Laporan Kasus: Pembimbing: dr. Rudi Ruskawan, Sp. A

LAPORAN KASUS

Pembimbing : dr. Rudi Ruskawan, Sp. A

Penyusun : Putri Yuliani 030.05.174

Kepaniteraan Klinik Ilmu Kesehatan Anak  Rumah Sakit Otorita Batam Periode 2 November 2009 – 9 Januari 2010

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STATUS PASIEN A. Iden Identi tita tass Pasie Pasien n

Nama

: By. R  

Usia

: 2 bulan

Jenis kelamin : Perempuan Perempuan Agama

: Islam

Pendidikan

:-

Alamat

: Kav. Dapur 12 Blok W No. 6 Bukit Kamboja

Orang Tua/Wali Ayah Nama

Ibu

: Tn F

Agama

: Islam

Alamat

: sda

Pekerjaan

: karyawan PT. Cepta

Peng Pengha hasi sila lann

: 1.50 1.500. 0.00 0000-2. 2.00 000. 0.00 0000

Nama

: Ny. N

Agama

: Islam

Alamat

: sda

Pekerjaan

: ibu rumah tangga

Penghasilan

:-

Hubungan dengan orang tua : Anak kandung Suku bangsa

B. Ana Anamnesi nesiss

: Batak  

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Batuk sejak 5 hari sebelum masuk rumah sakit (SMRS).

Keluhan Tambahan Sesak  Muntah

Riwayat Penyakit Sekarang OS masuk dengan keluhan batuk sejak 5 hari SMRS. Batuk berdahak dan berwarna kuning kehijauan tanpa disertai darah. Keluhan batuk disertai dengan sesak napas yang makin lama dirasa makin berat hingga orangtua pasien mengeluhkan bahwa OS sampai seolah-olah mengalami henti napas yang singkat dengan durasi kurang dari 1 menit. Orangtua pasien mengaku batuk tidak disertai demam ataupun riwayat demam sebelumnya. Dua hari SMRS, OS muntah sebanyak dua kali, berisi makanan (ASI) yang baru saja diminum, tidak terdapat lendir dan darah pada muntahan, dan tidak   bersifat proyektil. Saat masuk RS, muntah sudah tidak ada. Orangtua OS menyatakan  bahwa OS sering tersedak bila sedang menyusu. Saat masuk RS, OS masih bisa menyusu dengan baik (masih kuat mengisap). Tidak ada gangguan buang air kecil dan  buang air besar, serta tidak ada riwayat kejang sebelumnya.

Riwayat Kehamilan dan Kelahiran

Keham Kehamila ilann

Morbid Morbidita itass keha kehamil milan an : Demam Demam (-), Nyeri Nyeri supr suprap apubi ubikk (-), (-), Kep Keputi utiha hann (-) (-) Perawa Perawatan tan antena antenatal tal : di Bidan, Bidan, tidak tidak teratu teratur  r 

Kela Kelahi hira rann

Tempa mpat kelah lahira iran

: Rumah umah Bersa ersali linn

Peno Penolo long ng pers persal alin inan an : Bid Bidan an Cara persalinan

: Spontan

Masa gestasi

: kurang bulan (36 minggu)

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Langsung menangis (merintih) APGAR score 8/9 Kelainan bawaan (-)

Kesimpulan riwayat kehamilan dan persalinan :  NKB, SMK, lahir via partus normal dengan BBLR 

Riwayat Perkembangan Perkembangan Pertumbuhan gigi I

: belum ada

Psikomotor  a. Tengkurap  

: belum mampu

b. b. Dudu Dudukk

: belu belum m mamp mampuu

c. Berdiri

: belum mampu

d. Berjalan

: belum mampu

e. Bicara

: belum mampu

f. Membaca dan menulis

: belum mampu

Perkembangan Perkembangan pubertas a. Rambut pubis

: belum ada

b. Payudara

: belum ada

c. Menarche

: belum ada

Gangguan perkembangan perkembangan mental / emosi : belum dapat dinilai Riwayat Makanan

Umur (bulan) 0-2 2-4

ASI / PASI √

Buah / biskuit

Bubur Susu

Nasi Tim

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Riwayat Imunisasi Vaksin BCG DPT /DT Polio Campak  Hepatitis B MMR  TIPA

Dasar (umur)

Ulangan (umur)

2 bln

Riwayat Lingkungan Perumahan Tinggal dilingkungan perumahan yang cukup padat (rumah gandeng), milik sendiri. Jumlah orang yang tinggal dalam satu rumah adalah 5 orang, yaitu ayah, ibu, dan 3 anak. Lingkungan dan sanitasi rumah cukup baik dengan ventilasi kurang karena hanya ada dua jendela. Memiliki satu dapur, satu kamar mandi, dan tiga kamar tidur.

