RESUME PASIEN

Sri Dewi Ardiani/30thn

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

GCS : E4V5M6
TD : 120/80
RR : 28
SpO2 : 97%

Tx :
1. Obgin
- IVFD RL 28 tpm
- Tokolitik Nifedipin ~ Stop, maintenance
adalat oros 3x30 mg
- Dexamethason 1x12 mg (2hr)

St General :

N : 89
Tax : 36,9
Mata : an-/-

RESUME PASIEN
Sri Dewi Ardiani/30thn
Oral : leukoplakia (+)
Thorax : Cor : S1S2 tgl reg m(-)
Po : Ves +/+, Rho +/+,
Whz -/Abdomen ~ St Obstetri
Ext : hangat
St. Obstetri :
Abdomen :

VT

TFU pst-px, ( 20cm) AC : 75

His (-) DJJ (+) 144x/m
Dist (+), BU sulit dinilai
Shifting dullness (+)
CD 2 cm, eff 25%, ket(+)
Kesan bokong, Sacrum transverse,

HI
Ttb bag kecil/tali pusat
LAB :
DL
Kimia
128/2,97
AGD

WBC : 21,1
Hb : 11,5
Hct : 36,8
Plt : 501
SGOT/PT : 34,2/6,7
Na/K :
BUN/SC : 31/2,4
Alb : 1,91
Na/K : 124/2,4
pH : 7,38
PCO2 : 49

2.
3.
-

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 >2,5
Pulmo
O2 sungkup
Ceftriaxone 2x1 gr (IV)
Azythromycin 1x500mg (PO)

RESUME PASIEN
Sri Dewi Ardiani/30thn
pO2 : 131
HCO3- : 29
PT : 13,6/12,1
APTT : 47,2/32,6 (memanjang)
LED I/II : 0/18
BT/CT : 1.30/8.30
UL

pH : 6,5
Ery : 5+

Protein : 3+
sedimen leuko : banyak
Bakteri +
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