Author
novi-rista-ananda
View
214
Download
0
Embed Size (px)
7/23/2019 Lapkas Anak Opi
http://slidepdf.com/reader/full/lapkas-anak-opi 1/23
32
BAB III
KASUS
I. IDENTITAS PENDERITA
No. CM : 1-01-87-63
Nama : NurazizahTgl Lahir/Umur : 30 Januari 2011 (3 tahun 8 bulan)
Jenis Kelamin : Peremuan
!u"u : #$eh
#gama : %slam
Pe"er&aan : '
Penii"an : '
#lamat : Piie
Tanggal asu" : 1* !etember 201+ , Pu"ul : 1-.3 %
Tanggal Keluar : 2* "tber 201+, Pu"ul : 12.00 %
Jaminan : JK4#
II.IDENTITAS KELUARGA
a. Nama #5ah : ahi
Umur : +1 tahun
!u"u : #$eh
#gama : %slam
#lamat : !igli
b. Nama ibu : 6uraii
Umur : 37 tahun
!u"u : #$eh
#gama : %slam
#lamat : !igli
III. ANAMNESA
a. Keluhan Utama : Penurunan Kesaaran
b. Keluhan Tambahan : emam an "e&ang
7/23/2019 Lapkas Anak Opi
http://slidepdf.com/reader/full/lapkas-anak-opi 2/23
33
$. 4i9a5at Pen5a"it !e"arang :
Pasien merua"an ru&u"an ari 4! !igli an iba9a leh "eluargan5a engan
"eluhan enurunan "esaaran 5ang ialami se&a" 7 hari sebelum masu" rumah sa"it.
!ebelum mengalami enurunan "esaaran, asien &uga mengalami "e&ang 5ang
ialami selama lebih "urang * menit engan re"uensi 2 "ali. %nter;al "e&ang asien
antara satu an "eua selama * menit. iantara ase "e&ang asien tia" saar. Pasien
mengalami "e&ang iseluruh baan berua "e&ang "eln&tan. Pasien &uga mengalami
emam 5ang irasa"an 1* hari sebelum masu" rumah sa"it. emam irasa"an terus
menerus an hilang engan bat enurun anas. !ebelumn5a asien ira9at 3 hari i
4! !igli. !aat i 4! !igli, asien semat mengalami erbai"an imana tia" aa lagi
emam an "e&ang an semat iba9a ulang, namun bes"n5a asien mengalami
enurunan "esaaran an iba9a "embali "e rumah sa"it. Nasu ma"an menurun
se&a" asien mengalami emam, an asien &uga mengalami enurunan berat baan.
. 4i9a5at en5a"it ahulu :
Pasien tia" ernah menerita en5a"it 5ang sama sebelumn5a. %bu asien
mengata"an bah9a en5a"it 5ang ialami asien sebelumn5a aalah batu" ile"
e. 4i9a5at en5a"it "eluarga :
Tia" aa ari "eluarga 5ang menerita en5a"it 5ang sama, namun ibu asien
ernah menerita T aru an meng"nsumsi #T
. 4i9a5at ema"aian bat :
!aat emam, asien iberi"an bat enurun anas, namun rang tua asien tia"
tahu nama batn5a
g. 4i9a5at "ehamilan ibu :
%bu asien rutin #N< "e "ter. emam ('), hiertensi ('), ('), %!K ('),
"eutihan (').
h. 4i9a5at "elahiran :
Pasien merua"an ana" "e'* an lahir er;aginam i 4! engan L : 300 gr
i. 4i9a5at imunisasi : %munisasi tia" leng"a
&. 4i9a5at tumbuh "embang
Umur 4i9a5at emberian
ma"anan
4i9a5at er"embangan
7/23/2019 Lapkas Anak Opi
http://slidepdf.com/reader/full/lapkas-anak-opi 3/23
3+
0' bulan #!% e"s"lusi !esuai Usia
7'20 bulan #!% = P #!% !esuai Usia
21 bulan > se"arang a"anan "eluarga !esuai Usia
IV. PEMERIKSAAN FISIK
a. Stat! P"#!#$t
Keaaan Umum : sa"it berat
?<! : @3+A1
Te"anan arah : 130/80 mmBg
Beart rate : 1*0C / menit
4esiratr5 rate : + C / menit
Temeratur : 38,+D<
%. Data a$t"o&o'#t"(
erat baan : 10 "g
Tinggi baan : -* $m
!tatus gizi : Kesan : gizi "urang
Ling"ar "eala : +7,3 $m
). Stat! G#$#"a*
Keala : Nrm$heali
4ambut : Bitam su"ar i$abut, istribusi merata
ata : Kn&ungti;a u$at (' /'), s"lera i"teri" ('/'), mata$e"ung ('/'),
uil is"r, rele" $aha5a (=/=)
Telinga : bentu" nrmauri"ular, !erumen ('/')
Biung : !e"ret ('/'), N<B (')
ulut : ibir : Pu$at ('), !iansis ('), lembab(')
Tnsil : T1/T1
Earing : hieremis (')
gigi : "aries (')
L#+#"
entu" simetris, TAJ 4'2 $mB20
Pembesaran K? ('), Ka"u "uu" (=)
T+o"a,
7/23/2019 Lapkas Anak Opi
http://slidepdf.com/reader/full/lapkas-anak-opi 4/23