Riwayat Penyakit yang Pernah Diderita Penyakit Alergi Cacingan DBD Demam tifoid Otitis Parotitis

Umur -

Penyakit Difteria Diare Kejang Kecelakaan Morbili Operasi

Umur -

Penyakit Peny. Jantung Peny. Ginjal Peny. Darah Radang paru Tuberkulosis

Umur   -

Pasien pernah dirawat di rumah sakit selama 19 hari (3 September 2009-21 September 2009) dengan diagnosa NKB, SMK, lahir via PN dengan BBLR, HMD, dan Neonatal Hiperbilirubinemia. Saat itu diperbolehkan pulang dengan perbaikan keadaan umum.

Riwayat Penyakit Keluarga Kakak pertama pasien memiliki riwayat lahir BBLR, dirawat di rumah sakit. Tidak ada anggota keluarga yang mengidap infeksi kronis atau penyakit lainnya. Ayah pasien tidak merokok.

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C. Peme Pemeri riks ksaa aan n Fisi Fisik  k 

Tanggal 20 November 2009 Keadaan Um Umum

: le lemah, sa sakit se sedang

Kesadaran

: sadar 

Tanda vital

:

Tek. Darah  

Nadi

: tidak diperiksa : 160 kali/menit

Laju Na Napas

: 80 80 ka kali/ me menit

Suhu

: 37,2ºC

Saturasi

: 89 %

BB

: 3,5 kg

Kepala

: Normocephali, distribusi rambut merata, ubun-ubun besar  datar terbuka, asimetri wajah (-)

Mata

: Conjunctiva tidak anemis, sklera tidak ikterik, pupil isokor, RCL +/+, RCTL +/+, mata cekung (-), air mata (+)

Telinga

: normotia, membran tympani intak +/+, serumen (+), sekret (-)

Hidung

: de deviasi se septum ((-), se sekret (+ (+), kr krusta ((-), pe pernapasan cu cuping hidung (+)

Mulut

: bibir kering (-), sianosis perioral (-)

Leher

: tidak teraba pembesaran tiroid, tidak teraba pembesaran kelenjar getah bening, retraksi suprasternal (+), kaku kuduk (-) ( -)

Thoraks Paru Insp Inspek eksi si

: Ked Kedua hemito mitora rakks sime imetris tris dala dalam m kea keadaa daan statis dan dinamis, retraksi sela iga (-)

Palpasi

: Vo Vocal fr fremitus ka kanan sa sama de dengan ki kiri, ma massa

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Ausk Auskul ulta tasi si

: Sua Suara ra napa napass ves vesik ikul uler er,, ron ronkh khii +/+ +/+,w ,whh -/-/-

Jantung Inspeksi: Ictus cordis tidak terlihat Palpasi: Ictus cordis teraba di ICS V Auskultasi: S1 S2 reguler, murmur (-), Gallop (-) Abdomen

: su supel, da datar, bi bising us usus (+ (+), he hepar/lien ta tak te teraba, re retraksi epigastrium (+), turgor baik 

Ekstrem remitas tas

: ak akral ral ha hangat, si sianosis ak akral ((-) di di ke keempat ek ekstremitas, oe oedem (-) di keempat ekstremitas

D. Pemeri Pemeriksa ksaan an Laborat Laboratori orium um Tanggal 20 November 2009 Hb

: 9,6 gr/dL

Ht

: 26,8 %

Leukosit

: 22.800/mm3

Trombosit

: 575.000/mm 3

Gol. Darah

:O

LED

: 20/37

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F. Resume OS, 2 bulan, perempuan, datang dengan keluhan batuk berdahak sejak 5 hari SMRS. Batuk berdahak dan berwarna kuning kehijauan tanpa disertai darah. Keluhan batuk  disertai dengan sesak napas yang makin lama dirasa makin berat hingga orangtua   pasien mengeluhkan bahwa OS sampai seolah-olah mengalami henti napas yang singkat dengan durasi kurang dari 1 menit. Batuk tidak disertai demam ataupun riwayat demam sebelumnya. Dua hari SMRS, OS muntah sebanyak dua kali, berisi makana makanann (ASI) (ASI) yang yang baru baru saja saja diminu diminum, m, tidak tidak terda terdapat pat lendir lendir dan darah darah pada pada muntahan, dan tidak bersifat proyektil. Saat masuk RS, muntah sudah tidak ada. OS

