Power Point Responsi

7/26/2019 Power Point Responsi

1/78

R E S P O N S I

BIHA, BP dan TBDisusun Sebagai Salah Satu Tugas Kepanitraan Klinik

MadyaSMF Ilmu Kesehatan Anak RSU Jayapura.

Pembimbing :dr. Immaculata P, Sp. A

Disusun oleh :

Ulfah S. Madamar, S. ed !!"!#$!!%$Sumar Dian&i, S. ed !!"!#$!!'!


2/78

Iden&i&as Pasien

Nama : An. S.(

Umur : ) &ahun, ) *ulan

T+l lahir : ! No-em*er !)$

enis /elamin : Perem0uan

BB1TB : 2 /+13#

Alama& : Tanah Hi&am

A+ama : ris&en Pro&es&an

No. RM : ''"###

Su/u1Ban+sa : Dani1Indonesia

Ruan+ Pera4a&an : R 5Ruan+ Pulmo6

Tan++al MRS : )3 anuari !)%

Tan++al 0ulan+ : % anuari !)%

Pem*eri Informasi : I*u Pasien


3/78

Anamnesis.U&ama :Demam

RPS :

Pasien da&an+ den+an /eluhan u&ama demam 7 ) min++u 8an+ laluse*elum masu/ Rumah Sa/i& Umum Daerah A*e0ura. Demam dirasa/an&erus menerus. Demam &urun saa& 0em*erian 0ara9e&amol s8ru0 /ira/ira) sendo/ &eh saa& 0asien demam, &e&a0i se/i&ar /uran+ le*ih ) ;am/emudian 0asien /em*ali demam. Menuru& i*u 0asien, selain demam0asien ;u+a *a&u/ 7 ) *ulan. Ba&u/ *erlendir *er4arna 0u&ih diser&ai

sesa/. Sesa/ mulai dirasa/an se;a/ 0asien mulai *a&u/ 7 ) *ulan. Sesa/*er&am*ah *era& saa& 0asien menan+is. Menuru& i*u 0asien semen;a/sa/i& nafsu ma/an 0asien menurun, minum ;u+a menurun. Buan+ air*esar dan /e9il lan9ar.

RPD :

Ri4a8a& e;an+ disan+/alRi4a8a& AR< 5=6Ri4a8a& OAT 56

'


4/78

Ri4. >i?i

Se;a/ lahir 0asienhan8a di*eri/anPASI.

Ri4. Pen8. el

I*u dan a8ah0asien menderi&a0en8a/i& HI< 7

se;a/ &ahun 8an+lalu. A8ah 0asienmemil/i ri4a8a& TB0u&us o*a&.Ri4a8a& e0ile0s8,ri4a8a& hi0er&ensi,ri4a8a& asma,ri4a8a& dia*e&esmelli&us, dan

ri4a8a& ;an&un+,disan+/al oleh i*u0asien.

Ri4./e0ri*adian

Pasien meru0a/anana/ 8an+9enderun+ re4el

dan le*ih de/a&den+an a8ahdi*andin+ i*u0asien.

Ri4. sosial

Pasien adalah ana/ /edua, 0asien&in++al di &anah hi&am *ersamaden+an oran+ &uan8a. Tin++al dirumah 8an+ &er*ua& dari *a&u,lan&ain8a dari &anah dan serin+*eran+/a& 0ulan+ *ali/ 4amena @;a8a0ura. Pasien le*ih serin+*erada di 4amena di*andin+/andi ;a8a0ura. Di 4amena, 0asien&in++al di rumah /eluar+a *esar8an+ *er*en&u/ honai. Sum*erair minum *erasal dari air /ali,&e&a0i ;i/a air &ida/ men+alirmere/a men++un/an air hu;anse/alian un&u/ mandi danmen9u9i. Ban8a/ saudara 8an+mero/o/ 8an+ &in++al *ersamasama den+an 0asien &ermasu/a8ah 0asien. Memasa/ den+anmem*a/ar /a8u *a/ar, &ida/

masa/ di /om0or.