3*
%nse"si : !imetris, 4etra"si inter$stal (=), 4etra"si !ura$la;i"ular ('),
teraat ustula iatas ma"ula eritema, u"uran milier an
tersebar merata i thra"s anterir an sterir
Palasi : ! "a F s "i
Per"usi : snr
#us"ultasi : ;es (=/=), rh (=/=), 9h ('/'), ernaasan thra"abminal, 44:
*3C/i
a. a$t$
%nse"si : siansis ('), i"tus $ris (')
Palasi : i"tus $ris teraba aa linea mi$la;i$ula sinistra
Per"usi : alam batas nrmal
#us"ultasi : J1 G J %%, B4: 1+* C/i, reguler, bising (')
A%/o'#$
%nse"si : !imetris, istensi (')
Palasi : N5eri Te"an ('), turgr H 3 eti"
' Lien : tia" teraba
' Bear : tia" teraba
' 4enal : tia" teraba
Per"usi : tia" ila"u"an
#us"ultasi : Peristalti" = (N)
G#$#ta*(a : alam batas nrmal
A$! : atresia ani (')
E!t"#'(ta! : !uerir %nerir
Kanan Kiri Kanan Kiri
!iansis (') (') (') (')
@ema (') (') (') (')
?era"an sn sn sn sn
Ke"uatan sn sn sn sn
Tnus tt Biertnus Biertnus Nrmtnus Nrmtnus
#tri (') (') (') (')
!tatus Neurlgis
?<! : @3+A1 F 8
ata : bulat ,is"r
7/23/2019 Lapkas Anak Opi
http://slidepdf.com/reader/full/lapkas-anak-opi 5/23
3
T4 : alam batas nrmal
4ele" isilgis : nrmrele"s
4ele" atlgis : ('/')
!ensri" : !ulit inilai
tnm : alam batas nrmal
V. PEMERIKSAAN LABRATRIUM
#. arah 4utin 2- !etember 201+
Bt: 3* I
Bb: 12,8 gr/l
Leu"sit: -,3 C 103/ul
@ritrsit : +,* C 10/ul
Trmbsit : *+.000/mm3
@/a/N.btg/N.seg/Lim/: 1/0/1/*+/+0/+
Na/K/<l: 12/3,7/82
?!: 10- g/l
Ur/<r: +*/ 1,1
. Urinalisis 1- !etember 201+
erat &enis : 1,010
B : .0
Leu"sit : negati
Nitrit : negati
Prtein : negati
?lu"sa : siti
Ketn : negati
Urbilingen : negati
ilirubin : negati
l : siti
!eimen Urin : Leu"sit : 2'3/LP
@ritrsit : '8/LP
@itel : 3'*/LP
!el ragi siti
#. arah Leng"a 18 !etember 201+
Bt: 3 I
7/23/2019 Lapkas Anak Opi
http://slidepdf.com/reader/full/lapkas-anak-opi 6/23
37
Bb: 12,2 gr/l
Leu"sit: 1*,2 C 103/ul
@ritrsit : +,* C 10/ul
Trmbsit : 0+.000/mm3
<A : 81 L
<B : 27 g
<B< : 3+ I
L@ : +0 mm/&am
T : 3 menit
<T : - menit
#?# : B : 7,*28 mmBg
<2 : +1,- mmBg
2 : 8 mmBg
i"arbnat : 3*,1 mml/L
Ttal <2 : 3,+ mml/L
Kelebihan asa : 11,8
!aturasi 2 : -7,+I
ilirubin Ttal : 0,* mg/L
ilirubin ire$t : 0,2 mg/L
ilirubin %nire$t : 0,3 mg/L
#!T/!?T : * U/L
#LT/!?PT : 37 U/L
Prtein ttal : *, g/L
#lbumin : 3, g/L
?lbulin : 2 g/L
@/a/N.btg/N.seg/Lim/: 0/0/0/3/+
Na/K/<l: 128/+,+/88
?!: 121 g/l
Ur/<r : 1*/0.3
rlgi arah tei :
@ : nrm"rm, nrmsitter
L : Leu"sitsis
T : ¨ah mening"at, bentu" nrmal
Kesimulan : leu"sitsis = trmbsitsis
7/23/2019 Lapkas Anak Opi
http://slidepdf.com/reader/full/lapkas-anak-opi 7/23
38
. Urinalisis 1- !etember 201+
erat &enis : 1,010
B : .0
Leu"sit : negati
Nitrit : negati
Prtein : siti
?lu"sa : siti
Ketn : negati
Urbilingen : negati
ilirubin : negati
l : siti
!eimen Urin : Leu"sit : 10'1*/LP
@ritrsit : 1*'20/LP
@itel : 3'*/LP
!el ragi siti
<. ia"an mi"rrganisme an 4esistensi (23 !etember 201+)
ari samel sutum terislasi ba"teri atgen "lebsiella neumniae
#ntibiti"a : #mi$ilin : 4
?entami$in : 4
Tbrami$5n : 4
#mi"a$in : 4
#mC'<la;ulaniC a$i : 4
<etriaCn : 4
Esmi$in : 4
#mi$ilin'sulba$tam : 4
Piera$ilin'tazba$tam : 4
<eurCime : 4
<etaCim : 4
<eeime : !
<irlCa$in : !
erenem : 4
ari samel arah terislasi ba"teri atgen @s$heri$ia $li
#ntibiti"a : #mi$ilin : 4
?entami$in : !
7/23/2019 Lapkas Anak Opi
http://slidepdf.com/reader/full/lapkas-anak-opi 8/23
3-
Tbrami$5n : !
#mi"a$in : !
#mC'<la;ulaniC a$i : 4
<etriaCn : !
Esmi$in : 4
#mi$ilin'sulba$tam : !
Piera$ilin'tazba$tam : !
<eurCime : 4
<etaCim : !
<eeime : !
<irlCa$in : !
erenem : !
