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8/17/2019 Laporan Jaga Bronkiolitis RIA
1/22
LAPORAN JAGA27 FEBRUARI 2016
Dokter muda Ria Chairul
Konsulen Jaga dr. Devi Gusmaiyanto, Sp.A,
M.Biomed
Tanggal pemeriksaan 27/0/20!"
8/17/2019 Laporan Jaga Bronkiolitis RIA
2/22
IDENTITAS
No. MR : 16.40.25 Tangga !a"#$ : 27%0&%2016 Na!a : An. BN U!#' : 6 (#an J)n*" $)a!*n : P)')!+#an Ana$ ,) : 1 Aga!a : I"a! Aa!a- : B#ana !a$!#' Da/#n
8/17/2019 Laporan Jaga Bronkiolitis RIA
3/22
,ELUAN UTAMA
Aoana!n)"*" *(# a/a3
,U : ")"a$ na+a" ")a$ 1 a! SMRS
8/17/2019 Laporan Jaga Bronkiolitis RIA
4/22
RI8A9AT PEN9A,IT SE,ARANG
Pa"*)n ana$ #"*a 6 (#an '##$an a'* P,M a/#na-ang )ngan $)#3an )!a! )!a! 3*ang-*!(# an -*a$ -*ngg* (a-#$ ()'a3a$ ; ")a$2 3a'* SMRS
1 3a'* SMRS +a"*)n !)ng)#3$an BAB
8/17/2019 Laporan Jaga Bronkiolitis RIA
5/22
RI8A9AT PEN9A,IT DAULU
Pa"*)n +)'na3 !)ngaa!* $)#3an")+)'-* *n* ")()#! n/a an * *agno"*")ngan ('on$*o*-*" 1 (#an /ang a# an
*'a>a- ")a!a 5 3a'* * RSUD T)ng$#'aan
8/17/2019 Laporan Jaga Bronkiolitis RIA
6/22
RI8A9AT PEN9A,IT ,ELUARGA
T*a$ aa $)#a'ga /ang !)ngaa!*$)#3an ")+)'-* *n*
8/17/2019 Laporan Jaga Bronkiolitis RIA
7/22
RI8A9AT LING,UNGAN
R#!a3 -)!+a- -*ngga : *ng$#ngan (a*$ S#!()' a*' !*n#! a'* a*' gaon
B#ang a*' ()"a' * 8 +'*(a* *'#!a3 T)'a+a- -)!+a- +)!(#angan "a!+a3#!#! * *ng$#ngan '#!a3
8/17/2019 Laporan Jaga Bronkiolitis RIA
8/22
RI8A9AT ,EAMILAN
R*>a/a- AN * (*an '#-*n R*>a/a- +)n/a$*- ")a!a $)3a!*an*"ang$a La!a 3a!* &C?40 !*ngg# R*>a/a- +)'"a*nan: no'!a
8/17/2019 Laporan Jaga Bronkiolitis RIA
9/22
R*>a/a- *!#n*"a"*
)+a-*-*" : & $a* Po*o: & $a* BG : 1 $a* DTP : & $a* *( : & $a*
8/17/2019 Laporan Jaga Bronkiolitis RIA
10/22
Riwayat tumbuh kembang : I(# +a"*)n !)nga$# +)'-#!(#3an an
+)'$)!(angan ana$ no'!a
Riwayat pemberian ASI :
ASI )$"$#"*= "a!+a* #"*a 6 (#an
8/17/2019 Laporan Jaga Bronkiolitis RIA
11/22
P)!)'*$"aan #!#!
,)aaan #!#! : -a!+a$ "a$*- ()'a- ,)"aa'an : )n"* P)'na=a"an : 60%!)n*- S#3# -#(#3 : &2 O Da-a An-'o+o)!)-'*
B)'a- Baan : 7 $g
T*ngg* Baan : 64
8/17/2019 Laporan Jaga Bronkiolitis RIA
12/22
P)!)'*$"aan F*"*$
Kulit :
-#'go' $#*- $)!(a* ")+-#! ?
8/17/2019 Laporan Jaga Bronkiolitis RIA
13/22
P)!)'*$"aan F*"*$
M##- : g#"* ()'a'a3 ? *a3 $o-o' ? T)nggo'o$ :
Ton"* T1?T1 3*+)')!*" ?Fa'*ng 3*+)')!*" ?
L)3)' : P)!()"a'an ,GB ?
8/17/2019 Laporan Jaga Bronkiolitis RIA
14/22
P)!)'*$"aan F*"*$
Toraks (pulmo) In"+)$"* : "*!)-'*" ')-'a$"* ; )+*ga"-'*#!
*n-)'
8/17/2019 Laporan Jaga Bronkiolitis RIA
15/22
Abdomen
In"+)$"* : "#+) *"-)n"* ? A#"$#-a"*: BU ; no'!a P)'$#"* : T*!+an* * ")#'#3 $#a'an a(o!)n Pa+a"* : n/)'* -)$an )+*ga"-'*#! ? 3)+a'
*)n -$ -)'a(akstremitas
S#+)'*o' : a$'a 3anga- ))!a ? "*ano"*"? RT 2
In=)'*o' : a$'a 3anga- ))!a ? "*ano"*"? RT 2KK
8/17/2019 Laporan Jaga Bronkiolitis RIA
16/22
P)!)'*$"aan +)n#nang
27%0&%2016 B : 104 g' -: 2C7 E'*-'o"*- : 424 g'
8B :
12.C00%!!& PLT :
44.000%!!&
8/17/2019 Laporan Jaga Bronkiolitis RIA
17/22
!IA"#$SIS KR%A B'on$*o*-*"
8/17/2019 Laporan Jaga Bronkiolitis RIA
18/22
TATALA,SANA
IFD ,AEN IIIB 105
8/17/2019 Laporan Jaga Bronkiolitis RIA
19/22
PROGNOSIS
A H*-a! : (ona! A =#ng"*ona! : #(*a a (ona! A "ana-*ona! : (ona!
8/17/2019 Laporan Jaga Bronkiolitis RIA
20/22
FOLLO8?UP 2%0&%2016Sub&ecti'e
!emam () sesak napas () batuk () pilek (*) muntah(*) +A+ () normal +AK () normal
$b&ecti'e • ,U -a!+a$ "a$*- ")ang• ,)aaan o!+o"!)n-*"• R 110%!)n*-• RR 62%!)n*-• S#3# &7• PF -3o'a ')-'a$"* ; )+*ga"-'*#! *n-)'
8/17/2019 Laporan Jaga Bronkiolitis RIA
21/22
FOLLO8?UP 2C%0&%2016Sub&ecti'e
!emam (*) sesak napas berkurang batuk () pilek (*)muntah (*) +A+ () normal +AK () normal
$b&ecti'e • ,U -a!+a$ "a$*- ")ang• ,)aaan o!+o"!)n-*"• R 110%!)n*-•
RR 52%!)n*-• S#3# &7• PF -3o'a ')-'a$a"* ? "#a'a na+a" ('on$oH)"*$#a' '3 ;%;>3 ?%?
Assesment
Ta!+a$ +)'(a*$an
,lan • IFD $a)n III B 2 --"%* !*$'o• ASI 610
8/17/2019 Laporan Jaga Bronkiolitis RIA
22/22
T)'*!a $a"*3
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