BAB I LAPORAN KASUS
1.1 IDENTITAS Nama
: An. An. AR
Umur
: 4 bulan
Jenis Kelamin
: Perempuan
BBPB
: 4!" #$ %& 'm
Alama(
: D)# *III a(as +Serui,
Tan$$al masu#
: % -are( /10
N). Re#am -ei#
: &%1%02
Tan$$al Tan$$al Pemeri Pemeri#saan #saan : % -are( -are( /10 /10
1. ANA-NESIS 1..1 Kelu3an U(ama Pu'a(. 1.. Ria5a( Pen5a#i( Se#aran$ Pasien a(an$ bersama ibun5a 5an$ men$elu3#an #eaaan ana#n5a 5an$ san$a( pu'a( an lemas. 6a7a3 an (elapa# (an$an pasien (erli3a( san$a( pu'a(. ser(a emam +8,! emam sua3 aa se7a# min$$u sebelum masu# ruma3 sa#i( an si9a( emamn5a nai# (urun! ba(u# bera3a# +8, se7a# min$uu 5an$ lalu! sesa# +,! mual mun(a3 +,! BAB n)rmal! BAK n)rmal an berana #unin$ 7erni3. Ria5a( Ria5a( mimisan +,.
1.. 1..& & 1..4 1..4
Ria Ria5a 5a(( Pen5 Pen5a# a#i( i( Da3 Da3ul ulu u Pasien perna3 panas (in$$i sea#(u berusia bulan. Ria5 Ria5a( a( Pen5 Pen5a#i a#i(( Kelu Keluar ar$a $a Tan(e Tan(e pasie pasien n 5an$ (in$$a (in$$all bersama bersama mener meneri(a i(a (ube (uber'ul r'ul)si )siss paru. paru. Ibu pasie pasie (ia# (ia# men$e(a men$e(a3ui 3ui (en(a (en(an$ n$ riaa( riaa( pen5a# pen5a#i( i( #elain #elainan an ara3 ara3 alam #elua #eluar$ r$aa pasien #arena mere#a (in$$al i #amp)n$ 5an$ 7au3 ari sarana #ere3a(an.
1.& PE-ERIKSAAN ;ISIK Keaaan umum
: Tampa# sa#i( bera(! <=S:E4*1-2
: =)mp)s -en(is : %& 'm : 4!" K$
Kesaaran Pan7an$ Baan Bera( Baan Tana(ana >i(al Nai Su3u Baan Respirasi
: 1/ ?meni( : &@!2/= : %/?meni(
KepalaLe3er
-a(a
: =)n7un'(i>a anemis 88! s'lera i#eri# ! pupil is)#)r! re9#les
'a3a5a +88, iun$ : P'3 +8,! epis(a#sis +, -ulu( :-u#)sa mulu( (erli3a( #erin$! perara3an $usi +, Telin$a : Dalam ba(as n)rmal! bleein$+, Le3er : #elen7ar $e(a3 benin$ (ia# (eraba membesar
T3)ra#s
Sime(ris i#u( $era# na9as! re(ra#si +,!suara na9as >esi#uler! r3)n#i +88,! 3eein$ +,! B7 III re$ular.
Ab)men
Supel! a(ar! BU +88,! n5eri (e#an +,! 3epar (ia# (eraba! lien (ia# (eraba! per#usi (impani.