$


5/78

Pemeri/saan isi/

S : )3 5E$


6/78

Pemeri/saan isi/

A*domen I : Su0el, da&arA : Bisin+ usus 5=6 normal $C1mP : Su0el, He0ar 5&era*a6, ien 5&era*a6, N8eri Te/an 56,

&ur+or /uli& normal.

P : Tim0ani

E/s&remi&as : A/ral han+a&, oedem 516, 9a0illar8reGll &ime ' de&i/

uli& : anemis 5=1=6, i/&eri/ 516, sianosis 516.

>eni&alia : Tida/ dila/u/an 0emeri/saan

Status Neurologis

Tanda ran+san+ menin+eal : Tida/ ada

Ree/s Gsiolo+is : Normal

Ree/s 0a&olo+is : Tida/ ada

Tonus : Bai/

e/ua&an o&o& : Bai/

%


7/78

S&a&us >i?i

S&a&us +i?i An. S.(1 0erem0uan1 ) &ahun ) *ulan1 **2,)1 0* 3# 9m

Berdasar/an an&ro0ome&ri den+an men++una/an Js9ore 5(HO6

2


8/78

#


9/78

Pem. a*" a* :

eu/osi& ),"2 )!'1uDDR: ne+a&if

Pasien 0erem0uan, umur ) &ahun ) *ulan, *era& *adan 2 /+, &in++i *adan 3#9m da&an+ /e I>D Rumah Sa/i& A*e0ura den+an /eluhan u&ama demam 7 )min++u 8an+ lalu se*elum masu/ rumah Sa/i&, demam dirasa/an &erusmeners. Demam &urun saa& 0em*erian 0ara9e&amol s8ru0 /ira/ira ) sendo/&eh saa& 0asien demam, &e&a0i se/i&ar /uran+ le*ih ) ;am /emudian 0asien/em*ali demam. Menuru& i*u 0asien, selain demam 0asien ;u+a *a&u/ 7 )*ulan. Ba&u/ *erlendir *er4arna 0u&ih diser&ai sesa/. menuru& i*u 0asiensemen;a/ sa/i& nafsu ma/an 0asien menurun, minum ;u+a menurun. Pasienlahir se9ara s0on&andari i*u den+an HI< 0osi&if &er/on&rol AR


10/78

O*ser-asidis0neu e.9Bron/o0nemonia

BIHA = Oralandidiasis

Dia+nosaer;a

I


11/78

OO( UP

TAN>>A DAL S O A P

)% ANUARI

!)%

) demam,

sesa/,*a&u/0ile/.

eadaan Umum F

Tam0a/ sa/i& sedan+

esadaran F om0osMen&is

TT< F HR F )!C1m,R F %#C1m,SB F '2,)o, S0O F

"2

e0ala1eheron+;un+&i-a anemis5=1=6, S/elera I/&eri/5=1=6, Pem*esaran/elen;ar +e&ah *enin+51=6, O 5=6

Thora/s :Pulmo :I F Sim&eris, I/u&+era/ na0as

P F


12/78

OO( UP

TAN>>A DAL S O A P

)% ANUARI

!)%

) demam,

sesa/,*a&u/0ile/.

P F Sonor

A F Suara nafas-esi/uler, rhon/i 5=1=6,4hee?in+ 516

or :I F I9&su ordis &ida/&erliha&

P F I9&us ordis &ida/&era*a, &hrill 56P F Pe/a/A F Bun8i an&un+ IIIre+, murmur 56, +allo056

A*domen :I F Da&arA F Bisin+ Usus 5=6$C1mP F Su0el, N8eri Te/an56, He01ien F &era*a

BA1&&*P F T8m0ani

o*s. Dis0neu

e.9*ron/o0nemonia = BIHA= Oral9andidiasi

in;.

