Meningoensefalitis Ec Susp. Bakteri

8/16/2019 Meningoensefalitis Ec Susp. Bakteri

http://slidepdf.com/reader/full/meningoensefalitis-ec-susp-bakteri 1/20

MORNING

REPORT

SELASA2016



IDENTITAS PASIEN Nama : INRM

Usia : 39 tahun

!nis "!#amin : La"i$La"i

Su"u : %a#i

A&ama : 'in(u

A#amat : a#an Gunun& %atu) G&* Nan&"a I+ 6 %)*!)an(an,

D!n-asa)



SU%ETI.Keluhan Utama : Kejang

Keluhan Penyerta : gangguan pendengaran, nyeri kepala

Ri/aat P!na"it S!"a)an& :

Pasi!n #a"i$#a"i, usia 39 tahun, "inan, (atan& sa(a), (i)uu" (a)i RSASan&#ah (!n&an (ia&nsis s!)4asi "n4u#si !5 sus-!" m!nin&itis* Pasi!"!an& (!n&an -#a mata "! m!#i)i" "i)i, "!-a#a m!n#!h "! "i)i #a#u (ii&!)a"an "a"u -a(a "!(ua #!n&an (an tun&"ai* Mu#ut (i"ata"an 5a"!t, #78, n&m-# $8, mu#ut !)usa $8* !an& !)#an&sun& 3 m!nit* S!!-asi!n sa(a) ai", saat "!an& -asi!n (i"ata"an ti(a" sa(a), s!t!#ah "!tam-a" in&un& 30 m!nit, namun sa(a) "!ma#i* !an& -!)tama -a(a ;ITA, "!an& "!(ua -a(a -u"u# 1<*=0 ;ITA (an "!an& "!ti&a -a(a -u"u# Pasi!n s!!#umna -!)nah m!n&a#ami "!an& -!)tama "a#i -a(a 2 min&(!n&an -#a "!an& an& sama*

Pasi!n u&a (i"!#uh"an a(ana &an&&uan -!n(!n&a)an -a(a "!(ua t!#Di"ata"an "!#uhan ini mun5u# s!a" = u#an an& #a#u* A/a#na "!#uhan is!t!#ah -asi!n m!n&a#ami (!mam "!mu(ian ti(a" sa(a)"an (i)i* !#uha-!n(!n&a)an ini m!n!ta- hin&&a saat ini*

Pasi!n u&a m!n&!#uh n!)i "!-a#a s!a" = u#an an& #a#u * N!)i "!-a!)(!nut (i s!#u)uh "!-a#a (an (!n&an s"a#a s!(an&$!)at* N!)i "!-at!)us m!n!)us (an !)"u)an& (!n&an at anti n!)i* * Pan(an&an (!# $8* Ri/aat "!5!#a"aan 78 t!ta-i ti(a" a(a "!#ua)&a an& m!n&!tahui (Ri/aat (!mam ti(a" (i"!tahui -asti #!h "!#ua)&a, )i/aat &i&i #uan& atu" $8, )i/aat -!nu)unan !)at a(an $8



Ri/aat -!na"it (ahu#u :

oS!!#um (i)a/at (i RSUP San&#ah, -asi!n su(ah (i)a/aRSAD (an su(ah (i!)i"an at asam t)an!"samat 3>=0

I+8, 5!?t)ia>n 2>1 &), n(ans!nt)n 2>1 am-, (ia@!-amam-* Ri/aat -!na"it s!-!)ti antun&, hi-!)t!nsi, (iam!##itus (an &ina# (i"ata"an ti(a" a(a*

Ri/aat -!na"it "!#ua)&a

Ti(a" a(a "!#ua)&a an& m!n&a#ami "!#uhan s!)u-a* Ri/-!na"it hi-!)t!nsi, "!n5in& manis, antun& (an &a&a# &

-a(a "!#ua)&a (i"ata"an ti(a" a(a*

Ri/aat ssia#

Pasi!n saat ini ti(a" !"!)a* Ri/aat m!n&"nsumsi a#"(an m!)"" (i"ata"an a(a, namun s!a" = u#an an& su(ah !)h!nti*



O%ETI.

