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Laporan PagiSenin, 23

November 2015Dokter Onsite:

dr. Mars Nashrah.A., Sp.A

Dokter Muda:

Pocut Indah/ Bian Brillian/ Yoan Amara

Baian/ SM! Ilmu "esehatan Anak !" #NSYIA$/ %S#D dr. &ainoel A'idin Banda Aceh()*+

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1. Citra, 1 bl 10 hr, CM: 107

Tanggal masuk : 22 November 2015 (22.31 WIB)

Tanggal konsul IKA : 22 November 2015 (23.00 WIB)

Diagnosis:Saus Konvuls!" #

$$%

1. &en!ngoense"al!!s

2. &en!ng!!s

Ruang Rawat

PICU

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IDENTITA

Nama : '!ra

en!s kelam!n : erem*uan

+mur : 1 bulan 10 ,ar! Alama : +lee Kareng

No. '& : 1-0-1/-30

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 ANAMNEI

!"luhan Uta#a :Keang

!"luhan Ta#bahan :

$emam muna,

Riwa$at P"n$a%it "%arang:as!en aang engan kelu,an keang seak 3 am S&4S.Keang era! sebanak 6 kal! engan uras! kurang ar! 2

men! *er kal! keang. $! ruma, sak! *as!en mengalam! keangsekal! engan uras! leb!, ar! men!. Keang era! an*a!sera! *enurunan kesaaran. as!en mem!l!k! r!7aa emamseak 3 ,ar! ang lalu. $emam urun engan oba *enurun*anas. Keang on!k klon!k *aa sebag!an ubu, sebela, k!r!.

as!en uga mengelu,kan muna, seak 3 ,ar! ang lalu.&una, ber!s! ASI ang !m!num an era! erus menerus.

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 ANAMNEI

as!en mengalam! *enurunan na"su makan an kurangre"leks meng,!sa*. as!en erl!,a lemas an *u8a. 9erakankurang ak!". BAB an BAK lan8ar.Riwa$at P"n$a%it Dahulu :as!en !ak *erna, mengalam! ,al se*er! !n! sebelumna4!7aa ,!*erens! !ak aa r!7aa $& !ak aa r!7aaalerg! !ak aa.Riwa$at P"n$a%it !"luarga :T!ak aa anggoa kelurga engan kelu,an ang sama

Riwa$at P"#b"rian &bat:oba *enurun *anasRiwa$at %"ha#ilan:Ibu *as!en eraur AN' *aa b!an

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 ANAMNEI

Riwa$at P"rsalinan :Ibu *as!en AN' eraur ! b!an ba! la,!r se8ara*ervag!nam engan BB 3000 gr. as!en anak ke-ar! bersauara

Riwa$at I#unisasi :*as!en sua, ! !mun!sas! 1 kal! saa la,!r

Riwa$at Nutrisi :0-1 bulan: ASI

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TANDA 'ITA(

Kesadaran Compos Mentis

Nadi 122 x/menit (60-100 x / menit)

Pernafasan 32 x/menit (16-20 x/menit)

Temperatur Asi!a " 3#$0 %C

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Data Antro)o#"tri

BBS : 3 kg

TB : 51 8m

BB%+ : -2 s. -3 S$

TB%+ : 0 s. -2 S$BB%TB : 0 s. -2 S$

BBI : 66 kg

;A : 1 m!nggu 3 ,ar!Saus 9!<! : Normal

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!"butuhan *airan, %alori, )rot"in

Kebuu,an 'a!ran (;oll!a segar)= 120 > 3

= 3?0 88%,ar!

Kebuu,an Kalor! = 4@@ > a8or A8!v! > a8or Sress  = 150 > 11? > 0/

  =1?3/ = 1?6 kkal%,ar!

Kebuu,an *roe!n = 4$A > a8or A8!v! > "akor sres  = ?? > 11? > 0/

  = ? gr%,ar!

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PEMERI!AAN +II! 

!")ala : ++B membonolMata : Konung!va al*ebra In"er!or u8a

(#%#) Sklera Iker!k (-%-) @ema

er!orb!a (-%-)

T"linga : Normo!a

i-ung : N'; (-) sekre (-%-).

Mulut : B!b!r ker!ng (#) &ukosa ,!*erem!s (-)

  S!anos!s (-)

("h"r : embesaran K9B (-)

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- T&RA : S!mer!s 4eraks! (-) Ces!kuler (#%#) 4,onk! (-%-) W,ee<!ng (-%-)

- /ANTUN : B I D B II 4eguler (#) B!s!ng anung (-) murmur (-)

A2D&MEN Ins*eks! : S!mer!s al*as! : Soe*el Ner! ekan (#) unulas! (-) ;%%4 !ak eraba *erkus! : T!m*an! s,!"!ng ullness (-) Auskulas! : er!sal!k (#) Kesan normal

 

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E!TREMITA :• Su*er!or : eema (-%-) *u8a (-%-) akral !ng!n (-%-)

• In"er!or : eema (-%-) *u8a (#%#) akral !ng!n (#%#)

• '4T E 2F

ENITA(IA :Tidak dilakukan pemeriksaan.

tatus n"urologis:Kaku kuuk: (-)

4e"leks *aolog!s: (#)

4e"leks !s!olog!s: (#)

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aboraor!um (1%11%2015)

;b : ?/ gr%l

; : 20G@r!ros! : 2.100.000%mm3

eukos! : 1/. /00 % mm3

Trombos! : 55.000%mm3

@%B%N.B%N.S%%& = 0%0%0%63%35%23

'T%BT : H%2H

Na%k%8l : 131%3%101

9$S : 55 mg%l

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DIAN&I 2ANDIN

tatus !on3ulsi "* DD4 1. "ns"5alitis

-6. i#balan*" "l"%trolit

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Diagnosis !"ra

Saus Konvuls! e8 ense"al!!s

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TERAPI• ;ea +* 30

• J2 a8e &ask 1-2 %!• IC$ 6:1 12 g%! (m!kro)

• Sesol! su** 05 mg%KgBB

• In. Novalg!n 50 mg%?am

• $r!* en!o!n loa!ng ose ?0 mg !en8erkan engan 20 88Na8l 0/G !ber!kan alam 30 men!. $os!s ulangan"en!o!n loa!ng ose mg%12 am !v !en8erkan engan 1088 Na8l 0/G !ber!kan alam 30 men!.

• $!e ASI 30 88% 3 am% J9T

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lann!ng

4a7a !na* I'+

'ek ara, ru!n ur!n ru!n "eses ru!n

'ek ur%8r elekrol! K9$S

Kulur ara, # kulur ur!n@@9

;ea 'T-S8an

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T"ri#a !asih