: Tia# ie>aluasi
E#s(remi(as
: A#ral 3an$a( =RTC &! eema +8, an spas(i#
S(a(us
: C &SD + $ii buru#,
1.4 Pemeri#saan Penun7an$ 1.4.1 Pemeri#saan Dara3 Tan$$al /" -are( /10
Hasil
Normal Range
b
: @!"$l
1!/1%!/
Leu#)si(
: !%4 mmm&
4!/1/!/
Tr)mb)si( : &0mmm&
10/14/
-=* : 2%!& 9l
%&./"%!/
-= : &!0 p$
0!/&&!/
-== : &4!4 $l
%!/&2!/
DDR +,
Tan$$al 10 -are(/10 Hasil b : 1&!2$l Leu#)si( : 11.&& mmm& Tr)mb)si( : &/ mmm& -=* : @0!& 9l -= : 2!% p$ -== : &0!2 $l
Normal Range 11!/1%!/ +$L, &!011!/ +1/&mm&, 10/40/ +1/&mm&, @&!/1/2!/ &0!/&2!/ %!/&2!/
Tan$$al 1" -are( /10 Hasil b : 10!2$l RB= : 2!@ 1/2uLF Leu#)si( : %!"0 1/&uLF Tr)mb)si( : 04"mmm& -=* : @1!0 9l -= : 4!" p$ -== : &4!% $l
1.0 Da9(ar -asala3 Pu'a( Anemia b @!" $l =)n7u'(i>a anemis
Normal Range 11!/1%!/ +$L, &!2" G 0!42 &!011!/ +1/&mm&, 10/40/ +1/&mm&, @&!/1/2!/ &0!/&2!/ %!/&2!/
1.2 Dia$n)sa Ker7a Anemia De9isiensi Besi. 1.@ Dia$n)sa Banin$ Anemia T3alassemia Anemia #arena Pen5a#i( Kr)nis De9isiensi (emba$a Anemia sier)blas(i# 1.% Pena(ala#saan Pen$)ba(an iban$sal peraa(an o Nebulier ')mbi9en( 2 7am +/2:&/, I*;D H Ns mi#r) / (pm +/2:&/, o In7. o Pen$)ba(an 5an$ sua3 iberi#an o O -as#er & lpm In7. =e9)(a?im &? 10/ m$ o In7. Ampi'ilin &?10/ m$ o Raa( i RKK 7am 10://
1.1/ ;)ll) up ari(an$$al %/&/10
Peraa(an 3ari 1 +i I
S Pasien
O Keaaan umum: a(an$ Kesaaran: en$an Apa(is! #elu3an Tampa# sa#i( pu'a(! ma(a bera( <=S: E4*1-2 (ia# R: (erbu#a! N:1/?m SB:&@!2 ban5a# R:%/?m #)()ran ma(a!
Kepalale3er: e#s(remi(as ubunubun a(ar! =A+8 san$a( 8,! SI+,! pu'a( an re9le? in$in +8,! 'a3a5a+88,! emam +8,! pupil is)#)r P=+,!K
A Susp.sepsis 8 Br)n#)pneum)ni TB 8 -enin$i)ense9ali(is 8 ir)se9alus 8 $ii buru#
P In7. 'e9)(a?im &?140/ m$i.> In7.ampi'ilin &?12i.> +ST, O mas#er &lpm UPB: I*;D D0 H mi'r) / (pm +/2:&/, In7. Rani(iin ?1/ m$I.> Jaaban #)nsul r. elena Sp.A )n')le I*;D D0 H ns / (pm mi#r) In7. =e9(ia?)ne ?0/ m$ +i.>, In7. De?a 1? G
, T3)ra?: Sime(ris! re(ra#si +,!SN *esi#uler! R3) +88,! 63e+8 8,!BJIII re$ular! mur mur+,! (3rill +,
Ab)men: Supel! a(ar! BU +8, N! L+((b,! (ur$)r #uli( #embali 'epa(
!0 m$ +i>, 7am 1/://! selan7u(n5a &?1 m$+i>, =).SpPr) -RI P3eni()in ?/ m$ +p)pers)ne, Pr) (rsn9usi PR= @/ '' +se#ali pemberian, Pre !0 '' Nebulier en$an ')mbi9en( % 7am
