BAB I

LAPORAN KASUS

1.1 IDENTITAS
 Nama : An.
An. AR 
Umur : 4 bulan
Jenis Kelamin : Perempuan
BBPB : 4!" #$ %& 'm
Alama( : D)# *III a(as +Serui,
Tan$$al masu# : % -are( /10
 N). Re#am -ei# : &%1%02
Tan$$al
Tan$$al Pemeri
Pemeri#saan
#saan : % -are(
-are( /10
/10

1. ANA-NESIS

1..1 Kelu3an U(ama

 Pu'a(.

1.. Ria5a( Pen5a#i( Se#aran$

Pasien a(an$ bersama ibun5a 5an$ men$elu3#an #eaaan ana#n5a 5an$ san$a( pu'a(
an lemas. 6a7a3 an (elapa# (an$an pasien (erli3a( san$a( pu'a(. ser(a emam +8,!
emam sua3 aa se7a#  min$$u sebelum masu# ruma3 sa#i( an si9a( emamn5a
nai# (urun! ba(u# bera3a# +8, se7a#  min$uu 5an$ lalu! sesa# +,! mual mun(a3 +,!
BAB n)rmal! BAK n)rmal an berana #unin$ 7erni3. Ria5a(
Ria5a( mimisan +,.

1..
1..&
& Ria
Ria5a
5a(( Pen5
Pen5a#
a#i(
i( Da3
Da3ul
uluu
Pasien perna3 panas (in$$i sea#(u berusia  bulan.
1..4
1..4 Ria5
Ria5a(
a( Pen5
Pen5a#i
a#i(( Kelu
Keluar
ar$a
$a
 Tan(e
Tan(e pasie
pasienn 5an$ (in$$a
(in$$all bersama
bersama mener
meneri(a
i(a (ube
(uber'ul
r'ul)si
)siss paru.
paru.
 Ibu pasie
pasie (ia#
(ia# men$e(a
men$e(a3ui
3ui (en(a
(en(an$
n$ riaa(
riaa( pen5a#
pen5a#i(i( #elain
#elainan
an ara3
ara3 alam #elua
#eluar$
r$aa
 pasien #arena mere#a (in$$al i #amp)n$ 5an$ 7au3 ari sarana #ere3a(an.
1.& PE-ERIKSAAN ;ISIK 

Keaaan umum : Tampa# sa#i( bera(! <=S:E4*1-2

 Kesaaran : =)mp)s -en(is

 Pan7an$ Baan : %& 'm
 Bera( Baan : 4!" K$
 Tana(ana >i(al
 Nai : 1/ ?meni(
 Su3u Baan : &@!2/=
 Respirasi : %/?meni(

KepalaLe3er 

 -a(a : =)n7un'(i>a anemis 88! s'lera i#eri# ! pupil is)#)r! re9#les
'a3a5a +88,
 iun$ : P'3 +8,! epis(a#sis +,
 -ulu( :-u#)sa mulu( (erli3a( #erin$! perara3an $usi +,
 Telin$a : Dalam ba(as n)rmal! bleein$+,
 Le3er : #elen7ar $e(a3 benin$ (ia# (eraba membesar  

T3)ra#s
 Sime(ris i#u( $era# na9as! re(ra#si +,!suara na9as >esi#uler! r3)n#i +88,! 3eein$ +,!
B7 III re$ular.

Ab)men
 Supel! a(ar! BU +88,! n5eri (e#an +,! 3epar (ia# (eraba! lien (ia# (eraba! per#usi
(impani.

<ene(alia : Tia# ie>aluasi

E#s(remi(as : A#ral 3an$a( =RTC &! eema +8, an spas(i# 

S(a(us <ii : C  &SD + $ii buru#,

1.4 Pemeri#saan Penun7an$

1.4.1 Pemeri#saan Dara3
Tan$$al /" -are( /10
 Hasil Normal Range
b : @!"$l 1!/1%!/
Leu#)si( : !%4 mmm& 4!/1/!/
Tr)mb)si( : &0mmm& 10/14/
-=* : 2%!& 9l %&./"%!/
-= : &!0 p$ 0!/&&!/
-== : &4!4 $l %!/&2!/

DDR +,
<ula Dara3 Sea#(u @4 m$l

Tan$$al 10 -are(/10
Hasil Normal Range
b : 1&!2$l 11!/1%!/ +$L,
Leu#)si( : 11.&& mmm& &!011!/ +1/&mm&,
Tr)mb)si( : &/ mmm& 10/40/ +1/&mm&,
-=* : @0!& 9l @&!/1/2!/
-= : 2!% p$ &0!/&2!/
-== : &0!2 $l %!/&2!/
<ula Dara3 Sea#(u : 22 m$l