Et Tra"s #P (17 !etember 201+) : Kesimulan rn"itis Krni"
U!? #bmen (1 "tber 201+) : Kesimulan nrmal
Bea <T'!$an 3 "tber 201+ : Kesimulan : Birsealus engan eri;entri"uler eema
an suse$t ensealitis
VI. DIAGNSA BANDING
' eningnsealitis T = Pneumnia = T Paru = %!K = iliaria Pustulsa
' eningitis ba"terialis = Pneumnia = %!K = iliaria Pustulsa
VII. DIAGNSA SEMENTARA
eningensealitis T = Pneumnia = T Paru = %!K = iliaria Pustulsa
VIII. DIAGNSA AK2IR
eningensealitis T = Pneumnia = T Paru = %!K = iliaria Pustulsa
I. PENATALAKSANAAN
' 2 1 L/i nasal "anul
' iet: !ne 30 $$/3 &am
Kebutuhan "alri ++7,22 ""al/hari
Kebutuhan rtein 1+,3 gram/L' %AE N* 20 gtt/menit mi"r
7/23/2019 Lapkas Anak Opi
http://slidepdf.com/reader/full/lapkas-anak-opi 9/23
+0
' %n&. erenem +00 mg/ 8 &am
' %n&. 4anitiin * mg/8 &am
' %n&. N;algin 1*0 mg/8&am
' %n&. !tretmisin 2*0mg/2+ &am
' %n& <eiCim *00 mg/12 &am
' %n& Eursemi 10 mg/12 &am' %n& eCamethasne 0,* am/8 &am
' %NB 100 mg/hari
' 4iamisin 1*0 mg/hari
' Pirazinami 2*0 mg/hari
' <atril 2 C ,2* mg
' Aalsartan 1 C 8 mg ("/)
' Nieiin sub lingual
I. PRGNSIS
ubia et malam
FLL4 UP PASIEN PASIEN SEURUNEE 1
TGL VITAL SIGN PEMERIKSAAN FISIK 5
PENUNANGTERAPI
1*/0-/201+
1-:3
B'0
KU : enurunan
"esaaran
KT : batu", sesa",
emam,
Kes : aatis
B4 : 132C/i
44 : 28C/i
T : 38,0<
Keala : Nrm$ehali
ata : <n&. Pal. %n. Pu$at ('/'), !$lera
%$teri" ('/'), mata $e"ung ('/')
Biung : N<B ('), !e"ret (')
ulut : ibir : Pu$at ('), !iansis ('),
lembab (=)
Tnsil : T1/T1
Earing : hieremis (')
gigi : "aries (')
Th/
2 sung" *L/i
%AE K#@N 3 20 gtt/i
(mi"r)
%n&. erenem +00 mg/8 &am
%n&. eCamethasne 0,* am/8
&am
%n&. 4anitiin * mg/8 &am
anitl 2* $$/8 &am ri alam 1
7/23/2019 Lapkas Anak Opi
http://slidepdf.com/reader/full/lapkas-anak-opi 10/23
+1
! : 10 Kg
P : -* $m
Telinga : Nrmtia, se"ret (')
Leher : Pembesaran K? (') , retra"si
surasternal (=)
Thra" :
%nse"si : !imetris (=), retra"si inter$stal (=)
Palasi : s "a F s "i
Per"usi : tia" ila"u"an
#us"ultasi :Aesi"ular (=), 4h (=/=), h ('/')
<r : J % G J %%, 4eg, ising (')
#bmen:
%nse"si : !imetris, istensi (')
Palasi : !eel, hear ('), lien ('), renal, (').
N5eri te"an ('), turgr H 3 eti"
Per"usi : Tia" ila"u"am
#us"ultasi : Peristalti" (=) N
@Ctr : !u/in : eema ('/'),
!iansis ('/')
Pu$at ('/')
!tatus Neurlgis
?<! : @2*A3 F 10
ata : bulat ,is"r
T4 : alam batas nrmal
4ele" isilgis : nrmrele"
4ele" atlgis : ('/')
!ensri" : N
tnm : N
tri" : N
#ss : Penurunan "esaaran e.$
1. @nsealitis
2. eningitis
3. eningensealitis
&am
!tesli su * mg
iet N?T 30 $$/3 &am (iet
sne)
P/
Pasang "ateter
#9asi ;ital sign
#9asi balan$e $airan
4a9at P%<U
Knsul 4esirlgi
Test antuC
1/0-/201+
B'1
KU : enurunan
"esaaran
KT : batu", sesa",
emam
B4 : 138C/i
44 : 20C/i
T : +0,1<
! : 10 Kg
P :-* $m
Keala : Nrm$ehali
ata : <n&. Pal. %n. Pu$at ('/'), !$lera
%$teri" ('/'), mata $e"ung ('/')
Biung : N<B ('), !e"ret (')
ulut : ibir : Pu$at ('), !iansis ('),lembab (=)
Tnsil : T1/T1
Earing : hieremis (')
gigi : "aries (')
Telinga : Nrmtia, se"ret (')
Leher : Pembesaran K? (') , retra"si
surasternal (=)
Thra" :
%nse"si : !imetris (=), retra"si inter$stal (=)
Palasi : s "a F s "i
Per"usi : tia" ila"u"an
Th/
2 sung" *L/i
%AE K#@N 3 20 gtt/i
(mi"r)
%n&. eCamethasne 0,* am/8
&am
%n&. 4anitiin * mg/8 &am
anitl 2* $$/8 &am ri alam 1
&am
iet N?T 30 $$/3 &am (iet
sne)
P/
#9asi ;ital sign
7/23/2019 Lapkas Anak Opi
http://slidepdf.com/reader/full/lapkas-anak-opi 11/23
+2
#us"ultasi :Aesi"ular (=), 4h (=/=), h ('/')
<r : J % G J %%, 4eg, ising (')
#bmen:
%nse"si : !imetris, istensi (')
Palasi : !eel, hear ('), lien ('), renal, (').