Para9e&amol ' C#! m+5i.-6

Rani&idinC# m+

5i.-6

Ne*u9om*i-en& !,# 99 =NS !," 99 1 #

;am

Pro 9e/D, DDR,OT, PT,ur19r, 9r0,

fo&o&horaC

)


13/78

OO( UP

TAN>>A DAL S O A P

)% ANUARI

!)%

) demam,

sesa/,*a&u/0ile/.

E/s&remi&as: A/ral

han+a&, Udem 56,ul/us 56


14/78

OO( UP

TAN>>A DAL S O A P

)2 anuari

!)%

demam

56,sesa/5=6, *a&u/0ile/ 5=6

eadaan Umum F

Tam0a/ sa/i& sedan+


TT< F HR F )!C1m,R F 3#C1m,

SB F '2,)o,S0O F "2

e0ala1eher :on+;un+&i-a anemis5=1=6, S/elera I/&eri/5=1=6, Pem*esaran

/elen;ar +e&ah *enin+51=6, O 5=6

Thora/s : Pulmo :I F Sim&eris, I/u&+era/ na0as

P F


15/78

OO( UP

TAN>>A DAL S O A P

)2 anuari

!)%

demam

56,sesa/5=6, *a&u/0ile/ 5=6

P F Sonor




A*domen :I F Da&arA F Bisin+ Usus 5=6$C1mP F Su0el, N8eri Te/an56, He01ien F &era*a

BA1&&*P F T8m0ani

o*s. Dis0neu

e.9*ron/o0nemonia = BIHA= Oral9andidiasis

Rani&idin

C# m+5i.-6

Ne*u9om*i-en& !,# 99 =NS !," 99 1 #

;amPro

9e/ D,DDR, OT,PT, ur19r,9r0, fo&o&horaC,

0ros9orin+&*

)3

OO( UP


16/78

OO( UP

TAN>>A DAL S O A P

)2 anuari

!)%

demam

56,sesa/5=6, *a&u/0ile/ 5=6

E/s&remi&as : A/ral



17/78

OO( UP

TAN>>A DAL S O A P

)# anuari

!)%

' demam

56,sesa/56, *a&u/0ile/ 56

eadaan Umum F

Tam0a/ sa/i& sedan+


TT< F HR F )C1m,R F $#C1m,

SB F '2,)o,S0O F "2

e0ala1eher :on+;un+&i-a anemis5=1=6, S/elera I/&eri/5=1=6, Pem*esaran



o*s. Dis0neu


O nasal

) l0m5/106

I


18/78

OO( UP


19/78

OO( UP

TAN>>A DAL S O A P

)# anuari

!)%

' demam

56,sesa/56, *a&u/0ile/ 56

P F Su0el, N8eri Te/an

56, He01ien F &era*a BA1&&*P F T8m0ani

E/s&remi&as :A/ral han+a&, Udem 56,ul/us 56


20/78

OO( UP

TAN>>A DAL S O A P

)" ANUARI

!)%

$ demam

56,sesa/56, *a&u/0ile/ 56

eadaan Umum F

Tam0a/ sa/i& sedan+


TT< F HR F )!"C1m,R F $#C1m, SB F

'%,"o, S0O F ""

e0ala1eheron+;un+&i-a anemis5=1=6, S/elera I/&eri/5=1=6, Pem*esaran/elen;ar +e&ah *enin+

51=6, O 5=6


P F


21/78

OO( UP

TAN>>A DAL S O A P

)" ANUARI

!)%

$ demam

56,sesa/56, *a&u/0ile/ 56

P F Sonor




A*domen :I F Da&arA F Bisin+ Usus 5=6$C1mP F Su0el, N8eri Te/an56, He01ien F &era*a BA1&&*P F T8m0ani

o*s. Dis0neu


Rani&idin

C# m+5i.-6

Ne*u9om*i-en& !,# 99 =NS !,"

99 1 #;am

UrdaheC) C 23m+ 50.o6

Pro&ranfusi0r9 )2 99dalam '

;am

)

