Case Report Season

Asma
Identitas Pasien

Nama : An. RH
Jenis Kelamin : Laki-laki
TTL : Bandung, 24 Oktober 2014
Umur : 5 tahun
Alamat : Jl. Sukamanah 11 rt 03/07, Wates, Bandung
Tanggal masuk : 12 Oktober 2019
Tgl pemeriksaan : 12 Oktober 2019 – 14 Oktober 2019
 Identitas Orangtua
IBU
•Nama ibu : Ny. Y
•Umur : 24 tahun
•Pendidikan : SMA
•Pekerjaan : IRT
•Alamat : Jl. Sukamanah 11 rt 03/07, Wates, Bandung
AYAH

•Nama ibu : Ny. T

•Umur : 28 tahun
•Pendidikan : SMA
•Pekerjaan : Buruh
•Alamat : Jl. Sukamanah 11 rt 03/07, Wates,
Bandung
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Keluhan Utama

SESAK
NAFAS

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Anamnesis
Anak laki-laki usia 5 tahun datang dibawa orangtua
nya ke RS Muhammadiyah dengan keluhan sesak
nafas sejak 1 hari SMRS. Keluhan sesak muncul
secara tiba-tiba dan terus menerus sepanjang hari.
ibu pasien mengatakan keluhannya membaik bila
pasien dalam posisi duduk. Orangtua pasien
mengatakan bahwa sesaknya semakin berat terutama
saat malam hari. Orangtua pasien juga mengatakan
bahwa sesak nafasnya disertai suara mengi.
Anamnesis

Orangtua pasien mengatakan bahwa keluhan

ini didahului dengan adanya batuk berdahak
sejak 2 hari SMRS, dahaknya dapat dikeluarkan
pada saat pasien muntah setelah batuk dan
dahaknya berwarna putih. Keluhan batuk
dirasakan terutama saat malam hari, Keluhan
menyebabkan pasien tidak dapat tidur pada
malam hari.
Anamnesis
Keluhan tidak disertai dengan demam tinggi,
pilek. Keluhan berat badan sulit naik, atau
menurun drastis, keringat malam, benjolan
sekitar leher, ketiak maupun selangkangan juga
disangkal. Orangtua pasien mengatakan
anaknya tidak pernah berkontak dengan
penderita batuk-batuk lama atau sedang
pengobatan 6 bulan. Orangtua pasien pun
menyangkal bahwa keluhan sesaknya disertai
dengan kebiruan di daerah mulut, kaki dan
tangan ketika pasien menangis atau beraktivitas.
Orangtua pasien juga menyangkal bahwa
anaknya pernah jatuh atau terbentur di bagian
dada. Keluhan kebiruan pada tubuh, penurunan
kesadaran, merintih, tidak mau makan dan
minum, kejang dan BAK menjadi berkurang
disangkal oleh kedua orangtuanya.
ANAMNESIS
Keluhan ini baru pertama dirasakan oleh
pasien, keluhan ini muncul saat pasien dibawa
pergi jalan-jalan menggunakan motor tanpa
menggunakan jaket, kemudian pasien
mengalami batuk-batuk setelah itu timbul
sesak, nenek pasien mengatakan bahwa ibu
pasien pernah mengalami hal serupa dengan
pasien dan memiliki riwayat penyakit asma.
Ibu pasien mengatakan bahwa anaknya
memiliki alergi terhadap cuaca dingin.
Riwayat penyakit dahulu :
pasien belum pernah mengalami penyakit ini
sebelumnya.
o Riwayat penyakit keluarga :
ibu pasien memiliki riwayat penyakit Asma
Riwayat Kehamilan :
 Kesehatan ibu selama hamil : keputihan (-) perdarahan
(-) trauma (-) infeksi (-) penyakit kronis (-) konsumni
obat obatan (-)
 ANC : ke Bidan namun tidak rutin
 Obat – obatan selama kehamilan : vitamin
 Kebiasaan merokok, konsumsi alkohol di sangkal.
Riwayat Persalinan :
 tempat persalinan : di bidan
 proses persalinan : spontan
 kesulitan dalam persalinan (-)perdarahan (-) PEB (-)
 masa gestasi : 36 minggu
 BBL : 2980 gr PBL : 48 cm
 menangis langsung, kebiruan (-), kuning (-)
Riwayat Kehamilan :
 Kesehatan ibu selama hamil : keputihan (-) perdarahan
(-) trauma (-) infeksi (-) penyakit kronis (-) konsumni
obat obatan (-)
 ANC : ke Bidan namun tidak rutin
 Obat – obatan selama kehamilan : vitamin
 Kebiasaan merokok, konsumsi alkohol di sangkal.
Riwayat Persalinan :
 tempat persalinan : di bidan
 proses persalinan : spontan
 kesulitan dalam persalinan (-)perdarahan (-) PEB (-)
 masa gestasi : 36 minggu
 BBL : 2980 gr PBL : 48 cm
 menangis langsung, kebiruan (-), kuning (-)
Riwayat Imunisasi dan Makanan
hepatitis B : 0,2,3,4
 BCG :1
 Polio : 1,2,3,4
 DPT : 2,3,4
 Hib : 2,3,4
 MR :9