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G. Diag Diagno nosi siss Ker Kerja ja Pneumonia Aspirasi

H. Diagno Diagnosis sis Bandi Banding ng Bronkiolitis Akut

I. Anju Anjura rann Pemer Pemerik iksa saan an Pen Penun unja jang ng a. Kult Kultur ur sekr sekret et bron bronku kuss  b.  b. Bari Barium um kont kontra rass c. Bron Broncchosc hoscop opyy

J. Pena Penata tala laks ksan anaa aann a. Tirah ba baring b.

Oksigen lembab dengan nasal kanul 1-2 L/menit

c. Diet Diet : puas puasa, a, pasan pasangg OGT OGT terbuk terbukaa d. IVFD IVFD : D5 ¼ NS 15 cc/j cc/jam am ( 15 tetes tetes mikr mikro/m o/meni enit) t) e. Obat : •

Antibiotika spektrum luas : Amikasin 2 x 25 mg

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RR

: 65 kali/menit

Subjektif 

Sesak napas Batuk berdahak 

Objektif 

Kes/KU

: sa sadar, gelisah, sa sakit se sedang

Kepa Kepala la

: norm normoc ocep epha hali li,, uub uub data datarr ter terbu buka ka,, pch pch (+), (+), sian sianos osis is peri perior oral al (-) (-)

Leher

: retraksi suprasternal (-), kaku kuduk (-)

Thoraks

C : BJ BJ II-II reguler. Murmu rmur ((-), Gallop ((-) P : Suara napas vesikuler +/+, Wheezing -/-, Ronchi +/+

Abdo Abdome menn

: supe supel,l, data datar, r, BU (+) (+),, Hepa Hepar/ r/Li Lien en tak tak tera teraba ba,, retra retraks ksii epiga epigast stri rium um (+) (+)

Ekstre Ekstremit mitas as

: akral akral hanga hangat,t, sianos sianosis is akral akral (-) (-) di keemp keempat at ekstre ekstremit mitas as

 Assessment 

Pneumonia Aspirasi Dd/ Bronkiolitis

 Planning 

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 Ronde

Terapi lanjut

Tanggal 22 November 2009 Tanda Vital 

  Nadi : 120 kali/menit Suhu : 36,8ºC RR

: 70 kali/menit

Subjektif 

Sesak napas Batuk berdahak  Pilek 

Objektif 

Kes/KU

: sa sadar, gelisah, sa sakit se sedang

Kepa Kepala la

: norm normoc ocep epha hali li,, uub uub data datarr ter terbu buka ka,, pch pch (+), (+), sian sianos osis is peri perior oral al (-) (-)

Leher

: retraksi suprasternal (-), kaku kuduk (-)

Thoraks

C : BJ BJ II-II reguler. Murmu rmur ((-), Gallop ((-) P : Suara napas vesikuler +/+, Wheezing -/-, Ronchi +/+

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 Planning 

Tirah baring Oksigen lembab dengan nasal kanul 1-2 L/menit Diet : ASI per OGT 8 x 10 cc IVFD : D5 ¼ NS 15 cc/jam Obat : Amikasin 2 x 25 mg Ranitidin 2x 5 mg

 Ronde

Terapi lanjut Foto thoraks

Tanggal 23 November 2009 Tanda Vital 

  Nadi : 140 kali/menit

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Thoraks

C : BJ BJ II-II reguler. Murmu rmur ((-), Gallop ((-) P : Suara napas vesikuler +/+, Wheezing -/-, Ronchi -/-

Abdo Abdome menn

: supe supel,l, data datar, r, BU (+) (+),, Hepa Hepar/ r/Li Lien en tak tak tera teraba ba,, retra retraks ksii epiga epigast stri rium um (-) (-)

Ekstre Ekstremit mitas as

: akral akral hanga hangat,t, sianos sianosis is akral akral (-) (-) di keemp keempat at ekstre ekstremit mitas as

 Assessment 

Pneumonia Aspirasi Dd/ Bronkiolitis

 Planning 

Tirah baring Oksigen lembab dengan nasal kanul 1-2 L/menit Diet : ASI per OGT 8 x 10 cc IVFD : D5 ¼ NS 15 cc/jam Obat : Amikasin 2 x 25 mg

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Tanggal 24 November 2009 Tanda Vital 