OO( UP


22/78

OO( UP

TAN>>A DAL S O A P

)" ANUARI

!)%

$ demam

56,sesa/56, *a&u/0ile/ 56

E/s&remi&as: A/ral



23/78

OO( UP

TAN>>A DAL S O A P

! ANUARI

!)%

3 demam

5=6,sesa/56, *a&u/0ile/ 56

eadaan Umum F

Tam0a/ sa/i& sedan+


TT< F HR F )%C1m,R F $2C1m, SB F

'%,"o, S0O F ""

e0ala1eheron+;un+&i-a anemis5=1=6, S/elera I/&eri/5=1=6, Pem*esaran/elen;ar +e&ah *enin+

51=6, O 5=6


P F


24/78

OO( UP

TAN>>A DAL S O A P

! ANUARI

!)%

3 demam

5=6,sesa/56, *a&u/0ile/ 56

P F Sonor





o*s. Dis0neu


in;.

Para9e&amol ' C#! m+5i.-6 5/106

Rani&idinC# m+

5i.-6

Ne*u9om*i-en& !,# 99 =NS !," 99 1 #

;am


Pro&ranfusi

$

OO( UP


25/78

OO( UP

TAN>>A DAL S O A P

! ANUARI

!)%

3 demam

5=6,sesa/56, *a&u/0ile/ 56

E/s&remi&as: A/ral



26/78

OO( UP

TAN>>A DAL

S O A P

) ANUARI!)%

% demam56,sesa/56,*a&u/0ile/ 56

eadaan Umum FTam0a/ sa/i& sedan+


TT< F HR F ))#C1m,

R F $$C1m, SB F'%,3o, S0O F ""

e0ala1eheron+;un+&i-a anemis5=1=6, S/elera I/&eri/5=1=6, Pem*esaran



o*s. Dis0neue.9*ron/o0nemonia = BIHA =Oral 9andidias

Onasal ) l0m5/106

I


27/78

OO( UP

TAN>>A DAL S O A P

) ANUARI

!)%

% demam

56,sesa/56, *a&u/0ile/ 56

P F Sonor





o*s. Dis0neu


in;.

Para9e&amol ' C#! m+5i.-6 5/106

Rani&idinC# m+

5i.-6

Ne*u9om*i-en& !,# 99 =NS !," 99 1 #

;am


Pro OAT

2


28/78

OO( UP


29/78

OO( UP

TAN>>A DAL

S O A P

ANUARI!)% 2 demam56,sesa/56,*a&u/0ile/ 56



TT< F HR F )'$C1m,

R F $C1m, SB F'%,%o, S0O F "2





Onasal ) l0m5/106

I


30/78

OO( UP

TAN>>A DAL S O A P

ANUARI

!)%

2 demam

56,sesa/56,*a&u/0ile/ 56

P F Sonor





o*s. Dis0neu


in;.

Para9e&amol ' C#! m+5i.-6 5/106

Rani&idinC# m+

5i.-6

Ne*u9om*i-en& !,# 99 =NS !," 99 1 #

;am


Pro OAT

'!

OO( UP


31/78

OO( UP

TAN>>A DAL S O A P

ANUARI

!)%

2 demam

56,sesa/56,*a&u/0ile/ 56

E/s&remi&as: A/ral


OT1S>PT, *ila*ai/, OAT

')

OO( UP


32/78

OO( UP

TAN>>A DAL

S O A P

' ANUARI!)% # demam56,sesa/56,*a&u/0ile/ 56



TT< F HR F )''C1m,

R F '%C1m, SB F'%,%o, S0O F ""





Onasal ) l0m5/106

I


33/78

OO( UP


34/78

OO( UP

TAN>>A DAL S O A P

' ANUARI

!)%

# demam

56,sesa/56,*a&u/0ile/ 56

E/s&remi&as: A/ral



35/78

OO( UP

TAN>>A DAL

S O A P

$ ANUARI!)% " demam56,sesa/56,*a&u/0ile/ 56



TT< F HR F )'!C1m,

R F '#C1m, SB F'%,%o, S0O F "#





Onasal ) l0m5/106

I


36/78

OO( UP

TAN>>A DAL S O A P

$ ANUARI

!)%

" demam

56,sesa/56,*a&u/0ile/ 56

P F Sonor





o*s. Dis0neu


in;.

