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LAPORAN JAGA27 FEBRUARI 2016

Dokter muda Ria Chairul

Konsulen Jaga dr. Devi Gusmaiyanto, Sp.A,

M.Biomed

Tanggal pemeriksaan 27/0/20!"

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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

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,ELUAN UTAMA

Aoana!n)"*" *(# a/a3

,U : ")"a$ na+a" ")a$ 1 a! SMRS

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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

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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

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RI8A9AT PEN9A,IT ,ELUARGA

 T*a$ aa $)#a'ga /ang !)ngaa!*$)#3an ")+)'-* *n*

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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

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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

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R*>a/a- *!#n*"a"*

)+a-*-*" : & $a* Po*o: & $a* BG : 1 $a* DTP : & $a* *( : & $a*

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Riwayat tumbuh kembang :  I(# +a"*)n !)nga$# +)'-#!(#3an an

+)'$)!(angan ana$ no'!a

Riwayat pemberian ASI :

ASI )$"$#"*= "a!+a* #"*a 6 (#an

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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

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P)!)'*$"aan F*"*$

Kulit :

-#'go' $#*- $)!(a* ")+-#! ?

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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 ?

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P)!)'*$"aan F*"*$

Toraks (pulmo) In"+)$"* : "*!)-'*" ')-'a$"* ; )+*ga"-'*#!

*n-)'

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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

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P)!)'*$"aan +)n#nang

27%0&%2016 B : 104 g' -: 2C7 E'*-'o"*- : 424 g'

8B :

12.C00%!!& PLT :

44.000%!!&

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!IA"#$SIS KR%A  B'on$*o*-*"

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 TATALA,SANA

IFD ,AEN IIIB 105

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PROGNOSIS

A H*-a! : (ona! A =#ng"*ona! : #(*a a (ona! A "ana-*ona! : (ona!

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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-)'

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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

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 T)'*!a $a"*3