N5eri te"an ('), turgr H 3 eti"
Per"usi : Tia" ila"u"am
#us"ultasi : Peristalti" (=) N
@Ctr : !u/in : eema ('/'),
!iansis ('/')
Pu$at ('/')
!tatus Neurlgis
?<! : @2*A3 F 10
ata : bulat ,is"r
T4 : alam batas nrmal
4ele" isilgis : nrmrele"
4ele" atlgis : ('/')
!ensri" : N
tnm : N
tri" : N
#ss : Penurunan "esaaran e.$
eningensealitis
#9asi balan$e $airan
Urin rutin
Knsul 4esirlgi
Knsul Nerlgi
17/0-/201+
B'2
KU : enurunan
"esaaran
KT : batu", sesa",
emam
B4 : 12C/i
44 : 2C/i
T : 37,<
! : 10 Kg
P :-* $m
Keala : Nrm$ehali
ata : <n&. Pal. %n. Pu$at ('/'), !$lera
%$teri" ('/'), mata $e"ung ('/'),
mata "iri uem
Biung : N<B ('), !e"ret (')
ulut : ibir : Pu$at ('), !iansis ('),
Terasang geel
Telinga : Nrmtia, se"ret (')
Leher : Pembesaran K? (') , retra"si
surasternal (=)
Thra" :
%nse"si : !imetris (=), retra"si inter$stal (=)
Palasi : s "a F s "i
Per"usi : tia" ila"u"an
#us"ultasi :Aesi"ular (=), 4h (=/=), h ('/'),
strir (=)
<r : J % G J %%, 4eg, ising (')
#bmen:
Th/
Aentilatr !%A ee * Ti2 :
80I : 0,8, rate : 20C/i
%AE 4L +0 gtt/i (mi"r)
%n&. eCamethasne 0,* am/8
&am
%n&. erenem mg/8 &am%n&. 4anitiin * mg/8 &am
anitl 2* $$/8 &am ri alam 1
&am
%n& N;algin 1*0 mg/8 &am
iet N?T 30 $$/3 &am (iet
sne)
Nin5a 3C1
P/
%ntubasi @TT N. +.0 engan
"ealaman 12 $m
7/23/2019 Lapkas Anak Opi
http://slidepdf.com/reader/full/lapkas-anak-opi 12/23
+3
%nse"si : !imetris, istensi (')
Palasi : !eel, hear ('), lien ('), renal, (').
N5eri te"an ('), turgr H 3 eti"
Per"usi : Tia" ila"u"am
#us"ultasi : Peristalti" (=) N
@Ctr : !u/in : eema ('/'),
!iansis ('/')
Pu$at ('/')
!asti" (=/=)
!tatus Neurlgis
?<! : @11A1 F 3
ata : bulat ,anis"r (3mm/2mm)
4<L ('/') 4<TL ('/')
T4 : alam batas nrmal
4ele" isilgis : nrmrele"
4ele" atlgis : ('/')
!ensri" : N
tnm : N
tri" : N
#ss : Penurunan "esaaran e.$
eningensealitis
= Pneumnia berat an sus. T
#9asi ;ital sign
<e" arah rutin an ele"trlit
Jaga # <
Et thra"s $5t be
18/0-/201+
B'3
KU : enurunan
"esaaran
KT : batu" an sesa"
B4 : 127C/i
44 : +2C/i
T : 3,<
! :10 Kg
P :-* $m
Keala : Nrm$ehali
ata : <n&. Pal. %n. Pu$at ('/'), !$lera
%$teri" ('/'), mata $e"ung ('/'),
mata "iri uemBiung : N<B ('), !e"ret (')
ulut : ibir : Pu$at ('), !iansis ('),
Terasang geel
Telinga : Nrmtia, se"ret (')
Leher : Pembesaran K? (') , retra"si
surasternal (=)
Thra" :
%nse"si : !imetris (=), retra"si inter$stal (=)
retra"si eigastrium (=)
Palasi : s "a F s "i
Per"usi : tia" ila"u"an
#us"ultasi :Aesi"ular (=), 4h (=/=), h ('/'),
strir (=)
<r : J % G J %%, 4eg, ising (')
#bmen:
%nse"si : !imetris, istensi (')
Palasi : !eel, hear ('), lien ('), renal, (').
N5eri te"an ('), turgr H 3 eti"
Per"usi : Tia" ila"u"am
#us"ultasi : Peristalti" (=) N
Th/
T'ie$e
%AE 4L +0 gtt/i (mi"r)
%n&. eCamethasne 0,* am/8
&am
%n&. erenem +00mg/8 &am
%n&. 4anitiin * mg/8 &am
anitl 2* $$/8 &am ri alam 1
&am
%n& N;algin 1*0 mg/8 &am
iet N?T 30 $$/3 &am (iet
sne)
Nin5a 3C1
P/
#9asi ;ital sign
<e" arah rutin, ele"trlit, !?T,
!?PT, ureum, $reatinin, #LT,
itell, T
Et thra"s $5t be
Kebutuhan $airan restri"si 20I
7/23/2019 Lapkas Anak Opi
http://slidepdf.com/reader/full/lapkas-anak-opi 13/23
++
@Ctr : !u/in : eema ('/'),
!iansis ('/')
Pu$at ('/')
!asti" (=/=)
!tatus Neurlgis
?<! : @11A1 F 3
ata : bulat ,is"r (3mm/3mm)
4<L (=/=) 4<TL ('/')
T4 : alam batas nrmal
4ele" isilgis : nrmrele"
4ele" atlgis : ('/')
!ensri" : N
tnm : N
tri" : N
#ss : Penurunan "esaaran e.$
eningensealitis= Pneumnia berat an sus. T
1-/01/201+
B'+
KU : enurunan
"esaaran, sasti"
KT : batu" an sesa"
B4 : 11*C/i
44 : +0C/i
T : 37,+<
! :10 Kg
P :-* $m
Keala : Nrm$ehali
ata : <n&. Pal. %n. Pu$at ('/'), !$lera
%$teri" ('/'), mata $e"ung ('/'),
mata "iri uem
Biung : N<B ('), !e"ret (')
ulut : ibir : Pu$at ('), !iansis ('),
Terasang geel
Telinga : Nrmtia, se"ret (')
Leher : Pembesaran K? (') , retra"si
surasternal (=)
Thra" :
%nse"si : !imetris (=), retra"si inter$stal (=)
retra"si eigastrium (=)
Palasi : s "a F s "i
Per"usi : tia" ila"u"an
#us"ultasi :Aesi"ular (=), 4h (=/=), h ('/'),
strir (=)
<r : J % G J %%, 4eg, ising (')
#bmen:
%nse"si : !imetris, istensi (')
Palasi : !eel, hear ('), lien ('), renal, (').
