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7/21/2019 Laporan Jaga ANAK 28 DES 2015 (Seli)
http://slidepdf.com/reader/full/laporan-jaga-anak-28-des-2015-seli 1/23
LAPORAN JAGA
28 DESEMBER 2015
Dokter muda Tuti seli sugiarti
Konsulen Jaga Ddr.H.Devi G. Sp.A M.Biomed
Tanggal pemeriksaan 28/12/2015
7/21/2019 Laporan Jaga ANAK 28 DES 2015 (Seli)
http://slidepdf.com/reader/full/laporan-jaga-anak-28-des-2015-seli 2/23
IDENTITAS
• I.Identitas Pasien
• No. MR : 160470
• Tanggal a!"# : 28$12$2015• Naa : An. %
• &"' : ( )"lan
• J*n+! #*la+n : P*'*,"an
• Ana# %* : 2
• Agaa : I!la
• Alaa- : l")"# ")"-
7/21/2019 Laporan Jaga ANAK 28 DES 2015 (Seli)
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%EL&AN &TAMA
• Alloanan*!+! /+)"
•
%& : !*!a# !*a# 1 a'+ SMRS
7/21/2019 Laporan Jaga ANAK 28 DES 2015 (Seli)
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RI3AAT PENA%ITSE%ARANG
• Pa!+*n "la+ )a-"# !*a# "!+a 2 +ngg")a-"# )*'aa# #aang +!*'a-+ ,+l*#*n*' )*n+ng.
• 1 +ngg" SMRS ,a!+*n !*!a# )a-"# /)*'aa# an ,+l*# / !*a#+n *)*'a-.D*a / na+# -"'"n g"!+ )*'a'a /9++!an /9 "n-a /9 +n" a". BAB
an BA% no'al.• 1 a'+ SMRS !*!a# !*a#+n *)*'a-
!*+ngga ,a!+*n +)aa ol* +)"n;a #* RS.
7/21/2019 Laporan Jaga ANAK 28 DES 2015 (Seli)
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RI3AAT PENA%IT DA&L&
• Pa!+*n -+a# ,*'na *ngala+#*l"an !*,*'-+ +n+ !*)*l" n;a.
7/21/2019 Laporan Jaga ANAK 28 DES 2015 (Seli)
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RI3AAT PENA%IT%EL&ARGA
• T+a# aa #*l"a'ga ;ang *ngala+#*l"an !*,*'-+ +n+.
7/21/2019 Laporan Jaga ANAK 28 DES 2015 (Seli)
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RI3AAT LING%&NGAN
•O! -+nggal + l+ng#"ngan ,aa-,*n""#.
•S")*' a+' +n" : a+' "an ;ang
+a!a#
7/21/2019 Laporan Jaga ANAK 28 DES 2015 (Seli)
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RI3AAT %EAMILAN
• R+a;a- AN< '"-+n + )+an• R+a;a- ,*n;a#+- !*laa #*a+lan+!ang#al
• R+a;a- #on!"!+ o)a- !aa- a+l +!ang#alDitolong ole !idan "an#ang !adan lupa
$ara lair normal %ing&ar &epala %upa
Berat lair ''00 gram %ing&ar dada lupa
%angsung menangis
saat lair
(a )ndi&asi $u&up !ulan
7/21/2019 Laporan Jaga ANAK 28 DES 2015 (Seli)
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Kelainan bawaan :
•
/9
Riwayat imunisasi :
•M*n"'"- +)" ,a!+*n !a,a+ !aa-+n+ ,a!+*n *na,a- +"n+!a!+l*ng#a, + ,"!#*!a! *#a-
-*,a- -+nggaln;a.
7/21/2019 Laporan Jaga ANAK 28 DES 2015 (Seli)
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Riwayat tumbuh kembang :
Riwayat pemberian ASI :
• Sa,a+ !aa- +n+ ,a!+*n *na,a-#anASI *#!#l"!+=
*i+a(at tum!u &em!ang ,mur *i+a(at tum!u &em!ang ,mur
Terta+a lupa %ari -
Miring lupa Gigi pertama tum!u -
Teng&urap lupa Bi$ara -
Dudu& - Mem!a$a -
Merang&a& - Se&ola -
Berdiri -
7/21/2019 Laporan Jaga ANAK 28 DES 2015 (Seli)
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P**'+#!aan ""
• %*aaan "" : -a,a# !a#+- !*ang
• %*!aa'an : o,o! *n-+! #oo,*'a-+=
•
>'*#*n!+ Na+ : 1(2?$*n+-• >'*#*n!+ P*'na=a!an : 86?$*n+-
• S"" -")" : (7@ O<
• Da-a An-'o,o**-'+
B*'a- Baan : 67 #g
T+ngg+ Baan : 65
• S-a-"! g++ : @57C /g++ )a+#
7/21/2019 Laporan Jaga ANAK 28 DES 2015 (Seli)
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P**'+#!aan >+!+#
Kepala
• Ma-a : #on"ng -+a an*+! 9$9 !#l*'a +#-*'+# 9$9 **a ,al,*)'a9$9 a-a *#"ng 9$9.
• +"ng : na=a! ",+ng +"ng /!*#'*- /$ )*n+ng *n*' a'a /9
7/21/2019 Laporan Jaga ANAK 28 DES 2015 (Seli)
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P**'+#!aan >+!+#
• M"l"- : )+)+' #*'+ng /9 l+a #o-o' /9g"!+ )*'a'a /9.