•0 – 6 bulan : ASI eksklusif

•6 – 9 bulan : ASI eksklusif + bubur susu + bubur saring + bubur buah
•9 – 12 bulan : ASI + nasi tim + buah
•12 bulan – sekarang : menu keluarga

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Riwayat Tumbuh Kembang
Motorik halus
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Pemeriksaan Fisik

Keadaan umum : Tampak sakit

sedang
Kesadaran : CM
Tanda – tanda vital :
 Suhu : 36,5
 Nadi : 110 x/menit
 Respirasi : 48x / menit (meningkat)
 Saturasi O2 : 92% dengan bantuan
oksigen
Antropometri & Status gizi
•Antropometri :
 BB : kg
 PB : cm
 LK : cm
• Status Gizi :
 BB/U : SD  normal weight
PB/U : SD  normal length
BB/PB : SD  normal
LK/U : SD  normal
Kesimpulan :
Pemeriksaan fisik
(kepala)
•Bentuk : normocephal
•Rambut : hitam, tumbuh merata, tidak mudah rontok
•Wajah : simetris , edema (-), deformitas (-), pucat (-)
•Mata : simetris, anemis konjungtiva (-/-), sklera ikterik (-/-), pupil bulat
isokor, reflex cahaya pupil (+/+)
•Hidung : simetris, deviasi septum (-), sekret (-) PCH (+/+), epitaksis (-/-)
•Telinga : simetris, secret (-/-), hiperemis (-/-)
•Mulut : perioral sianosis (-), pucat (-) mukosa bucal basah
•Tonsil : normal TI/TI
Leher dan KGB
Leher :
 Tiroid : tidak ada pembesaran
 JVP : tidak dilakukan pemeriksaan
o KGB :
 tidak ada pembesaran di cervical limpnode
Pemeriksaan Thoraks
Paru :
 inspeksi : pergerakan dada simetris kanan dan kiri, retraksi
epigastric (+) retraksi subostal (+)
 palpasi : pengembangan paru simetris kanan = kiri,
Perkusi : sonor
 Auskultasi :
 dinding dada anterior : VBS kanan = kiri, wheezing (+/+)
Pemeriksaan Thoraks
Jantung :
 inspeksi : ictus cordis terlihat di apex
 palpasi : kuat angkat (+), thrill (+), pulsasi (+)
 perkusi : batas jantung normal
 auskultasi : s1 – s2, murni regular, gallop (-), murmur (-)
o abdomen :
 inspeksi : tampak datar, lembut, tidak ada massa
 auskultasi : bising usus (+)
 palpasi : tidak teraba massa, pembesaran hepar (-),
pembersaran lien (-), nyeri tekang (-), turgor dalam
batas normal.
 perkusi :timpanik
Pemeriksaan genital dan ekstrimitas
Genital dan Ekstrimitas Pemeriksaan neurologis