N5eri te"an ('), turgr H 3 eti"
Per"usi : Tia" ila"u"am
#us"ultasi : Peristalti" (=) N
@Ctr : !u/in : eema ('/'),
!iansis ('/')
Pu$at ('/')
!asti" (=/=)!tatus Neurlgis
Th/
@TT nasal "anul
%AE N* 3 gtt/i (mi"r)
%n&. eCamethasne 0,* am/8
&am
%n&. erenem +00mg/8 &am
%n&. 4anitiin * mg/8 &am
anitl 2* $$/8 &am ri alam 1
&am
%n& N;algin 1*0 mg/8 &am
iet N?T 30 $$/3 &am (iet
sne)
Nin5a 3C1
P/
Kultur se"ret @TT
Knsul rehab mei"
<e" ulang ele"trlit
#9asi T
7/23/2019 Lapkas Anak Opi
http://slidepdf.com/reader/full/lapkas-anak-opi 14/23
+*
?<! : @22A1 F *
ata : bulat ,is"r (3mm/3mm)
4<L (=/=) 4<TL ('/')
T4 : alam batas nrmal
4ele" isilgis : nrmrele"
4ele" atlgis : ('/')!ensri" : N
tnm : N
tri" : N
#ss : Penurunan "esaaran e.$
eningensealitis
= Pneumnia berat an sus. T = #n$aman
gagal naas
= Binatremi
20/0-/201+
B'*
KU : enurunan
"esaaran, emamKT : batu" an sesa"
T : 127/88
B4 : 122C/i
44 : 30C/i
T : 37,-<
! :10 Kg
P :-* $m
Keala : Nrm$ehali
ata : <n&. Pal. %n. Pu$at ('/'), !$lera
%$teri" ('/'), mata $e"ung ('/'),
mata "iri uem
Biung : N<B ('), !e"ret (')
ulut : ibir : Pu$at ('), !iansis ('),
Terasang geel,
hierse"resi
Telinga : Nrmtia, se"ret (')
Leher : Pembesaran K? (') , retra"si
surasternal (=)
Thra" :
%nse"si : !imetris (=), retra"si inter$stal (=)
retra"si eigastrium (=)
Palasi : s "a F s "i
Per"usi : tia" ila"u"an
#us"ultasi :Aesi"ular (=), 4h (=/=), h ('/'),
strir (=)
<r : J % G J %%, 4eg, ising (')
#bmen:
%nse"si : !imetris, istensi (')
Palasi : !eel, hear ('), lien ('), renal, (').
N5eri te"an ('), turgr H 3 eti"
Per"usi : Tia" ila"u"am
#us"ultasi : Peristalti" (=) N
@Ctr : !u/in : eema ('/'),
!iansis ('/')
Pu$at ('/')
!asti" (=/=)
!tatus Neurlgis
?<! : @11A1 F 3ata : bulat ,is"r (3mm/3mm)
Th/
2 sung"u
%AE N* 3 gtt/i (mi"r)
%n&. eCamethasne 0,* am/8
&am
%n&. erenem +00mg/8 &am
%n&. 4anitiin * mg/8 &am
anitl 2* $$/8 &am ri alam 1
&am
%n& N;algin 1*0 mg/8 &am
iet N?T 30 $$/3 &am (iet
sne)
Nin5a 3C1
!tretmisin 2*0 mg/2+ &am %
%NB 100 gr/hari N?T
4iamisin 1*0 mg/hari N?T
Pirazinami 2*0 mg/hari N?T
P/
#9asi ;ital sign
<e" 4, ele"trlit,
7/23/2019 Lapkas Anak Opi
http://slidepdf.com/reader/full/lapkas-anak-opi 15/23
+
4<L (=/=) 4<TL (=/=)
T4 : alam batas nrmal
4ele" isilgis : nrmrele"
4ele" atlgis : ('/')
!ensri" : N
tnm : Ntri" : N
#ss : Penurunan "esaaran e.$
eningensealitis
= Pneumnia berat an sus. T
= %!K
= T Paru
21/0-/201+
B'
KU : enurunan
"esaaran
KT : batu" an sesa"
T : 1+1/-0
B4 : 128C/i
44 : *0C/i
T : 37,7<
! :10 Kg
P :-* $m
Keala : Nrm$ehali
ata : <n&. Pal. %n. Pu$at ('/'), !$lera
%$teri" ('/'), mata $e"ung ('/'),
mata "iri uemBiung : N<B ('), !e"ret (')
ulut : ibir : Pu$at ('), !iansis ('),
Terasang geel,
hierse"resi
Telinga : Nrmtia, se"ret (')
Leher : Pembesaran K? (') , retra"si
surasternal (=)
Thra" :
%nse"si : !imetris (=), retra"si inter$stal (=)
retra"si eigastrium (=)
Palasi : s "a F s "i
Per"usi : tia" ila"u"an
#us"ultasi :Aesi"ular (=), 4h (=/=), h ('/'),
strir (=)
<r : J % G J %%, 4eg, ising (')
#bmen:
%nse"si : !imetris, istensi (')
Palasi : !eel, hear ('), lien ('), renal, (').