E#s(remi(as: A#ral 3an$a(! eema +,! =RT C
11/&/10
ari 4 +i RKK,
Pasien emam +,!#e7an$ +,! ba(u# +8,! sesa# +8,! aa lenir
Kuli(: Sian)sis +,! anemis +,! i#(eri# +, Keaaan umum: Kesaaran: apa(is N: "/?m SB &2 = R: 4?m Kepalale3er: =A +88,! SI +,! papul 8 i#epala! lin$#ar #epala 44'm T3)ra#s: R3)n#i +88,
Susp. Sepsis susp. Br)n#)pneum)ni Susp. -enin$)ense9ali(is
N
, Rani(iine &?0 m$ Nebu ?se3ari P3eni()in ?0/ m$ In7.e?ame(a?)ne &?1 m$ S(es)i e?(ra !0 m$ +re'(al, Pr' 4 ''
P)s(eri)r +pappul 8,
1/&/10
ari 0 +i RKK,
Demam +,! #e7an$ +,! ba(u# +8,! sesa# +8,! lenir +8,
Ab)men: lembe#! L +((b, E#s(remi(as: a#ral 3an$a( eem +, Keaaan umum: (ampa# sa#i( bera(! apa(is <=S " R: %1?m R: 24?m SB:&2!2
Susp. Br)n#)pneum)ni 8 3ir)'ep3alus 8
N, Rani(iine &?0 m$ Nebu ?se3ari P3eni()in ?0/ m$ In7.e?ame(a?)ne &?1 m$ S(es)i e?(ra !0 m$ +re'(al,
Susp. Br)n#)pneum)ni 8 3ir)'ep3alus 8
N, Rani(iine &?0 m$ P3eni()in ?0/ m$
Kepalale3er: =A +88,! SI +,! re9le? 'a3a5a +88,! pus(ule +8, i#epala! lin$#ar #epala 44 'm
1&/&/10
ari 2 +iRKK,
Demam +,! #e7an$ +,! ba(u# +8,! sesa# +8,! lenir +8,
T3)ra#s re(ra#si +8, r3)n#i +88, Ab)men: a(ar! L +((b, Keaaan umum: (ampa# sa#i( bera(! apa(is <=S " R: @/?m R: 2?m SB:&2!1 Kepalale3er: =A +88,! SI +,! re9le? 'a3a5a +88,! ma(a '))n$
pus(ule +8, i#epala! lin$#ar #epala membesar 8SD
14/&/10
ari @ +i RKK,
Demam +,! #e7an$ +,! ba(u# +8,! sesa# +8,! lenir +8,
T3)ra#s re(ra#si +8, r3)n#i +88, Ab)men: a(ar! L +((b, Keaaan umum: (ampa# sa#i( bera(! apa(is <=S " R: 11"?m R: 4%?m SB:&2!&
Susp. Br)n#)pneum)ni 8 3ir)'ep3alus 8
Kepalale3er: =A +88,! SI +,! re9le? 'a3a5a +88,! ma(a '))n$ pus(ule +8, i#epala! lin$#ar #epala 44'm 8SD
10/&/10
ari % +i RKK,
Demam +,! #e7an$ +,! ba(u# +8,! lenir +8,! 3ip)(ermi &0!/=
T3)ra#s re(ra#si +8, r3)n#i +88, Ab)men: a(ar! L +((b, Keaaan Susp. TB Paru umum: (ampa# 8 3ir)'ep3alus 8 sa#i( bera(!
N, Rani(iine ?0/ m$ P3eni()in ?0/ m$ In7.e?ame(a?)ne &?1 m$ S(es)i e?(ra !0 m$ +re'(al,
N, Rani(iine ?0/ m$ P3eni()in ?0/ m$ In7.e?ame(a?)ne &?1
+,! re9le? 'a3a5a +,! lin$#ar #epala 44 'm 8SD T3)ra#s re(ra#si +8, r3)n#i +88, Ab)men: a(ar! L +((b, E#s(remi(as: a#ral in$in eem +,! babins#5 +8,! #a#u #uu# +,
./ Pr)$n)sis u) a >i(am u) a 9un'(i)nam
: ubia a b)nam : ubia a b)nam
m$ S(es)i e?(ra !0 m$ +re'(al,