  Nadi : 156 kali/menit Suhu : 36,5ºC RR

: 58 kali/menit

Subjektif 

Sesak napas berkurang Batuk berdahak 

Objektif 

Kes/KU

: sadar, sakit sedang

Kepa Kepala la

: norm normoc ocep epha hali li,, uub uub data datarr ter terbu buka ka,, pch pch (-), (-), sian sianos osis is peri perior oral al (-) (-)

Leher

: retraksi suprasternal (+), kaku kuduk (-)

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Diet : ASI per OGT 8 x 10 cc IVFD : D5 ¼ NS 15 cc/jam Obat : Amikasin 2 x 25 mg Ranitidin 2x 5 mg

 Ronde

IVFD dikurangi menjadi 6 cc/jam ASI on demand

Tanggal 25 November 2009 Tanda Vital 

  Nadi : 126 kali/menit Suhu : 36ºC RR

: 56 kali/menit

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 Assessment 

Pneumonia Aspirasi (dengan perbaikan)

 Planning 

Tirah baring Diet : ASI on demand IVFD : D5 ¼ NS 6 cc/jam Obat : Amikasin 2 x 25 mg Ranitidin 2x 5 mg

 Ronde

Pasien diperbolehkan pulang

L. Prognosis

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ANALISA KASUS

A.

Anamnesis dan Pemeriksaan Fisik 

Pasien, 2 bulan, perempuan, datang diantar oleh orangtuanya dengan keluhan batuk  dan sesak.

 Diagnosis banding anak usia 2 bulan-5 tahun yang datang dengan batuk dan atau kesulitan bernapas 1 Diagnosis

Gejala yang ditemukan

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Tuberkulosis

Pertusis

Benda asing

Pneumotoraks

Riwaya Riwayatt konta kontakk positi positiff dengan dengan pasien pasien TB dewasa Uji tuberkulin positif  Pertumbuhan buruk/kurus atau berat badan menurun Demam (≥2 minggu) tanpa sebab yang jelas Batuk kronis (≥3 minggu) Pembengkakan kelenjar getah bening leher, aksila, inguinal yang spesifik  Batu Batukk paro paroks ksis isma mall yang yang diik diikut utii deng dengan an whoop, muntah, sianosis atau apnu Bisa tanpa demam Imunisasi DPT tidak ada atau tidak lengkap Klinis baik diantara episode batuk  Riwayat tiba-tiba tersedak  Stridor atau distress pernapasan tiba-tiba Wheeze atau suara pernapasan menurun yang  bersifat fokal Onset tiba-tiba

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•

Riwayat sering tersedak 

•

Riwayat lahir prematur dengan BBLR 

•

Riwayat Penyakit Membran Hialin

•

Riwayat tinggal di pemukimam yang cukup padat

Pada pemeriksaan fisik, pada pasien ini ditemukan : •

Umum o

Keadaan umum gelisah

o

Suhu afebris (37,2ºC)

o

Pernapasan cuping hidung

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akibat be benda as asing (a (aspirasi)

Gejala Tanda

B.

dan

Mycoplasma pn pneumoniae Adenovirus Parainfluenza virus Demam Demam yang tidak terlalu tinggi Batuk, Batuk, sesak sesak,, merint merintih, ih, kesul kesulita itann Batu Batuk, k,se sesa sak, k, meng mengi,i, kesu kesuli lita tann menyusu menyusu Retraksi Sianosis Pernapasan cuping hidung Pernapasan cuping hidung Posttusive emesis Retraksi Gelisah, letargi Gelisah Hipoksemia Takipneu, Takikardi Ronkhi basah halus Hipoksia Otitis media

Pemeriksaan Laboratorium dan Pemeriksaan Radiologi

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Pneumonia Aspirasi

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C. Dia Diagno gnosis sis

Maka Maka,, dari dari anal analis isaa meny menyel elur uruh uh anam anamne nesi sis, s, peme pemeri riks ksaa aann fisi fisik, k, dan dan   pemeriks pemeriksaan aan penunjan penunjangg yang dilakukan dilakukan,, dapat dapat ditegakka ditegakkann diagnosi diagnosiss Pneumoni Pneumoniaa Aspirasi pada pasien ini. Pneumonia aspirasi adalah suatu radang jaringan parenkim   paru yang disebabkan oleh teraspirasinya benda asing ataupun flora normal dari orofaring.

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E. Progno ognossis

Secara Secara umum, umum, prognosis prognosis adalah baik karena jarang jarang ditemukan ditemukan adanya gangguan gangguan fungsi pulmonal jangka panjang. Meskipun begitu, pneumonia yang disebabkan oleh kelainan anatomis berisiko tinggi untuk terulang kembali apabila kelaianan tersebut tidak diperbaiki.

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