CASE Dr.maya
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Transcript of CASE Dr.maya
7/17/2019 CASE Dr.maya
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Presentasi KasusPEMBIM BING : DR. MAYA, SP. PD
OLEH:
CLAR ISSA 20!"0#"0$
DEDE C IN%YA 20!"0"0$&
7/17/2019 CASE Dr.maya
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I'entitas
Na(a : IS Status )erni*a+an : Meni*a+
%e()at, tana- -a+ir : a*arta, / A)ri- &$
A-a(at : Pu-au seri1u
Su*u 1ansa : aa
Pe*er3aan : I1u ru(a+ tana
Pen'i'i*an : SD 4ta(at5
N6(6r re*a( (e'is : 2$/#!$
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Ke-u+an 7ta(a
Sesa* na8as 9an (e(1erat se3a* 2 +ari se1e-u( (asusa*it.
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Ke-u+an %a(1a+an
Sa*it *e)a-a se3a* ! 1u-an se1e-u( (asu* ru(a+ sa*it.
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Ria9at Pen9a*it Se*aran3 bulan SMRS 2 minggu
• Pasien (ena-a(i batuk se)an3an +ari, 1atu*ti'a* 1er'a+a*, 'ara+ 4"5. Pasien ti'a* (erasa*an
a'an9a 8a*t6r 9an (e()er1erat 'an (erinan*an1atu* ini. Pasien se()at (e(inu( OBH na(un ti'a*(e(1ai*.
• Nyeri dada 3ua 'irasa*an setia) )asien 1atu*. N9eri)a'a 'aera+ 'a'a se1e-a+ *anan atas se)erti'itusu*"tusu*, 'an ti'a* (en3a-ar. N9eri 'a'a(en+i-an 1e1era)a (enit sete-a+ )asien 1er+enti1atu*.
• Pasien (ena-a(i sakit kepala 9an 'irasa*an)a'a sisi *anan *e)a-a teruta(a 1aian tena+,(en3a-ar *e 1e-a*an *e)a-a, ti'a* 1er'en9ut. Sa*it*e)a-a teruta(a 'irasa*an saat )asien 1atu*.
• Ke-u+an 'e(a( 1eru-an 45, setia) 'e(a( se-a(a"2 +ari, su+u ti'a* 'iu*ur, 'e(a( 'irasa*anse)an3an +ari. Pasien ti'a* (erasa*an a'an9aa*tu tertentu 'i(ana 'e(a( 'irasa*an -e1i+ tini.
• Ke-u+an *erinat )a'a (a-a( +ari 45
• Pasien (u-ai (eras
nafas. Sesa* 'iras
)asien su-it (enari*'isertai rasa 1er'e1'irasa*an 1erta(1ateruta(a sete-a+ )aKeti*a )asien 1er+ena8as i*ut (ere'a. )erna+ ter1anun 'sesa* (au)un 1atu
ti'a* (erasa*an a'rasa sesa* 'enan (au)un a*ti;itas. S(enanu a*ti;itse+ari"+ari.
• Ben*a* )a'a tanan6ta tu1u+ -ain
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1 minggu SMRS 2 hari SMRS
• Pasien 9an se(u-a (ena-a(i 1atu*
ti'a* 1er'a+a* *e(u'ian (en3a'i batukberdahak . Da+a* *enta- 1erarna*e+i3auan, 'ara+ 4"5.
•Ke-u+an sesa* (asi+ 'irasa*an, se'i*it1erta(1a+ 1erat.
• Sesa* 'an 1atu* 'irasa*an 11erat, +ina )asien *esu-ita(e-a*u*an a*ti;itas se+ari"+4(en<u<i )a*aian, (en9a)u
'irasa*an saat )asien se'an1eristira+at. Sesa* 'irasa*an+ari, 1a+*an *eti*a )asien ti
Pasien 3ua (erasa*an a'an9a )enurunan 1erat 1a'an se1an9a* = * 'a-a(tera*+ir.