Tan$$al 1" -are( /10

Hasil Normal Range
b : 10!2$l 11!/1%!/ +$L,
RB= : 2!@ 1/2uLF &!2" G 0!42
Leu#)si( : %!"0 1/&uLF &!011!/ +1/&mm&,
Tr)mb)si( : 04"mmm& 10/40/ +1/&mm&,
-=* : @1!0 9l @&!/1/2!/
-= : 4!" p$ &0!/&2!/
-== : &4!% $l %!/&2!/

1.0 Da9(ar -asala3

 Pu'a(
 Anemia b @!" $l
 =)n7u'(i>a anemis
 <ii buru#  
 Ba(u# se7a#  min$$u 5an$ lalu
 1.2 Dia$n)sa Ker7a
Anemia De9isiensi Besi.

1.@ Dia$n)sa Banin$

 Anemia T3alassemia
 Anemia #arena Pen5a#i( Kr)nis
 De9isiensi (emba$a
 Anemia sier)blas(i# 

1.% Pena(ala#saan
 Pen$)ba(an iban$sal peraa(an
o  Nebulier ')mbi9en( 2 7am +/2:&/,

o I*;D H Ns mi#r) / (pm +/2:&/,

o In7.
 Pen$)ba(an 5an$ sua3 iberi#an
o O -as#er & lpm
o In7. =e9)(a?im &? 10/ m$
o In7. Ampi'ilin &?10/ m$
 Raa( i RKK 7am 10://

1.1/ ;)ll) up

ari(an$$al Peraa(an S O A P
%/&/10 3ari 1 +i Pasien Keaaan Susp.sepsis 8 In7. 'e9)(a?im &?140/
I<D, a(an$ umum: Br)n#)pneum)ni m$i.>
Kesaaran:  TB 8 In7.ampi'ilin &?12i.>
en$an
Apa(is! -enin$i)ense9ali(is +ST,
#elu3an Tampa# sa#i( 8 ir)se9alus 8 O mas#er &lpm
 pu'a(! ma(a  bera( <=S: $ii buru#  UPB:
E4*1-2  I*;D D0 H
(ia# mi'r) / (pm
R:
(erbu#a!  N:1/?m +/2:&/,
 In7. Rani(iin
 ban5a# SB:&@!2
?1/ m$I.>
R:%/?m
#)()ran 
Jaaban #)nsul r.
ma(a! Kepalale3er: elena Sp.A )n')le
e#s(remi(as ubunubun  I*;D D0 H
a(ar! =A+8 ns / (pm
san$a(
8,! SI+,! mi#r)
 pu'a( an re9le?  In7.
in$in +8,! 'a3a5a+88,! =e9(ia?)ne
?0/ m$
emam +8,!  pupil is)#)r  +i.>,
P=+,!K<B+
sesa# +8,  In7. De?a 1? G  
 , !0 m$ +i>,
 7am 1/://!
T3)ra?: selan7u(n5a
&?1 m$+i>,
Sime(ris!
 =).Sp-
re(ra#si +,!SN
 Pr) -RI
*esi#uler! R3)  P3eni()in
+88,! 63e+8 ?/ m$
8,!BJIII +p)pers)ne,
re$ular! mur  Pr) (rsn9usi
mur+,! (3rill PR= @/ ''
+se#ali
+,
 pemberian,
 Pre !0 ''
Ab)men:  Nebulier
Supel! a(ar! en$an
BU +8, N! ')mbi9en( %
L+((b,!  7am
(ur$)r #uli(
#embali 'epa(

E#s(remi(as:
A#ral 3an$a(!
eema +,!
=RT C

Kuli(:
Sian)sis +,!
anemis +,!
i#(eri# +,
11/&/10 ari 4 +i Pasien Keaaan Susp. Sepsis susp.  N<T (erpasan$! puasa
RKK, emam umum: Br)n#)pneum)ni I*;D D014 saline/
+,!#e7an$ Kesaaran: Susp. (pmmi#r)
+,! ba(u# apa(is -enin$)ense9ali(is In7. =e9(ria?)ne
+8,! sesa#  N: "/?m ?0/ m$
+8,! aa SB &2 = Sanm)l 4? 2/ m$ +i>,
lenir  R: 4?m Rani(iine &?0 m$
Kepalale3er:  Nebu ?se3ari
=A +88,! SI P3eni()in ?0/ m$
+,! papul 8 In7.e?ame(a?)ne &?1
i#epala! m$
lin$#ar S(es)i e?(ra !0 m$
#epala 44'm +re'(al,
Pr' 4 ''
T3)ra#s:
R3)n#i +88,
 P)s(eri)r
+pappul 8,

