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  • Case Report 25-1-18

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    Mediana adrianne
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    - This document summarizes a case study of a 3 day old female infant presented with jaundice. - On examination, the infant was found to have a heart rate of 130 bpm, respiratory rate of 53 bpm, and fever of 37°C. Laboratory results showed elevated bilirubin levels of 12.2 mg/dL. - The working diagnosis was hyperbilirubinemia. Treatment included phototherapy and monitoring of vital signs and general condition.

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    - This document summarizes a case study of a 3 day old female infant presented with jaundice. - On examination, the infant was found to have a heart rate of 130 bpm, respiratory rate of 53 bpm, and fever of 37°C. Laboratory results showed elevated bilirubin levels of 12.2 mg/dL. - The working diagnosis was hyperbilirubinemia. Treatment included phototherapy and monitoring of vital signs and general condition.

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    Download as PPTX, PDF, TXT or read online from Scribd
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    12 views12 pages

    Case Report 25-1-18

    Uploaded by

    Mediana adrianne
    - This document summarizes a case study of a 3 day old female infant presented with jaundice. - On examination, the infant was found to have a heart rate of 130 bpm, respiratory rate of 53 bpm, and fever of 37°C. Laboratory results showed elevated bilirubin levels of 12.2 mg/dL. - The working diagnosis was hyperbilirubinemia. Treatment included phototherapy and monitoring of vital signs and general condition.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
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    of 12

    CASE KOAS ANAK 25/1/18

    Pembimbing: dr. Diana


    Disusun: Mediana Adrianne Riyanto - 406162128

    KEPANITERAAN KLINIK ILMU KESEHATAN ANAK


    RUMAH SAKIT UMUM CIAWI
    FAKULTAS KEDOKTERAN UNIVERSITAS TARUMANAGARA
    Identitas Pasien

    • Nama : By. ZI
    • Umur : 3 hari
    • Jenis Kelamin : Perempuan
    Anamnesa
    Riwayat perjalanan penyakit :
    Bayi lahir cukup bulan, sesuai masa kehamilan, lahir
    spontan dari ibu dengan riwayat kehamilan G3P2A0.
    Anamnesa
    • Riwayat Penyakit Dahulu : -
    • Riwayat Penyakit Keluarga : -
    Pemeriksaan Fisik
    • Keadaan Umum : Tampak sakit sedang
    • Nadi : 130x/menit
    • Suhu : 37 oC
    • Frekuensi Nafas : 53x/menit

    • Data antropometri
    • BBL : 3200gr
    • PB : 49 cm
    • LK : 32 cm
    • LD : 31 cm
    Pemeriksaan Fisik
    • Mata:
    CA -/-; SI +/+; pupil isokor
    • Mulut:
    Sianosis (-), lidah kotor (-), dinding faring posterior hiperemis (-),
    Tonsil T1-T1, tidak hiperemis, detritus (-)
    • Leher:
    Tidak ada tanda-tanda peradangan, letak trakea ditengah,
    kelenjar tiroid tidak terlihat,
    • Toraks:
    (I) Bentuk dada bagian depan simetris, tidak ada tanda-
    tanda peradangan, tidak ada retraksi interkostal
    (Pe) Sonor pada kedua lapang paru
    (A) Suara nafas vesikuler, ronchi -/-, wheezing -/-
    Pemeriksaan Fisik
    • Jantung:
    (I) Ictus cordis tak tampak

    (Pa) Ictus cordis teraba di i.c.s. V midclavicula line sin., tak


    kuat angkat

    (Pe) Redup
    batas atas : ICS II parasternal line sinistra
    batas kanan : midsternal line
    batas kiri : ICS V midclavicula line sinistra

    (A) Bunyi jantung I dan II reguler murni, murmur (-),


    gallop (-)
    Pemeriksaan Fisik
    • Inspeksi Abdomen : Datar, Bowel Contour (-), Bowel
    Movement (-).

    • Auskultasi Abdomen: BU (+) normal.

    • Palpasi Abdomen : Nyeri tekan epigastrium (-), Defans


    muskular(-)
    • Perkusi Abdomen : Timpani
    • Ekstremitas : sianosis (-), ikterik (+)
    Pemeriksaan penunjang
    • Hb 11,9g/dL
    • Ht 37%
    • Leukosit 11.000/uL
    • Thrombosit 215.000/uL
    • GDS 79
    • Bilirubin total 12.2 mg/dL
    Diagnosis
    Diagnosis Kerja:
    • hiperbilirubinemia
    Terapi
    • Fototerapi
    • Pertahankan suhu tubuh
    • Observasi keadaan umum dan ttv
    • Menjaga hygiene
    THANK YOU

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