Karena (erasa teranu 'enan sesa* terse1ut, )asien (e(utus*an untu*RS At(a a9a.
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Ria9at Pen9a*it Da+u-u
Ria9at +i)ertensi 'isan*a- Ria9at )en9a*it +ati 'isan*a-
Ria9at 1atu* -a(a se1e-u(n9a 'isan*a-
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Ria9at Ke-uara
I1u )asien (enina- *arena )en9a*it )aru 9an (ena+un.
Ria9at Ke1iasaan Pasien (en6nsu(si *6)i se1an9a* 2 e-as setia) +arin9a.
Pasien ti'a* (er6*6*, 'i ru(a+ ti'a* a'a an6ta *e-uara 9an (
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PEMERIKSAAN >ISIK
Kea'aan u(u( : ta()a* sa*it se'an, )asien ta()a* Kesa'aran : <6()6s (entis
Berat 1a'an : =$ *
%ini 1a'an : // <(
BMI : .$ *?(2
%an'a"tan'a ;ita-
@ %e*anan 'ara+ : 0?0((H
@Na'i : ?(enit
@RR : 2?(enit
@Su+u tu1u+ : !$.2 @C
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Kepala : N6r(6se)+a-i, 'e86r(itas 45
Mata
K6n3unti;a : )u<at "
S*-era : i*teri* "
Pu)i- : is6*6r !((?!((
Lensa : 6)a*
Mukosa oral : Mu*6sa 6ra- 1asa+
Hiperemia faring : 4"5
Leher : Ke-en3ar tir6i' ti'a* (e(1esar
%er-i+at -u*a )a'a -e+er 1aian anteri6r *arena )enunaan at (enurut )asien 'a)at (e-ea*an rasa sesa*. 4*rusta <6*-at 'enan e
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Da'a: %er-i+at si(etris
Paru")aru :
Ins)e*si : si(etris 'a-a( *ea'aan statis 'an 'ina(is
Pa-)asi: si(etris 'a-a( *ea'aan statis 'an 'ina(is, 8re(itus ta*ti- *iri*an
Per*usi: *iri*anan, s6n6r, BPH 'i ICS /
Aus*u-tasi : suara nafas vesikuler !" rhonki !" #hee$ing %!%@ Kiri : ter'enar r+6n*i *erin
@ Kanan : rhonki kering lebih keras dibanding paru kiri" lebih &elas terdenapeks'
antun:
Ins)e*si : ti'a* ter-i+at Pa-)asi: ti'a* tera1a
Per*usi:@ Batas atas : ICS II
@ Batas *iri : Linea a*si-aris anteri6r sinistra
@ Batas *anan : Linea sterna-is *iri
@ Aus*u-tasi : B 'an 2 reu-ar, a--6) ", (ur(ur "
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A1'6(en Ins)e*si: <e(1un, -inea nira
Pa-)asi: su)e-, n9eri te*an su)ra)u1is
Hati : ti'a* tera1a
Li()a : ti'a* tera1a
Gin3a- : Ba--6te(en
E*stre(itas
A*ra- +anat, CR% 2 'eti*, e'e(a "?"?"?"
