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IDENTITAS PASIEN
Campak : 9 bulan
WHZ : -2,38
WAZ : -2,53
HAZ : -1,72
Anthropometri
Cross sectional : Gizi kurang perawakan normal
RIWAYAT PERKEMBANGAN
Senyum (+) 2 bulan
Tengkurap (+) 4 bulan
Berdiri (+) 10 bulan
Berjalan (+) 12 bulan
SGOT 15-34 27
Hb (g/dL) 11 13 12.1 (U/L)
Ht (%) 36 44 35.9 SGPT 15-60 17
Ureum 15-39 73
Erit (juta/uL) 3.1 5.1 4.61 (mg/dl)
MCH (pg) 23 31 26.2 Kreatinin 0.60-1.30 0.8
(mg/dl)
MCV (fL) 77 101 77.9 Natrium 136-145 127
MCHC 29 36 33.7 (mmol/L)
(g/dL) Kalium 3.5-7.2 3.4
Leu 5.5-15.5 22.4 (mmol/L)
(ribu/uL) Chlorida 98-107 88
Tro (ribu/uL) 150 400 295 (mmol/L)
Calcium 2.12-2.52 1.95
RDW (%) 11.6 14.8 13,3 (mmol/L)
MPV (fL) 4 11 10.2
Ro thorax (28-2-17)
Daftar Masalah
Sesak
Batuk
Gizi buruk
Klinis down syndrome
PJB asianotik
DIAGNOSIS
Bronkopneumonia
Klinis Down syndrome
Severe Acute Malnutrition
DE: PJB asianotik
DA: suspek VSD
DF: gagal jantung ross II/III
TATALAKSANA
O2 nasal 2 lpm
Infus D5 1/2 NS 120/5/5 tpm mikro
Injeksi ampisilin 100 mg/6 jam intravena
Injeksi gentamisin 7 mg/24 jam intravena
Po:
Digoxin 2 x 0.05 mg
Furosemid 2 x 1 mg
Diet:
ASI 250 ml
Tatalaksana
Program
- Evakuasi KU, TV, distress pernapasan
- Nebu Ventolin 1 respule dilanjutkan pulmicort
1 respule/8 jam
- Suction post nebul
Cairan (D) Kalori Protein
400 ml (100kkal/kg/hr) (1 gr/kg/hr)
400 kkal 4 gr
Mohon Asupan
Terima Kasih