gastro sch is is
DESCRIPTION
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LAPORAN KASUS PASIEN
Gastroschisis
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Oleh ROZALINA ZULVI
&VITRI LESTARI
Pembimbing :
Dr. RASYIDAH Sp.A
DEPARTEMEN ILMU KESEHATAN ANAK
RSU dr. PIRNGADI MEDAN2011
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ANAMNESA PRIBADI
Nama : a/d Rahayu Pertiwi Umur : 1 hari Jenis Kelamin : perempuan Alamat : jl. Sei perogo lk IV
desa muara sentosa Agama : islam Tanggal Masuk : 19 april 2011 Berat Badan Masuk : 2200 gr Panjang Badan Masuk: 42 cm
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Keterangan Ayah Ibu
Nama Shalahuddin sitorus
Rahayu pertiwi
Umur 21 tahun 20 tahun
Agama Islam Islam
Perkawinan I I
Pendidikan SMP SMP
Suku Batak jawa
Pekerjaan Wiraswasta IRT
Alamat Jl. Sei perogo lk IV desa muara sentosa
Anamnesa orang tua
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RIWAYAT KELAHIRAN
Usia Kehamilan : 9 bulanCara Lahir : PSPTanggal Lahir : 18 april 2011Tempat lahir : klinik bersalinPenolong : BidanBerat Badan Lahir : 2200 gramPanjang Badan Lahir : 42 cm
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PERKEMBANGAN FISIK
Saat lahir : langsung menangis
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RIWAYAT IMUNISASI
BCG : -Hepatitis B : -Polio : -DPT : -Campak : -
Kesan : belum dilakukan imunisasi
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Keterangan mengenai saudara os
OS anak tunggal
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KELUHAN UTAMA : USUS TERBURAI
Telaah:
Hal ini telah dialami os sejak lahir
Demam (-)RPT : -RPO : -
Anamnesa Penyakit
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PEMERIKSAAN FISIK
Status Present
Leher:
Tidak dilakukan pemeriksaan
Ekstremitas :
Pols 150x/i, reg, t/v cukup, akral hangat
THORAX
•Sensorium : Composmentis•KU/KP/KG : Sedang/Sedang/
Sedang•Frekuensi Nadi : 150X/ i, reg, •Frekuensi Nafas : 48x/i, reg, •Temperatur : 35,5 0 C•Tekanan Darah : -•ikterus (-)
Kepala•Mata : RC(+/+), anemis (-), ikterik (-), conj palpebra inf (-/-)•Hidung : O2 nasal kanul terpasang•Telinga : DBN•Mulut : OGT terpasang
•Inspeksi : simetris fusiformis•Palpasi: tdk dilakukan•Perkusi: tdk dilakukan•Auskultasi: HR 150x/I,reg,
desah (-) RR 48x/I,reg, ronchi (-)
Abdomen
•Inspeksi : usus terburai
•Palpasi : soepel, h/l: sulit dinilai
•Perkusi : tdk dilakukan
•Auskultasi : peristaltik sulit dinilai
Genitalia :
perempuan anus (+) tak ada kelainan
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Laboratorium
Tanggal 19 april 2011:
Hb : 16,1 gr/dlLeukosit : 8.200/ mm3
Hematokrit : 48%Trombosit : 621.000/mm3
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• Pemeriksaan AGDA• PH : 7,235• PCO2 : 50,4 mmhg• PO2 :157,9 mmhg• TCO2 : 23 mmol/l• HCO3 : 21,5 mmol/l• BE : -6,2 mmol/l• O2 saturasi : 99,0 %
• Pemeriksaan elektrolit• Natrium : 131 mmol/dl• Kalium : 5,6 mmol/dl• Chloride : 111 mmol/dl
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•KGD adrandom : 170 mg/dl•Pemeriksan fungsi hatiBilirubin total : 1,3 mg/dlBilirubin direct : 0,41 mg/dlSGOT : 52 u/iSGPT : 12 u/iAlkali phosphatase : 70 u/i •Pemeriksaan fungsi ginjalUreum : 46 mg/dlCreatinin : 1.18 mg/dlUric acid : 9,7 mg/dl
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DIAGNOSIS KERJA
gastroschisis
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PENATALAKSANAAN
•Kebutuhan total cairan: 60cc/kgbb/hari•D 10 % : 6 gtt micro/I•Inj vit. K 1 mg/im (1 x pemberian)•Inj. Cefotaxime 110 mg/12 jam/IV•Inj. Gentamycine 11 mg/36 jam/IV bila UOP (+)•T/P rawat kassa steril•Popok basah segera ganti
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USUL
Operasi repair gastroschisis
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PROGNOSIS : buruk
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TERIMA KASIH