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RESUME PASIEN Sri Dewi Ardiani/30thn S Nyeri Perut Hilang timbul (-) Keluar Air pervaginam (-) Gerak Anak (+) baik Sesak (+) Riwayat nyeri BAK (+) BAB cair (+) hingga 4x.hr Riwayat batuk lama (+), demam sumer-sumer sejak 1 bln yll BB menurun sejak 3 bln Pdx : 1.Obgin - Cek marker sepsis? 2.Tropik-infeksi - BOF - USG Urologi - Protein esbach @24jam - FL + cryptospora - UL - Swab lidah KOH - UC/CC/ST - Analisa cairan ascites - Analisa cairan pleura - HbsAG, Anti HCV 3.Pulmo - Sputum BTA 3x, Gen expert (cek resistensi INH) - Kultur sputum/sensitivity test - Rontgen thorax ulang setelah 7hr AB
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RESUME PASIENSri Dewi Ardiani/30thn
S Nyeri Perut Hilang timbul (-)Keluar Air pervaginam (-)Gerak Anak (+) baikSesak (+)Riwayat nyeri BAK (+)BAB cair (+) hingga 4x.hrRiwayat batuk lama (+),demam sumer-sumer sejak 1 bln yllBB menurun sejak 3 bln
Pdx :1. Obgin
- Cek marker sepsis?2. Tropik-infeksi
- BOF- USG Urologi- Protein esbach @24jam- FL + cryptospora- UL- Swab lidah KOH- UC/CC/ST- Analisa cairan ascites- Analisa cairan pleura- HbsAG, Anti HCV
3. Pulmo- Sputum BTA 3x, Gen expert (cek resistensi
INH)- Kultur sputum/sensitivity test- Rontgen thorax ulang setelah 7hr AB
O GCS : E4V5M6TD : 120/80 N : 89RR : 28 Tax : 36,9SpO2 : 97%
St General : Mata : an-/-
Tx :1. Obgin- IVFD RL 28 tpm- Tokolitik Nifedipin ~ Stop, maintenance adalat
oros 3x30 mg- Dexamethason 1x12 mg (2hr)
RESUME PASIENSri Dewi Ardiani/30thn
Oral : leukoplakia (+)Thorax : Cor : S1S2 tgl reg m(-)
Po : Ves +/+, Rho +/+, Whz -/-Abdomen ~ St ObstetriExt : hangat
St. Obstetri :Abdomen : TFU ½ pst-px, ( 20cm) AC : 75
His (-) DJJ (+) 144x/mDist (+), BU sulit dinilaiShifting dullness (+)
VT : CD 2 cm, eff 25%, ket(+)Kesan bokong, Sacrum transverse, HITtb bag kecil/tali pusat
LAB :DL WBC : 21,1 Hb : 11,5
Hct : 36,8 Plt : 501Kimia SGOT/PT : 34,2/6,7 Na/K : 128/2,97
BUN/SC : 31/2,4Alb : 1,91
AGD Na/K : 124/2,4pH : 7,38 PCO2 : 49pO2 : 131 HCO3- : 29PT : 13,6/12,1APTT : 47,2/32,6 (memanjang)
2. Tropik-infeksi- IVFD NS + KCL 50 meq- Diet TKTP- Nystatin drop 3x20 gtt- ARV : efaviren 1x600mg, Duviral 2x300mg
(PO)- Fluconazole 1x150mg (PO)- Ambroxol 3xC1- Transfusi albumin 20% s/d alb >2,53. Pulmo- O2 sungkup- Ceftriaxone 2x1 gr (IV)- Azythromycin 1x500mg (PO)
RESUME PASIENSri Dewi Ardiani/30thn
LED I/II : 0/18BT/CT : 1.30/8.30
UL pH : 6,5 Protein : 3+Ery : 5+ sedimen leuko : banyak
Bakteri +
A G4P2102 28 mg T/H, letak lintang, f.up PPI- Infeksi HIV std IV pre HAART
- Susp TB Paru- CAP PSI class IV- Wasting syndrome- Oral candidiasis
- ACKD pre-renal on CKD ec Susp. HIV Acquired Nephropathy dd/GNC
- Hipoalbuminemia ec. Low intake + Loss- Ascites Grade II- Efusi pleura minimal
- ISK Komplikata Sepsis berat
Mx:- Kel, VS- CM-CK- Tanda-tanda inpartu- Albumin post transfusi- BUN/SC, AGD elektrolit @ hari
Cek Kalium
