DAFTAR PASIEN CEMPAKA 1 NEONATUS 28 Januari 2017

KM IDENTITAS MRS DIAGNOSIS AWAL DIAGNOSIS AKHIR TERAPI PLAN OF CARE

R/B
ED
1.1 By I Sri Ratna 05/01/2 BCB (30-31 minggu) BCB (30-31 minggu) - ASI + HMF 34ml tiap 3 jam
Dewi 017 + BBLR (1300 + BBLR (1300 - FE elemental 0,3 ml tiap 24
P/ 05.01.17 gram) + aspirasi gram) + SMK + jam peroral
17000677 berat + SMK + pneumonia - Apyalis drop 0,3ml tiap 24
respiratory distress neonatal (membaik) jam peroral
ec HMD dd/ + retina imatur ODS
pneumonia + icterus
neonatal dd/ SNAD neonatorum ec
prematuritas
1.2 I Komang Eka 20/01/2 Bayi kurang bulan Bayi kurang bulan - ASI + HMF 30 ml tiap 3 jam Diagnostic:
Pradana Putra 017 (36-37 minggu) + (36-37 minggu) + - Re-echo
L/ 30.12.16 BBLR (1600 gram) BBLR (1600 gram) april 2017
17001635 + gemeli + PJB + gemeli + TOF Monitoring:
sianotik ec suspek with pulmonary - Cyanotic
TGA dd/ atresia atresia turtous spell,
pulmonal moderate PDA, PFO failure to
thrive,
pulmonary
hipertensi
1.3 By Parida 27/01/2 BKB (36 minggu) + BKB (36 minggu) + -Trofik feeding Diagnostic:
P/ 27.01.17 017 SMK + respiratory SMK + respiratory -IVFD D12,5% 128ml + Nacl - Tunggu
17003831 distress ec suspek distress ec suspek 3% 11ml + KCL 2,5ml + ca hasil kultur
pneumonia pneumonia gluconas 2,5ml + aminofusin darah 2 sisi
neonatal dd/ suspek neonatal ped 50 ml, GIR 4,3, kecepatan (27/1/17)
sepsis neonatal 8ml/jam
awitan dini -2 ampicilin 130mg tiap 6 jam
(IV)
-Amikasin 20mg tiap 12 jam
(IV)
-CPAP support weaning
1.4 Kosong -
1.5 By Ni Wyn Sri 23/1/20 Bayi cukup bulan + Bayi cukup bulan + -4 ceftriaxone 100mg tiap 12 Monitoring: vital
Astuti 17 sesuai masa besar masa jam (IV) sign
P/ 23.01.17 kehamilan + kehamilan + -Paracetamol drip 3ml tiap 6
17003364 asfiksia sedang + asfiksia sedang + jam (IV)
hidrocepalus dd/ hidranencepali post
hidranencepali + VP shunt hari ke 3
hemangioma regio + hemangioma
femoral regionfemoral
1.6 By Kumala Sari II 12/1/20 Bayi kurang bulan Bayi kurang bulan - ASI 26ml tiap 3 jam Diagnostic:
P/ 11.01.17 17 (30 minggu) + (30 minggu) + - Aminofilin 3,5 mg tiap - Screening
17001635 BBLSR (1100 gram) BBLSR (1100 gram) 12 jam peroral ROP
+ SMK + respiratory + SMK + HMD (2/2/17)
distress ec suspek grade III + bacterial Monitoring:
HMD dd/ pneumonia sepsis of newborn Keluhan dan vital
neonatal + apnea of unspecified + sign
prematurity + apnea of
suspek sepsis prematurity +
neonatal awitan dini omphalitis + icterus
+ gemeli II neonatorum ec
prematurity
1.7 By Ibu Nin 19/01/2 BKB (31-32 minggu) Apnea of -ASI 4ml tiap 3 jam 36ml Diagnostic:
Komang Tika 017 + BBLR (1590 prematurity + BKB tiap 3 jam - Cek
Riandani I gram) + SMK + (31-32 minggu) + -IVFD D10% 185ml + Nacl 3% elektrolit
L/ 26.12.16 moderate PDA + BBLR (1590 gram) 12ml + KCL 2,5ml + Ca Monitoring:
17002897 PFO + mild TR + SMK + moderate gluconas 2,5ml + aminofusin Keluhan dan vital
PDA + PFO + mild paed 6% 40ml, GIR: 8, kec: sign
TR + suspek 8ml/jam
hipoksik -CPAP support (PEEP 6, flow 8,
encepalopati grade FiO2 21%)
I + hiponatremia
1.8 By Hikmah 9/1/201 Suspek sepsis Suspek sepsis -14 meropenem 96mg tiap 8 Diagnostic:
L/ 29.12.16 7 neonatal awitan neonatal awitan jam (IV) - Evaluasi
17001243 lambat + kolestasis lambat + suspek -5 fluconazole 6mg tiap 72 jam LFT saat
intrahepatal dd/ meningitis + -Transfuse PRC 2x20ml fluconazole
ekstrahepatal + kolestasis -Trabsfusi TC 3x30ml hari ke 7
hiponatremia intrahepatal dd/ - LP evaluasi
ekstrahepatal + jika >
suspek stenosis 50.000
duodenal - Cek septic
marker
post
transfuse
Monitoring:
- Tanda vital,
klinis