• L**' : -on!+l T19T1 +,*'*+! /9,*)*!a'an %GB /9.
7/21/2019 Laporan Jaga ANAK 28 DES 2015 (Seli)
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P**'+#!aan >+!+#
Toraks (pulmo
• In!,*#!+ : '*-'a#!+ / *,+ga!-'+" +n-*'#o!-al
• Pal,a!+ : o#al ='*+-"! !+*-'+! #a$#+
• P*'#"!+ : !ono' + !*l"'" la,angan ,a'"
• A"!#"l-a!+ : )'on#o*!+#"l*' $ ' $ )a!a #a!a' 9$9
Toraks (pulmo
• In!,*#!+ : +-"! o'+! -+a# -*'l+a-
• Pal,a!+ : +-"! o'+! -*'a)a + SI< 5 +la+"la !+n
• P*'#"!+ : )a-a! an-"ng ala )a-a! no'al
• A"!#"l-a!+ : BJ 1 an 2 '*g"l*' "'"' /9 gallo, /9
7/21/2019 Laporan Jaga ANAK 28 DES 2015 (Seli)
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Abdomen
• In!,*#!+ : +!-*!+ /9
• A"!#"l-a!+: B& / No'al
• P*'#"!+ : T+,an+ + !*l"'" la,ang ,*'"-
• Pal,a!+ : *,a-o*gal+ /9 !,l*no*gal+/9.
!kstremitas
• S",*'+o' : a#'al anga- **a /9
!+ano!+! /9• In=*'+o' : a#'al anga- **a /9 <RT
2FF !+ano!+! /9
7/21/2019 Laporan Jaga ANAK 28 DES 2015 (Seli)
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P**'+#!aan ,*n"nang
LAB /28$12$2015
• B : 121 g$l
• -: (6( C
• 3B< : 15.100 "L
• PLT : 286.000"L
AGDA /28$12$2015
• , : 7(4
• P<O2 : 51 g
• PO2 : (@ g
• <O( : 27( ol$l
• SaO2 : 7( C
• Na : 1(( E$l• % : (5 E$l
• <l : 104 E$l
7/21/2019 Laporan Jaga ANAK 28 DES 2015 (Seli)
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RES&ME
• An. A 4 )"lan a-ang #* IGD RS&D -*ng#"'aHan *ngan #*l"an :
• P> : -a,a# !a#+- !*ang !"" (7@ O< RR :8@?$*n+- N< / '*-'*#!+ +n+ng aa /'on#+ )a!a #a!a' /.
• P*.,*n"nang : l*"#o!+-o!+! ,*n+ng#a-anP<O2 ,*n"'"nan PO2 an Sa-"'a!+ O2
)a-"#
(5)"lanSMRS
!*!a#
IGD
,+l*#
1 a'+SMRS
S*!a#*)*'a-
1+ngg"SMRS
,+l*#)a-"# *a
7/21/2019 Laporan Jaga ANAK 28 DES 2015 (Seli)
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"IA#$%SIS K!R&A
• )'on#o,n*"on+a
"IA#$%SIS 'A$"I$#• ISPA
• B'on#+ol+-+!
7/21/2019 Laporan Jaga ANAK 28 DES 2015 (Seli)
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TATALA%SANA
• TERAPI <AIRAN : I>D %AEN IB
RL : BB 6 #g
#*)"-"an : 105 $ #g))$ a'+
6 ? 105 6(0 $a'+ /26 -,$+#'o
• O2 1L$I• Pa!ang NGT
• ,"a!a
•
D*?a*-a!on (g I• P<T 'o, : ( ? 07
• <*='+a?on* : 1? 450 g
• B'o*?+n : (?1 g
7/21/2019 Laporan Jaga ANAK 28 DES 2015 (Seli)
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PROGNOSIS
• A +-a : )ona
• A Hng!+ona : )ona
•
A !ana-+ona: )ona
7/21/2019 Laporan Jaga ANAK 28 DES 2015 (Seli)
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>OLLO3 &P
)*+*,+-
S : *a / !*!a# /)a-"# / ,+l*# / "n-a
/9. BAB an BA% no'alO : #" : !*ang #*! : <M
! : (@1 O< RR : 50?$I
#*,ala : N< /
-o'a? : '*-'a#!+ / ' $
a) : !",*l B& No'al
*#! : a#'al anga- ,*'="!+)a+#
A : B'on#o,n*"on+a
P : O2 1L$I
I>D %AEN 1B 28
-,$+#'oASI 8? 15 $ NGT
<*=-'+a?on* 1 ? 450g /2
*?a*-a!on ( ? 1g
)'o*?+n (?1 g
P<T 'o, 4 ? 07
7/21/2019 Laporan Jaga ANAK 28 DES 2015 (Seli)
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>OLLO3 &P
,*+*,+-
S : *a /9 !*!a# /)a-"# / ,+l*# / "n-a
/9. BAB an BA% no'alO : #" : !*ang #*! : <M
! : (7( O< RR : 60?$I
#*,ala : N< /
-o'a? : '*-'a#!+ / ' $
a) : !",*l B& No'al
*#! : a#'al anga- ,*'="!+)a+#
A : B'on#o,n*"on+a
P : O2 K L$I
I>D %AEN 1B 20
-,$+#'oASI 8? (0 $ NGT
<*=-'+a?on* 1 ? 450g /(
*?a*-a!on ( ? 1g
)'o*?+n (?1 g
P<T 'o, 4 ? 07
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T!RI/A KASI0