N5eri te"an ('), turgr H 3 eti"
Per"usi : Tia" ila"u"am
#us"ultasi : Peristalti" (=) N
@Ctr : !u/in : eema ('/'),
!iansis ('/')
Pu$at ('/')
!asti" (=/=)
!tatus Neurlgis
?<! : @11A1 F 3
ata : bulat ,is"r (3mm/3mm)
4<L (=/=) 4<TL (=/=)T4 : alam batas nrmal
Th/
2 sung"u
%AE N* 3 gtt/i (mi"r)
%n&. eCamethasne 0,* am/8
&am
%n&. erenem +00mg/8 &am
%n&. 4anitiin * mg/8 &am
anitl 2* $$/8 &am ri alam 1
&am
%n& N;algin 1*0 mg/8 &am
iet N?T 30 $$/3 &am (iet
sne)
Nin5a 3C1
Nieiin 1 mg sublingual
!tretmisin 2*0 mg/2+ &am %
%NB 100 gr/hari N?T
4iamisin 1*0 mg/hari N?T
Pirazinami 2*0 mg/hari N?T
P/
#9asi ;ital sign (T er 1*
menit)
7/23/2019 Lapkas Anak Opi
http://slidepdf.com/reader/full/lapkas-anak-opi 16/23
+7
4ele" isilgis : nrmrele"
4ele" atlgis : ('/')
!ensri" : N
tnm : N
tri" : N
#ss : Penurunan "esaaran e.$
eningensealitis
= Pneumnia berat an sus. T
= %!K
= T Paru
22/0-/201+
B'7
KU : enurunan
"esaaran
KT : batu" an sesa"
B4 : 127C/i
44 : +2C/i
T : 3,<
! :10 Kg
P :-* $m
Keala : Nrm$ehali
ata : <n&. Pal. %n. Pu$at ('/'), !$lera
%$teri" ('/'), mata $e"ung ('/'),
mata "iri uem
Biung : N<B ('), !e"ret (')
ulut : ibir : Pu$at ('), !iansis ('),
Terasang geel,
hierse"resi
Telinga : Nrmtia, se"ret (')
Leher : Pembesaran K? (') , retra"si
surasternal (=)
Thra" :
%nse"si : !imetris (=), retra"si inter$stal (=)
retra"si eigastrium (=)
Palasi : s "a F s "i
Per"usi : tia" ila"u"an
#us"ultasi :Aesi"ular (=), 4h (=/=), h ('/'),
strir (=)
<r : J % G J %%, 4eg, ising (')
#bmen:
%nse"si : !imetris, istensi (')
Palasi : !eel, hear ('), lien ('), renal, (').
N5eri te"an ('), turgr H 3 eti"
Per"usi : Tia" ila"u"am
#us"ultasi : Peristalti" (=) N
@Ctr : !u/in : eema ('/'),
!iansis ('/')
Pu$at ('/')
!asti" (=/=)
!tatus Neurlgis
?<! : @22A1 F 3
ata : bulat ,is"r (3mm/3mm)
4<L (=/=) 4<TL (=/=)
T4 : alam batas nrmal
4ele" isilgis : nrmrele" 4ele" atlgis : ('/')
Th/
2 sung"u
%AE N* 3 gtt/i (mi"r)
%n&. erenem +00mg/8 &am
%n&. 4anitiin * mg/8 &am
%n& N;algin 1*0 mg/8 &am
iet N?T 30 $$/3 &am (iet
sne)
Nin5a 3C1
Nieiin 1 mg sublingual
Aalsartan 1C8 mg (ul;is)
!tretmisin 2*0 mg/2+ &am %
%NB 100 gr/hari N?T
4iamisin 1*0 mg/hari N?T
Pirazinami 2*0 mg/hari N?T
P/
#9asi ;ital sign
!u$tin ber"ala
7/23/2019 Lapkas Anak Opi
http://slidepdf.com/reader/full/lapkas-anak-opi 17/23
+8
!ensri" : N
tnm : N
tri" : N
#ss : Penurunan "esaaran e.$
eningensealitis
= %!K
= T Paru
= Pneumnia
23/0-/201+
B'8
KU : enurunan
"esaaran an
emam
KT : batu" an sesa"
T : -0/*3
B4 : 11C/i
44 : 27C/i
T : 3,<
! :10 Kg
P :-* $m
Keala : Nrm$ehali
ata : <n&. Pal. %n. Pu$at ('/'), !$lera
%$teri" ('/'), mata $e"ung ('/'),
mata "iri uem
Biung : N<B ('), !e"ret (')
ulut : ibir : Pu$at ('), !iansis ('),
Terasang geel,
hierse"resi
Telinga : Nrmtia, se"ret (')
Leher : Pembesaran K? (') , retra"si
surasternal (=)
Thra" :
%nse"si : !imetris (=), retra"si inter$stal (=)
retra"si eigastrium (=)
Palasi : s "a F s "i
Per"usi : tia" ila"u"an
#us"ultasi :Aesi"ular (=), 4h (=/=), h ('/'),strir (=)
<r : J % G J %%, 4eg, ising (')
#bmen:
%nse"si : !imetris, istensi (')
Palasi : !eel, hear ('), lien ('), renal, (').
