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  • POMR Hepatitis Akut

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    D.s. Putri Nastiti
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    1. An Alfin Abadi, 13 years old, was admitted with complaints of jaundice, anorexia, feverish feeling, and abdominal pain for 4 days. On examination, he appeared lethargic with scleral icterus. 2. Laboratory tests showed elevated liver enzymes. Abdominal ultrasound revealed hepatomegaly without focal lesions. 3. The patient was diagnosed with acute hepatitis and treated conservatively with intravenous fluids, antipyretics, and nutritional support. Further evaluation including liver function tests and viral markers was planned.

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    Problem Oriented Medical Record

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    1. An Alfin Abadi, 13 years old, was admitted with complaints of jaundice, anorexia, feverish feeling, and abdominal pain for 4 days. On examination, he appeared lethargic with scleral icterus. 2. Laboratory tests showed elevated liver enzymes. Abdominal ultrasound revealed hepatomegaly without focal lesions. 3. The patient was diagnosed with acute hepatitis and treated conservatively with intravenous fluids, antipyretics, and nutritional support. Further evaluation including liver function tests and viral markers was planned.

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    178 views3 pages

    POMR Hepatitis Akut

    Uploaded by

    D.s. Putri Nastiti
    1. An Alfin Abadi, 13 years old, was admitted with complaints of jaundice, anorexia, feverish feeling, and abdominal pain for 4 days. On examination, he appeared lethargic with scleral icterus. 2. Laboratory tests showed elevated liver enzymes. Abdominal ultrasound revealed hepatomegaly without focal lesions. 3. The patient was diagnosed with acute hepatitis and treated conservatively with intravenous fluids, antipyretics, and nutritional support. Further evaluation including liver function tests and viral markers was planned.

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    PROBLEM ORIENTED MEDICAL RECORD D.S. PUTRI NASTITI 201210401011051 Nama Usia !!"T!

    Summary of data a!" Identitas : An Alfin Abadi, 13 tahun. +,* pada $-.$1. $14, 1..$$ A$am$"!%! ) 1.,&* +ata dan badan menguning se(a# 4 ha'i *+,* Nafsu ma#an tu'un, se(a# 4 ha'i *+,* /emam 012 +ual 012 !A3 te'a#hi', 4 (am *+,*, )a'na sepe'ti teh. +a#in malas ma#an1 minum se(a# 1$ (am *+,* . ,&/ : 012 3. ,.*os : 012 P*y!%+a# E,am%$at%o$ ) 3eadaan umum : tampa# lemah, 56* 45. A1"I7"61"/1 8ITA9 *I5N*: T/ 11$"4$, n 44:, ,, $ +ata %o)ong !A3 te'a#hi' 4 (am *+,*, sedi#it . /ehid'asi sedang .1 /ehid'asi sedang *e'um @le#t'olit ,ehid'asi ,inge' 1. 8ital *igns Asetat 5$$%%"3 . &'odu#si (am U'ine 3. 3eadaan Umum pasien

    : An. Alfin Abadi : 13 tahun : 44 #g"15$ %m


    C#u" a$d Cu" An. AA, 13 thn, la#i1la#i Jaundi%e #'ame' 5 Ano'e:ia ;eb'is !A3 sepeti teh &ening#atan en<im hepati# Nye'i te#an =uad'ant #anan atas abdomen dan epigast'ium

    Alamat Nama ayah &e#e'(aan


    Pro #"m #%!t 1. Jaundi%e

    : Tapen, Jombang : Tn. Agus, 45 thn : #a'ya)an s)asta


    I$%t%a# D%a&$o!%! 1.1 >epatitis A#ut

    Nama Ibu &e#e'(aan

    : Ny. Astuti, 4 thn : &N*


    P#a$$%$& T"ra'% Mo$%tor%$& 1. +,* bed 1. 8ital *igns . 3eluhan 'est total nye'i pe'ut . Infus ,inge' Asetat 1$$$ %%" 4 (am 3. In( ,anitidin 3:5$ mg 4. In(. &a'a%etamol 44$ mg 044 %%2 (i#a feb'is 5. 3apsul U'sodeo:y%holi% A%id 3:1 .. /iet bebas T3T& A. Nut'isi pe' N5T Edu(a!% /iagnosis hepatitis a#ut &e'lu isti'ahat %u#up dan inta#e nut'isi bai# Ana# malas ma#an minum %ai'an int'a?ena, nut'isi pa'ente'al &eme'i#saan 9ab untu# men%a'i etiologi hepatitis &'ognosis : umumnya bai#

    D%a&$o!%! 1. Ig+ Anti >A8 . Ig5 Anti >A8 3. >!sAg 4. Anti >!s 5. 9i?e' ;un%tion Test .. U'inalisis

    1. .

    3.

    4.

    5.

    1. Tinda#an yang dila#u#an 'ehid'asi #a'ena ana# dehid'asi sedang . Inta#e %ai'an %u#up aga'

    PROBLEM ORIENTED MEDICAL RECORD D.S. PUTRI NASTITI 201210401011051


    :, suhu 3A.Ao6 6o)ong 072 Tho'a: : &ulmo : *imet'is, 'et'a#si 012, ,hon%hi 01"12, Bhee<ing 01"12 6o' : *1* i'egule'. +u'mu'072, 5allop 012 +u'mu' fase systoli%, g'ade 3"., pun%tum ma:. pada ape:, pen(ala'an 012 Abdomen : +embesa' simet'is, f'og shape 012, undulasi 012, shifting dullness 012. !ising usus 072, tu'go' dbn >epa'1lien tida# te'aba Nye'i te#an : pada =uad'ant #anan atas dan epigast'ium @#st'emitas: Jaundi%e 3'ame' 5 @dema 012 La oratory -%$d%$&!) >b : 13.4 9eu#osit : 4.A$$ @'it'osit : 4.5$$.$$$ T'ombosit : 33..$$$ 3. &enya#it Jantung 3ongenital asianoti# 3.1 A*/ 3. 8*/ 1. @65 . @%ho%a'diog'aphy 1. 3onsul spesialis ana# dan spesialis (antung 1. 8ital signs . 3eluhan tida# dehid'asi be'ulang 1. 3emung#inan adanya #elainan (antung pada ana# . &eme'i#saan yang a#an dila#u#an : @35 #'n i'ama (antung ana# tida# te'atu' @%ho untu# men%a'i (enis #elainan (antung yang dide'ita 3. &e'lu #onsul #e do#te' spesialis ana# dan (antung untu# penatala#sanaan lebih lan(ut.

    I'ama (antung i'egule' +u'mu' systoli% 3a'diomegal i *ianosis 012 /yspnea 012

    PROBLEM ORIENTED MEDICAL RECORD D.S. PUTRI NASTITI 201210401011051


    >%t : 3-.4 *5CT : 35$ *5&T : 1A$ Nat'ium : 14$ 3alium : 3../Ray ) Tho'a: A& : 6T, .5D

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