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  • 28 Ok 2015

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    Bumi Agung
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    A 33-year-old patient presented with fever, decreased consciousness, and was suspected of having meningoencephalitis, immunocompromise, or polycythemia vera. The patient was given oxygen, IV fluids, antibiotics, anti-inflammatory drugs, and anti-seizure medication. Blood tests showed increased white blood cell count, hemoglobin, hematocrit, and liver enzymes. A CT scan of the head and consult with neurology were planned.

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    28 ok 2015

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    A 33-year-old patient presented with fever, decreased consciousness, and was suspected of having meningoencephalitis, immunocompromise, or polycythemia vera. The patient was given oxygen, IV fluids, antibiotics, anti-inflammatory drugs, and anti-seizure medication. Blood tests showed increased white blood cell count, hemoglobin, hematocrit, and liver enzymes. A CT scan of the head and consult with neurology were planned.

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    0 views1 page

    28 Ok 2015

    Uploaded by

    Bumi Agung
    A 33-year-old patient presented with fever, decreased consciousness, and was suspected of having meningoencephalitis, immunocompromise, or polycythemia vera. The patient was given oxygen, IV fluids, antibiotics, anti-inflammatory drugs, and anti-seizure medication. Blood tests showed increased white blood cell count, hemoglobin, hematocrit, and liver enzymes. A CT scan of the head and consult with neurology were planned.

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    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
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    of 1

    No

    Identitas

    Assessment

    1.

    SMS/33th/L/
    Tampaksirin
    g/543583
    18.30 WITA

    Penatalaksanaan

    Planning

    Febris hr I
    Meningoensefalitis +
    Susp
    Imunocompromise +
    Susp Polisitemia Vera +
    Susp SOL

    O2 3 lpm
    IVFD RL 28 tpm
    Sanmol 3 x 1 gr (iv)
    Ceftriaxone 3 x 2 gr
    (iv)

    Penurunan kesadaran
    ec Susp
    Meningoencefalitis dd
    SOL
    Susp Polisitemia Vera
    Susp
    Immunocompromise

    Cek DL ulang,
    jika Hb tetap
    tinggi
    phelebotomy
    CT-Scan
    Kepala
    dengan
    kontras

    Konsul Neurologi
    Piracetam 3 x 1 gr
    (IV)
    Ketorolac 3 x 30 mg Mx
    Keluhan
    (IV)
    Diazepam 10mg (IV) Vital Sign
    pelan
    Dexametasone 4 x 4
    mg (IV)
    Ranitidin 2 x 50 mg
    (IV)

    GCS: E2V1M6
    TD :120 /80 mmHg
    N : 92 x/mnt
    RR :40 x/m
    Tx : 39,5 C
    DL:
    WBC: 25,1 (H), Lymph%:6,9 (L) , Gran%: 86,0 (H),
    RBC: 8,10 (H) , Hb: 23,3 (H) , HCT :71,0 (H) ,
    MCV:87,7 (N) , MCH : 28,8 (N) PLT : 190 (N)
    GDA: 127 (N)
    Ureum: 25 (N)
    Creatinin: 1,0 (N)
    SGOT: 89 (H)

    Elektrolit :
    Natrium: 143 (N)
    Kalium: 4,4 (N)
    Clhorida: 107 (N)

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