N5eri te"an ('), turgr H 3 eti"
Per"usi : Tia" ila"u"am
#us"ultasi : Peristalti" (=) N
@Ctr : !u/in : eema ('/'),
!iansis ('/')
Pu$at ('/')
!asti" (=/=)
!tatus Neurlgis
?<! : @22A1 F 3
ata : bulat ,is"r (3mm/3mm)
4<L (=/=) 4<TL (=/=)
T4 : alam batas nrmal
4ele" isilgis : nrmrele"
4ele" atlgis : ('/')
!ensri" : Ntnm : N
Th/
2 nasal "anul 1'2 L/i
%AE N* 3 gtt/i (mi"r)
%n&. erenem +00mg/8 &am
%n&. 4anitiin * mg/8 &am
%n& N;algin 1*0 mg/8 &am
iet N?T 30 $$/3 &am (iet
sne)
Nin5a 3C1
Nieiin 1 mg sublingual
Aalsartan 1C8 mg (ul;is)
Katril 2C3 mg
!tretmisin 2*0 mg/2+ &am %
%NB 100 gr/hari N?T
4iamisin 1*0 mg/hari N?T
Pirazinami 2*0 mg/hari N?T
eCamethasn 1,* am/8 &am
P/
#9asi ;ital sign
!u$tin ber"ala
7/23/2019 Lapkas Anak Opi
http://slidepdf.com/reader/full/lapkas-anak-opi 18/23
+-
tri" : N
#ss : Penurunan "esaaran e.$
eningensealitis
= %!K
= T Paru
= Pneumnia
2+/0-/201+
B'-
KU : enurunan
"esaaran an
emam
KT : batu" an sesa"
B4 : 1+0C/i
44 : 31C/i
T : 3,8
<! :10 Kg
P :-* $m
Keala : Nrm$ehali
ata : <n&. Pal. %n. Pu$at ('/'), !$lera
%$teri" ('/'), mata $e"ung ('/'),
mata "iri uem
Biung : N<B ('), !e"ret (')
ulut : ibir : Pu$at ('), !iansis ('),
Terasang geel,
hierse"resi
Telinga : Nrmtia, se"ret (')
Leher : Pembesaran K? (') , retra"si
surasternal (=)
Thra" :
%nse"si : !imetris (=), retra"si inter$stal (=)
retra"si eigastrium (=)
Palasi : s "a F s "i
Per"usi : tia" ila"u"an
#us"ultasi :Aesi"ular (=), 4h (=/=), h ('/'),
strir (=)
<r : J % G J %%, 4eg, ising (')
#bmen:
%nse"si : !imetris, istensi (')
Palasi : !eel, hear ('), lien ('), renal, (').
N5eri te"an ('), turgr H 3 eti"
Per"usi : Tia" ila"u"am
#us"ultasi : Peristalti" (=) N
@Ctr : !u/in : eema ('/'),
!iansis ('/')
Pu$at ('/')
!asti" (=/=)
!tatus Neurlgis
?<! : @3+A1 F 8
ata : bulat ,is"r (3mm/3mm)
4<L (=/=) 4<TL (=/=)
T4 : alam batas nrmal
4ele" isilgis : nrmrele"
4ele" atlgis : ('/')
!ensri" : N
tnm : N
tri" : N
Th/
2 nasal "anul 1'2 L/i
%AE N* 20 gtt/i (mi"r)
%n&. erenem +00mg/8 &am
%n&. 4anitiin * mg/8 &am
%n& N;algin 1*0 mg/8 &am
iet N?T 30 $$/3 &am (iet
sne)
Nin5a 3C1
Nieiin 1 mg sublingual
Katril 2C3 mg
<eeim *00 mg/12 &am
!anml su (K/P)
!tretmisin 2*0 mg/2+ &am %
%NB 100 gr/hari N?T
4iamisin 1*0 mg/hari N?T
Pirazinami 2*0 mg/hari N?TeCamethasn 0,* am/8 &am
P/
#9asi se"ret
Eisiterai lan&ut
7/23/2019 Lapkas Anak Opi
http://slidepdf.com/reader/full/lapkas-anak-opi 19/23
*0
#ss : Penurunan "esaaran e.$
eningensealitis
= %!K
= T Paru
= Pneumnia (Klebsiella)
2*/0-/201+
B'10
KU : enurunan
"esaaran
KT : batu" an sesa"
T : 100/0
B4 : 13*C/i
44 : 20C/i
T : 3,-
<! :10 Kg
P :-* $m
Keala : Nrm$ehali
ata : <n&. Pal. %n. Pu$at ('/'), !$lera
%$teri" ('/'), mata $e"ung ('/'),
mata "iri uem
Biung : N<B ('), !e"ret (')
ulut : ibir : Pu$at ('), !iansis ('),
Terasang geel,
hierse"resi
Telinga : Nrmtia, se"ret (')
Leher : Pembesaran K? (') , retra"si
surasternal (=)
Thra" :
%nse"si : !imetris (=), retra"si inter$stal (=)
retra"si eigastrium (=)
Palasi : s "a F s "i
Per"usi : tia" ila"u"an
#us"ultasi :Aesi"ular (=), 4h (=/=), h ('/'),
strir (=)
<r : J % G J %%, 4eg, ising (')
#bmen:
%nse"si : !imetris, istensi (')
Palasi : !eel, hear ('), lien ('), renal, (').