Para9e&amol ' C#! m+5i.-6 5/106

Rani&idinC# m+

5i.-6

Ne*u9om*i-en& !,# 99 =NS !," 99 1 #

;am


'%


37/78

OO( UP


38/78

OO( UP

TAN>>A DAL

S O A P

3 ANUARI!)% )! demam56,sesa/56,*a&u/0ile/ 56



TT< F HR F )'!C1m,

R F '#C1m, SB F'%,%o, S0O F "#

e0ala1eheron+;un+&i-a anemis5=1=6, S/elera I/&eri/

5=1=6, Pem*esaran/elen;ar +e&ah *enin+51=6, O 5=6

Thora/s :Pulmo :I F Sim&eris, I/u&

+era/ na0as

B0ron/o0nemonia =TB5&undaOAT6 = BIHA= Oral9andidiasis50er*ai/an6=

he0a&i&isa/u&5S>OT1S>PT6

Onasal ) l0m5/106

I


39/78

OO( UP

TAN>>A DAL S O A P

3 ANUARI

!)%

)! demam

56,sesa/56,*a&u/0ile/ 56

P F Sonor





B0ron/o0ne

monia =TB5&undaOAT6 = BIHA= Oral9andidiasis50er*ai/an6=he0a&i&is

5S>OT1S>PT6

in;.

Para9e&amol ' C#! m+5i.-6 5/106

Rani&idinC# m+

5i.-6

Ne*u9om*i-en& !,# 99 =NS !," 99 1 #

;am

UrdaheC C )0ul-50.o6

'"

OO( UP


40/78

OO( UP

TAN>>A DAL S O A P

3 ANUARI

!)%

)! demam

56,sesa/56,*a&u/0ile/ 56

E/s&remi&as: A/ral


OT1S>PT6

ur9uma

) C 9&h

o&rimoCasol $ C )9&h

AR>A DAL

S O A P

% ANUARI!)% )) demam56,sesa/56,*a&u/0ile/ 56



TT< F HR F )'!C1m,

R F '#C1m, SB F'%,%o, S0O F"#

e0ala1eheron+;un+&i-a anemis

5=1=6, S/elera I/&eri/5=1=6, Pem*esaran/elen;ar +e&ah *enin+51=6, O 5=6

Thora/s :Pulmo :

I F Sim&eris, I/u&+era/ na0as

B0ron/o0nemonia =TB5&undaOAT6 = BIHA= Oral9andidiasis50er*ai/an6=

he0a&i&is5S>OT1S>PT6

Onasal ) l0m5/106

I


42/78

OO( UP

TAN>>A DAL S O A P

% ANUARI

!)%

)) demam

56,sesa/56,*a&u/0ile/ 56

P F Sonor




A*domen :I F Da&arA F Bisin+ Usus 5=6$C1mP F Su0el, N8eri Te/an56, He01ien F &era*a BA1&&*

P F T8m0ani

B0ron/o0ne

monia =TB5&undaOAT6 = BIHA= Oral9andidiasis50er*ai/an6=he0a&i&is

5S>OT1S>PT6

in;.

Para9e&amol ' C#! m+5i.-6 5/106

Rani&idinC# m+

5i.-6

Ne*u9om*i-en& !,# 99 =NS !," 99 1 #

;am

UrdaheC C )0ul-50.o6

$

OO( UP


43/78

OO( UP

TAN>>A DAL S O A P

% ANUARI

!)%

)) demam

56,sesa/56,*a&u/0ile/ 56

E/s&remi&as: A/ral


OT1S>PT6

ur9uma

) C 9&h

o&rimoCasol $ C )9&h

AR

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