/8 hb 12,8 ht 34 L 20600 Tr 470000 MCV/MCH/MCHC 76,3/29/38 LED 2 DC 0/1/0/52/37/10 ret 1,5 ALP 125 SGOT 87 SGPT 52 GGT 63 PT/alb 5,5/3,9 BSS 82 Ur/Cr/asur

TANGGAL : 2 AGUSTUS 2013

LAPORAN HARIAN GIZI ENDOKRIN

DR. ANDRA/DR. LIVI/ DR. FAJAR/DR. FAHMI/ DR. DESMAN

3SD=2,6

+ susp trakeomalasia

4 lt.1

andini/Pr/1th 3bln/ 5,1kg 13021772/750973 MRS: 1-8-13

marasmus K II + Bronkopneumonia + ulcus R. Temporalis + susp ODHA

20jam II 330cc 16,5cc/jam ampisilin 3x75mg(1) gentamisin 2x3mg(1) Nystatin drop 4x0,2cc vit B/vitC/as.folat 1x1tab O2 HB 5L/m menunggu hasil K.darah&urin dikirim tgl 2-8-13 menunggu expertise Ro thorax konsul THT (?) timbang BB tiap hari obs muntah&BAB cair F75 12x55cc D5 1/4NS 6makro ampisilin 4x250mg(1) gentamisin 1x40mg(1) vitB/vitC/as.folat 1x1tab akilen eardrop 2x5gtt ADS H2O2 3% eardrop 2x5gtt ADS menunggu hasil K.darah&urin dan K.swab abses R/transfusi WB 1x150cc Transfusi albumin 25cc/hari (1) R/bilas lambung BTA R/mantoux test explorasi TB & HIV

26/0,19/2,4 Na 111 K 5,7 Ca 9,2 Cl 90 CRP(-) GDT : menyusul

1/8 hb 6,4 ht 23 L 15800 Tr 306000 MCV/MCH/MCHC 70,6/20/28 LED 6 DC 0/0/0/60/30/10 ret 2,2 ferr ? SI 20 TIBC 21 SGOT 28 SGPT 29 PT/alb 4,1/1,4 BSS 113 Ur/Cr/asur 14/0,09/1,4 Na 132 K 3,2 Ca 7 Cl 102 CRP(+)165 GDT menyusul