Ab)men:
lembe#! L
+((b,
E#s(remi(as:
a#ral 3an$a(
eem +,
1/&/10 ari 0 +i Keaaan Susp.  N<T (erpasan$! puasa
RKK, Demam +,! umum: (ampa#  Br)n#)pneum)ni I*;D D014 saline/
#e7an$ +,! sa#i( bera(! 8 3ir)'ep3alus 8 (pmmi#r)
 ba(u# +8,! apa(is <=S " <ii Buru#  In7. =e9(ria?)ne
sesa# +8,! R: %1?m ?0/ m$
lenir +8, R: 24?m Sanm)l 4? 2/ m$ +i>,
SB:&2!2 Rani(iine &?0 m$
 Nebu ?se3ari
Kepalale3er: P3eni()in ?0/ m$
=A +88,! SI In7.e?ame(a?)ne &?1
+,! re9le? m$
'a3a5a +88,! S(es)i e?(ra !0 m$
 pus(ule +8, +re'(al,
i#epala!
lin$#ar #epala
44 'm

T3)ra#s
re(ra#si +8,
r3)n#i +88,
Ab)men:
a(ar! L +((b,
1&/&/10 ari 2 Demam +,! Keaaan Susp.  N<T (erpasan$!
+iRKK, #e7an$ +,! umum: (ampa#  Br)n#)pneum)ni minum susu
 ba(u# +8,! sa#i( bera(! 8 3ir)'ep3alus 8 I*;D D014 saline/
sesa# +8,! apa(is <=S " <ii Buru#  (pmmi#r)
lenir +8, R: @/?m In7. =e9(ria?)ne
R: 2?m ?0/ m$
SB:&2!1 In7. Sanm)l ?0/ m$
+i>,
Kepalale3er: Rani(iine &?0 m$
=A +88,! SI P3eni()in ?0/ m$
+,! re9le?
'a3a5a +88,!
ma(a '))n$
  pus(ule +8,
i#epala!
lin$#ar #epala
membesar
8SD

T3)ra#s
re(ra#si +8,
r3)n#i +88,
Ab)men:
a(ar! L +((b,
14/&/10 ari @ +i Demam +,! Keaaan Susp.  N<T (erpasan$!
RKK, #e7an$ +,! umum: (ampa#  Br)n#)pneum)ni minum susu
 ba(u# +8,! sa#i( bera(! 8 3ir)'ep3alus 8 I*;D D014 saline/
sesa# +8,! apa(is <=S " <ii Buru#  (pmmi#r)
lenir +8, R: 11"?m In7. =e9(ria?)ne
R: 4%?m ?0/ m$
SB:&2!& In7. Sanm)l ?0/ m$
+i>,
Kepalale3er: Rani(iine ?0/ m$
=A +88,! SI P3eni()in ?0/ m$
+,! re9le? In7.e?ame(a?)ne &?1
'a3a5a +88,! m$
ma(a '))n$ S(es)i e?(ra !0 m$
 pus(ule +8, +re'(al,
i#epala!
lin$#ar #epala
44'm 8SD

T3)ra#s
re(ra#si +8,
r3)n#i +88,
Ab)men:
a(ar! L +((b,
10/&/10 ari % +i Demam +,! Keaaan Susp. TB Paru  N<T (erpasan$!
RKK, #e7an$ +,! umum: (ampa#  8 3ir)'ep3alus 8 I*;D D014 saline/
 ba(u# +8,! sa#i( bera(! <ii Buru#  (pmmi#r)
lenir +8,! apa(is <=S " In7. =e9(ria?)ne
3ip)(ermi R: 1&?m ?0/ m$
&0!/= R: 0"?m In7. Sanm)l ?0/ m$
SB:&0! +i>,
Rani(iine ?0/ m$
Kepalale3er: P3eni()in ?0/ m$
=A +88,! SI In7.e?ame(a?)ne &?1
 +,! re9le? m$
'a3a5a +,! S(es)i e?(ra !0 m$
lin$#ar #epala +re'(al,
44 'm 8SD

T3)ra#s
re(ra#si +8,
r3)n#i +88,
Ab)men:
a(ar! L +((b,
E#s(remi(as:
a#ral in$in
eem +,!
 babins#5 +8,!
#a#u #uu#
+,

./ Pr)$n)sis
 u) a >i(am : ubia a b)nam
 u) a 9un'(i)nam : ubia a b)nam