Bed Side Teaching

Pembimbing :
dr. hj.Rini sulviani,Sp.A,M.Kes

Yayan Samayang Putra Latuconsina

(2015730133)

KEPANITRAAN KLINIK STASE PEDIATRI RSUD SYAMSUDIN SH

FAKULTAS KEDOKTERAN DAN KESEHATAN
UNIVERSITAS MUHAMMADIYAH JAKARTA
2020
IDENTITAS

• Nama Ibu : Ny. L

• Usia : -
• Pendidikan : -

• Nama Ayah : -
• Usia : -
• Pendidikan : -
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• Nama : An. R
• Usia : 13 tahun
• Jenis Kelamin : Laki - laki
• Pendidikan : SMP
Anamnesis

Mual muntah
Anamnesis

Seorang pasien datang dibawa oleh ibunya dengan keluhan mual

muntah sejak 3 minggu SMRS. Sang ibu mengatakan mual muntah yang
dirasakan terus menerus dan semakin memberat tetapi pasien masih bisa
makan sedikit-sedikit. muntah berisi cairan.
Keluhan mual muntah ini pertama kali dirasakan 3 bulan yang lalu. saat
3 bulan yang lalu pasien juga mengalami keluhan mual muntah yang dirasakan
terus - menerus. pasien sempat dibawa ke mantri dan diberikan obat namun ibu
pasien lupa obat apa yang diberikan. ibu pasien mengatakan gejala yang
dirasakan membaik saat meminum obat tersebut. Keluhan ini disertai dengan
adanya demam sejak seminggu yang lalu. Pasien sempat minum obat dari
mantri lagi tetapi keluhan demam membaik namun mual muntah masih
menetap. mata pasien juga tampak kuning, pasien sering merasa pusing
seperti berputar, gatal pada seluruh tubuh, serta ibu pasien juga mengatakan
bab pasien cair tetapi masih ada ampas dan ketika bak terlihat seperti teh.
Anamnesis

Sang ibu mengatakan pasien belum pernah mengalami

gejala serupa dan di rumah tidak ada yang memiliki gejala
seperti pasien. Pasien sering jajan diluar sembarangan seperti
jajanan di pinggir jalan dekat sekolah.
Riwayat Persalinan

• Pasien lahir secara spontan dengan berat badan lahir 2300 g

dan panjang badan lahir tidak ditanyakan.
Riwayat Imunisasi

Ibu pasien tidak ingat apakah anaknya diimunisasi dar lengkap atau tidak.
Pemeriksaan Fisik

• Keadaan umum: sakit sedang

• Kesadaran : compos mentis
• Tanda vital :
• TD : 110/70 mmHg
• Suhu : 36,9 ℃
• Nadi : 94x/menit
• Respirasi : 20x/menit
Pemeriksaan Fisik

• Kepala : Rambut distribusi merata, tidak mudah rontok

- Mata : sclera ikterik +/+, conjunctiva anemis +/+, reflek cahaya
+/+,
- Telinga : Otorea -/- , nyeri tekan tragus -/-
- Hidung : tidak ada deviasi septum, tidak ada secret, pch -/-
- Mulut : perioral sianosis (-), mukosa lembab, palatum tertutup,
gusi tidak berdarah,lidah ,tonsil t1/t1
• KGB : tidak ada pembesaran kgb
• Leher : trakea ditengah tidak ada deviasi
Pemeriksaan Fisik

• Thoraks : simetris kanan kiri

-pulmo
- inspeksi : bentuk dan gerak simetris , retraksi -/-
- palpasi : Pengembangan dada teraba simetris, fremitus taktil kiri =
kanan
- perkusi: Sonor di selurung lapang paru
- Auskultasi : Vesikuler (+/+), Ronki (-/-), Wheezing (-/-)
- cor
-inspeksi : ictus kordis tidak terlihat
- palpasi : ictus kordis tidak dinilai
- Perkusi : Batas atas jantung : ICS 2
Batas kanan jantung : Linea parasternal dextra
Batas kiri jantung : Linea midclavicula sinistra
- auskultasi : S1 S2 regular, tidak ada murmur atau gallop
Pemeriksaan Fisik

Abdomen
- Inspeksi: Datar
- Auskultasi : Bising usus tiap 10-20 detik
- Perkusi : timpani
- Palpasi : lembut, tidak ada massa, hepar dan spleen tidak
teraba
Pemeriksaan Fisik

• Ekstremitas
- Ektremitas atas : bentuk normal, hangat, crt 4 detik
- Ekstremitas bawah : bentuk normal, akral hangat, crt 4 detik
Pemeriksaan Fisik

• Refleks fisiologis
- Bicep +/+
- Tricep +/+
- Patela +/+

Pemeriksaan Nervus Cranialis : tidak dilakukan

Resume

Seorang pasien datang dibawa oleh ibunya dengan keluhan mual muntah sejak 3 minggu SMRS.
Sang ibu mengatakan mual muntah yang dirasakan terus menerus dan semakin memberat tetapi pasien
masih bisa makan sedikit-sedikit. muntah berisi cairan.
mata pasien juga tampak kuning, pasien sering merasa pusing seperti berputar, gatal pada seluruh
tubuh, serta ibu pasien juga mengatakan bab pasien cair tetapi masih ada ampas dan ketika bak terlihat
seperti teh.

Keadaan umum: sakit sedang

Kesadaran : compos mentis
Tanda vital :
TD : 110/70 mmHg
Suhu : 36,9 ℃
Nadi : 94x/menit
Respirasi : 20x/menit
Diagnosis Banding

- Hepatitis A
- Koleosistitis
- Gastroenteritis akut
Usulan Pemeriksaan

- Pemeriksaan darah lengkap

- SGOT & SGPT
- Bilirubin direct & bilirubin indirect
Diagnosis Kerja

- Hepatitis A
Tatalaksana Umum

• Rawat inap
• Terapi cairan
• Rumus Holiday Segar (cc/hari)
< 10 kg : 100xBB
10-20 kg : 1000 + ((BB-10)x50)
> 20 kg : 1500 + ((BB-20)x20)
4.780cc/72 jam = 66 tpm (makrodrip)
Jumlah cairan yang dibutuhkan x faktör tetesan
Waktu yang dibutuhkan(jam ) x 60 menit
• Makro drip: 20
• mikro drip : 60

• Kebutuhan kalori
Bb : 34
Kalori: 34 x 55 = 1.870 kkal
Karbohidrat 60%: 1.122 kkal
Protein 15%:280 kkal
Lemak 25%: 467kkal
Tatalaksana Khusus

bila ada demam  paracetamol iv 10-15mg/kgBB

Ondansentron iv 0.15 mg/kgbb

Prognosis

Quo ad Vitam : Bonam

Quo ad Functionam : Bonam
Quo ad Sanationam : Bonam
Berat badan dan Keluhan penurunan berat badan tidak
ditanyakan.
Riwayat penggunaan minuman alkohol tidak ditanyakan, jarum
suntik tidak ditanyakan, terpapar darah tidak ditanyakan.
Riwayat persalinan
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THANKS
TITLE
TEMPLATES
reporter :

THANK YOU FOR COMFORTING ME WHEN I'M SAD

LOVING ME WHEN I'M MAD
PICKING ME UP WHEN I'M DOWN
THANK YOU FOR BEING MY FRIEND AND BEING AROUND
TEACHING ME THE MEANING OF LOVE
ENCOURAGING ME WHEN I NEED A SHOVE
BUT MOST OF ALL THANK YOU FOR
LOVING ME FOR WHO I AM
C ONTENTS
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THANKS
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