Genital :
Refleks fisiologis : +/+
tidak dilakukan pemeriksaan  refleks patologis : -/ -
o ekstrimitas :  motorik : 5 5
- bentuk normal, 5 5
- deformitas (-)
- akral hangat
- CRT < 2 detik
 Resume
Anak laki-laki usia 5 tahun datang dibawa orangtua nya ke RS Muhammadiyah
dengan keluhan sesak nafas sejak 1 hari SMRS Keluhan sesak muncul secara
tiba-tiba dan terus menerus sepanjang hari. keluhannya membaik bila pasien
dalam posisi duduk. sesaknya semakin berat terutama saat malam hari. sesak
nafasnya disertai suara mengi. keluhan ini didahului dengan adanya batuk
berdahak sejak 2 hari SMRS, dahaknya dapat dikeluarkan pada saat pasien
muntah setelah batuk dan dahaknya berwarna putih. Keluhan batuk dirasakan
terutama saat malam hari.
Dari pemeriksaan fisik di dapatkan keadaan umum tampak sakit sedang,
kesadaran compos mentis Tanda – tanda vital : Suhu : 36,5 Nadi : 110 x/menit
Respirasi : 48x / menit, Saturasi O2 : 92% dengan bantuan oksigen. Terdapat
pernafasan cuping hidung, retraksi, dan wheezing.
DIAGNOSIS BANDING

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USULAN PEMERIKSAAN
 Tanggal :
S O
• Minum 8x20 ml perspen
• Gerakan cukup aktif
• BAB (+) BAK (+)
• Pasien Masih terlihat
rewel
• Muntah (-) , Kejang (-)
sesak(-)
• Luka pada kaki kiri
A P
Usia : 1 bulan 6 hari Pre Term Infant + Ceftazidine 3x35 mg IV
KU : prectle stage 5 Appropriate for Gestational
Kesadaran : CM
Age + late onset Neonatal Amikasin 3x16,5 mg IV
TTV :
- Nadi: 130 Sepsis + Plebitis
- RR: 40 Cairan 100ml/kgBB/hari
- Suhu: 37,5 C 100x2,2 = 220 ml/hari
Kepala :
- UUB : datar dan lembut
- Hidung : PCH (-) ,
- Mulut : cyanosis
Thorax :
- Retraksi : (-)
- Wheezing (-)
- Ronkhi (-)
Abdomen :
- datar , lembut, massa (-)
- hepar tidak teraba
- lien tidak teraba
- bising usus + normal
Ekstremitas :
- cyanosis (-)
- akral hangat
- Ekskoriasi a/r maleolus median
pedis kiri
BB hari ini : 2370 gram
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 PROGNOSIS
Quo ad vitam : dubia ad bonam
Quo ad functionam : dubia ad bonam
Quo ad sanasionam : ad bonam

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PEMBAHASAN

ASTHMA
DEFINISI
Asma merupakan penyakit yang heterogen yang ditandai
dengan inflamasi kronik saluran napas.

EPIDEMIOLOGI
 Prevalensi anak dan dewasa kurang lebih 1-18 %
(GINA).
 Perbandingan pada anak laki-laki dengan anak
perempuan (14:10%)
Etiologi dan Faktor
Resiko
1. Intermiten
Gejala kurang dari 1 kali/ minggu
Serangan singkat
Gejala nokturnal tidak lebih dari 2 kali/ bulan (kurang
samadengan 2 kali)
FEV1 ≥80% predicted atau PEF ≥80% nilai terbaik individu
Variabilitas PEF atau FEV1 <20%
3. Persisten sedang (Moderate Persistent)
Gejala terjadi setiap hari
Serangan dapat mengganggu aktivitas dan tidur
Gejala nokturnal >1 kali dalam seminggu
FEV1 60-80% predicted atau PEF 60-80% nilai terbaik
individu
Variabilitas PEF atau FEV1 >30%
2. Persisten ringan (Mild Persistent)
Gejala lebih dari 1 kali/ minggu tapi kurang dari 1 kali/ hari
Serangan dapat mengganggu aktivitas dan tidur
Gejala nokturnal >2 kali/bulan
FEV1 ≥ 80% predicted atau PEF ≥ 80% nilai terbaik individu
Variabilitas PEF atau FEV1 20-30%
4. Persisten berat (Severe Persistent)
Gejala terjadi setiap hari
Serangan sering terjadi
Gejala asma nokturnal sering terjadi
FEV1 ≤60% predicted atau PEF ≤ 60% nilai terbaik individu
Variabilitas PEF atau FEV1 > 30%
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