1* !a(aan Umum : tam-a" sa"it !)at

!sa(a)an : 5m-sm!ntis

GS E+=M6

2* Status P)!s!nt

TD : "anan 120BC0 mm'&, "i)i 120BC0 mm'&

Na(i : "anan 96 >Bm!nit, "i)i 9 >Bm!nit

RR : 22 >Bm!nit

T!m- : 36,6

Satu)asi : 9C



O%ETI.Status G!n!)a#

Mata : An!mis $B$ I"t!)us $B$

T'T : T!#in&a: hi-!)!mis $B$, s!")!t $B$

'i(un&: hi-!)!mis $B$, s!")!t $B$

T!n&&)": !#um (a-at (i!4a#uasi

L!h!) : )uit $B$, -!m!sa)an G% $8

Th)a"s :

5) : S1, S2 tun&&a# )!&u#!) mu)mu) $B$, "!san n)ma#

-u#m : 4!s 7B7 )n"hi $B$ /h!!@in& $B$

A(m!n : h!-a) tt #i!n tt, isin& usus 78 n)ma#

E"st)!mitas : han&at 7 # 7 !(!ma $ # $

7 # 7 $ # $



O%ETI.

GS E+=M6 5m-sm!ntis8R!F!" M!nin&!a# :

a"u "u(u" 78

%)u(@ins"i I (an II$8

L!si n!)4us +III D !t S

!san #at!)a#isasi t!na&a $8

R!F!" -ata#&i $B$

S!?a#&ia ti-! 4as"u#a)

Ri/aat an&"itan -a)sia# m!na(i umum tni" "#ni"

DIAGNOSIS LINIS NEUROLOGIS



ASSESSMENT

Dia&nsis T-is :

S!#a-ut M!nin&!a# (an Pa)!n"im ta"

Dia&nsis %an(in& :

M!nin&!n5!?a#itis !5 sus-!" %a"t!)i

M!nin&!n5!?a#itis !5 sus-!" +i)us

M!nin&itis

Dia&nsis !)a :

M!nin&!n5!?a#itis !5 sus-!" %a"t!)i



PLANNING

Dia&nsti5

1*MRI "!-a#a 7 "nt)as

2*EEG (i -#i"#ini" n!u)#&i



HASIL R

!" 26,01

R!" ,<3

HG! 12,C< 1

H"# 1,=0 3

$"% C<,<0 C

$"H 2<,19

$"H" 31,00

PL# <<,20 1

$P% 6,32 6

&NEU# C=,=

&L'$PH 6,3C

&$( 6,96 1

)NEU# 22,2=

)L'$PH 1,66

)$( 1,C1

R*+"% 12,96 1

PE$ERIKSAAN*ARAH LENGKAP

-./.0/1.234



HASIL RANGE

!UN 9,00 C$23

"REA#ININE 0,9= 0,<$1,2

SG(#/AS# 30,0 11,00$33,00

SGP#/AL# 30,0 11,00$=0,00

NA#RIU$/S(*IU$ 11 136$1=

KALIU$/P(#ASSIU$

3,C1 3,=$=,1

KL(RI*A/"L(RI*E 99,C0 9,00$110,00

"RP KUAN#I#A#I5 11,C9 0,00$0,=0

G*S 9,00 <0,00$10,00

PE$ERIKSAAN KI$IA -.+.0+1.234



HASIL RANGE

pH <,39 <,3=$<,=

p"(1 3C,9 3=,00$=,00

p(1 9C,20 C0,00$100,00

!Ee67 $1,< $2$2

H"(-+ 23,20 22,00$26,00

S(16 9<, 9=$100

#"(1 2,0 2,00$30,00

NA#RIU$ 10 136$1=

KALIU$ 3,=C 3,=0$=,10

KL(RI*A 102 96$10C

ANALISIS GAS *ARAH -.+.0+1.234



HASIL RANGE

P# 13,2 10,C$1,

INR 1,0< 0,9$1,1

AP## 31,0 2$36

HE$A#(L(GI -.+.0+1.234



PEMERISAAN LP 30$0=$2016PARA$E#ER HASIL

Ana#isa ai)an LS

R!a"si Pan( Psiti? 778

R!a"si Nn! Psiti? 778

Ma")s"-is $

;a)na !)nih

Da)ah N!&ati?

%!"uan N!&ati?

Mi")s"-is $

Mn 90

P# 10

E)it)sit $BLP

%!ntu" $

G#u"sa 6=m&B(L

um#ah S!# Liu) 62 L!"sitBmm3

TP Liu)BMTP 9C,CCm&B(L



PE$ERIKSAAN "#+S"AN 20+.1+1.234



PE$ERIKSAAN "#+S"AN 20+.1+1.234





PLANNING

1*nsu# TS T'T, TS Gi&i (an Mu#ut (i )uan&an



PLANNINGMnit)in&

1*+ita# Si&n

2*!sa(a)an

3*!#uhan



T'AN HOU

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Meningoensefalitis Ec Susp. Bakteri