N5eri te"an ('), turgr H 3 eti"
Per"usi : Tia" ila"u"am
#us"ultasi : Peristalti" (=) N
@Ctr : !u/in : eema ('/'),
!iansis ('/')
Pu$at ('/')
!asti" (=/=)
!tatus Neurlgis
?<! : @3+A1 F 8
ata : bulat ,is"r (3mm/3mm)
4<L (=/=) 4<TL (=/=)
T4 : alam batas nrmal
4ele" isilgis : nrmrele"
4ele" atlgis : ('/')
!ensri" : N
tnm : N
tri" : N
Th/
2 nasal "anul 1'2 L/i
%AE N* 20 gtt/i (mi"r)
%n&. erenem +00mg/8 &am
%n&. 4anitiin * mg/8 &am
%n& N;algin 1*0 mg/8 &am
iet N?T 2*'30 $$/3 &am (iet
sne)
Nin5a 3C1
Katril 2C3 mg
<eeim *00 mg/12 &am
Eursemi 10 mg/12 &am
!tretmisin 2*0 mg/2+ &am %
%NB 100 gr/hari N?T
4iamisin 1*0 mg/hari N?T
Pirazinami 2*0 mg/hari N?T
eCamethasn 0,* am/8 &am
P/
Urinalisa
7/23/2019 Lapkas Anak Opi
http://slidepdf.com/reader/full/lapkas-anak-opi 20/23
*1
#ss : Penurunan "esaaran e.$
eningensealitis
= %!K
= T Paru
= Pneumnia (Klebsiella)
7/23/2019 Lapkas Anak Opi
http://slidepdf.com/reader/full/lapkas-anak-opi 21/23
*2
2/-/201+
B'11
27/-/201+
KU : enurunan
"esaaran
KT : ening"atan
se"ret
B4 : 1++C/i
44 : 32C/i
T : 38, <
! : 11 Kg
P :- $m
Keala : Nrm$ehali
ata : <n&. Pal. %n. Pu$at ('/'), !$lera
%$teri" ('/'), mata $e"ung ('/'),
mata "iri uem
Biung : N<B ('), !e"ret (')
ulut : ibir : Pu$at ('), !iansis ('),
hierse"resi
Telinga : Nrmtia, se"ret (')
Leher : Pembesaran K? (') , retra"si
surasternal (=)
Thra" :
%nse"si : !imetris (=), retra"si inter$stal (=)
retra"si eigastrium (=)
Palasi : s "a F s "i
Per"usi : tia" ila"u"an
#us"ultasi :Aesi"ular (=), 4h (=/=), h ('/'),
strir (=)
<r : J % G J %%, 4eg, ising (')
#bmen:
%nse"si : !imetris, istensi (')
Palasi : !eel, hear ('), lien ('), renal, (').
N5eri te"an ('), turgr H 3 eti"
Per"usi : Tia" ila"u"am
#us"ultasi : Peristalti" (=) N
@Ctr : !u/in : eema ('/'),
!iansis ('/')
Pu$at ('/')
!asti" (=/=)
!tatus Neurlgis
?<! : @3+A1 F 8
ata : bulat ,is"r (3mm/3mm)
4<L (=/=) 4<TL (=/=)
T4 : alam batas nrmal
4ele" isilgis : nrmrele"
4ele" atlgis : ('/')
!ensri" : N
tnm : N
tri" : N
#ss : Penurunan "esaaran e.$
eningensealitis
= %!K
= T Paru
= Pneumnia (Klebsiella)
Th/
2 nasal "anul 1'2 L/i
%AE N* 20 gtt/i (mi"r)
%n&. erenem +00mg/8 &am
%n&. 4anitiin * mg/8 &am%n& N;algin 1*0 mg/8 &am
iet N?T 2*'30 $$/3 &am (iet
sne)
Nin5a 3C1
Katril 2C3 mg
<eeim *00 mg/12 &am
Eursemi 10 mg/12 &am
!tretmisin 2*0 mg/2+ &am %
%NB 100 gr/hari N?T
4iamisin 1*0 mg/hari N?T
Pirazinami 2*0 mg/hari N?T
eCamethasn 0,* am/8 &am
P/
Eisiterai
7/23/2019 Lapkas Anak Opi
http://slidepdf.com/reader/full/lapkas-anak-opi 22/23
*3
B'12 KU : enurunan
"esaaran
KT : ening"atan
se"ret
B4 : 1++C/i
44 : 32C/i
T : 38, <
! : 11 Kg
P :- $m
Keala : Nrm$ehali
ata : <n&. Pal. %n. Pu$at ('/'), !$lera
%$teri" ('/'), mata $e"ung ('/'),
mata "iri uem
Biung : N<B ('), !e"ret (')
ulut : ibir : Pu$at ('), !iansis ('),
hierse"resi
Telinga : Nrmtia, se"ret (')
Leher : Pembesaran K? (') , retra"si
surasternal (=)
Thra" :
%nse"si : !imetris (=), retra"si inter$stal (=)
retra"si eigastrium (=)
Palasi : s "a F s "i
Per"usi : tia" ila"u"an
#us"ultasi :Aesi"ular (=), 4h (=/=), h ('/'),
strir (=)
<r : J % G J %%, 4eg, ising (')
#bmen:
%nse"si : !imetris, istensi (')
Palasi : !eel, hear ('), lien ('), renal, (').
N5eri te"an ('), turgr H 3 eti"
Per"usi : Tia" ila"u"am
#us"ultasi : Peristalti" (=) N
@Ctr : !u/in : eema ('/'),
!iansis ('/')
Pu$at ('/')
!asti" (=/=)
!tatus Neurlgis
?<! : @3+A1 F 8
ata : bulat ,is"r (3mm/3mm)
4<L (=/=) 4<TL (=/=)
T4 : alam batas nrmal
4ele" isilgis : nrmrele"
4ele" atlgis : ('/')
!ensri" : N
tnm : N
tri" : N
#ss : Penurunan "esaaran e.$
eningensealitis
= %!K
= T Paru
= Pneumnia (Klebsiella)
Th/
2 nasal "anul 1'2 L/i
%AE N* 20 gtt/i (mi"r)
%n&. erenem +00mg/8 &am
%n&. 4anitiin * mg/8 &am%n& N;algin 1*0 mg/8 &am
iet N?T 2*'30 $$/3 &am (iet
sne)
Nin5a 3C1
Katril 2C3 mg
<eeim *00 mg/12 &am
Eursemi 10 mg/12 &am
!tretmisin 2*0 mg/2+ &am %
%NB 100 gr/hari N?T
4iamisin 1*0 mg/hari N?T
Pirazinami 2*0 mg/hari N?T
eCamethasn 0,* am/8 &am
P/
Eisiterai
7/23/2019 Lapkas Anak Opi
http://slidepdf.com/reader/full/lapkas-anak-opi 23/23
*+