7/17/2019 CASE Dr.maya
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Pe(eri*saan La16rat6riu( He(at6-6i :
@ He(6-61in : .# ?'L
@ He(at6*rit : !/F
@ Leukosit ( 12'3))
@ %r6(16sit : !$.000
@ L*+ ( ,1 mm!&am -.1/ mm!&am0
@ Hitun 3enis : 0??!?$$?/?=
@ Ki(ia Dara+ :@ SGO% : !&
@ SGP% : #
@ 7reu( : 0 420"=05
@ Kreatinin : 0.= 40.#".25
@ GDS: $/
7/17/2019 CASE Dr.maya
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Resu(e
anita, 2$ ta+un, 'atan *e RS At(a a9a 'enan *e-u+ase3a* 2 (inu SMRS, 9an (e(1erat 2 +ari SMRS. D9s
e6rt 4"5. Se1e-u(n9a )asien (ena-a(i 1atu* 'an sa*it
se3a* ! 1u-an SMRS. Batu* 1er'a+a* 45, +i3au *enta-. Setia
)asien (erasa*an n9eri )a'a *e)a-a 1aian *anan, ti'a* 1e
De(a( inter(iten 45, )enurunan 1erat 1a'an 45 'a-a(
tera*+ir, *erinat )a'a (a-a( +ari 45. Ria9at )en9a*it )a
*e-uara 45. Ke-u+an seru)a )a'a -in*unan ru(a+ 'an se
Pasien saat ini +a(i- &"20 (inu (enurut HPH%.
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Resu(e
Pa'a )e(eri*saan Jsi* 'i'a)at*an )asien ta()a* sa*it *esa'aran <6()6s (entis, )asien ta()a* sesa*.
%%:
%D 0?0 ((H, HR ?(, RR 2?(, Su+u !$.2 C
Pe(eri*saan )aru 'ite(u*an suara na)as ta(1a+an r+6*erin ? )a'a )aru *anan 1aian a)e*s -e1i+ *eras.
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Resu(e
Pa'a )e(eri*saan -a16rat6riu( 'i'a)at*an:. -eu*6sit6sis 42!00 7?'L5
2. Penin*atan LED 4 ((?+5
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Dian6sis
@Sus)e* %BC Paru DD? Pneu(6nia@G2PA0 ra;i' &"20 (inu (enurut HPH%
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%ata La*sana
Raat 'a-a( 1ansa-
Diet: nasi %K%P
Para<eta(6- /00 ( )rn
In3 Ce8tria6ne 2 ra(
Saran )e(eri*saan: S)utu( B%A ! 4Sea*tu"Pai"Sea*tu5
Pe(eri*saan s)utu(
K6nsu- O1s9n untu* 7SG
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Hasi- Pe(eri*saan
@S)utu(@ a(ur
@ Gra( stre)t6*6*us
@ 73i Ba*teri %a+an Asa( 4B%A5 : Neati8 4"5
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Pr6n6sis
u6 a' ;ita( : 16na(
u6 a' 8un<ti6na( : 'u1ia a' 16na(
u6 a' sanati6na(: 'u1ia a' 16na(
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ANALISIS *asus
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%e(uan *-inis %BC )aru
%EORI
Batu* 1iasa aa-n9a ti'a* 1er'a+a* )a'a )ai +ari -e1i+ 1erat, *e(u'ian(en3a'i s)utu( )uru-en
Le(a+
Na8su (a*an 1er*uran, )enurunan BB
De(a( 'iurna-
Kerinat (a-a( +ari
Biasan9a )a'a a)e*s atau se(en su)eri6r -61us 1asa-
N9eri 'a'a )-euriti*
He(6)tisis
PASIEN
B
Kerin
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Sus)e* %B )aru
Pe(eri*saan B%A s)utu(
B%A 4"5
K-inis 'an 86t6 t6ra*s
Sesuai %B
Kasus %B B%A 4"5
%i'a* sesuai %B
AB 2 (inu
Per1ai*an
Bu*an %B
%i'a* )er1ai*an, *-inis sesuai %B
%B B%A 4"5
B%A 45, Kasus 'eJniti8 %B
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Pe(1erian OA% Pasien 'enan *asus 1aru: 2 HRE?=HR
Pe(antauan: )e(eri*saan a)usan 'a+a* B%A )a'a a*+*e'ua, 3i*a 45 'iu-an *e(1a-i )a'a 1u-an *etia
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Pe(1erian OA% )a'a i1u +a( %B )aru )enin*atan risi*6 a16rtus s)6ntan, (6rta-ita)erinata-, *e<i- untu* usia estasi 4I7GR5 'an BBLR.
Is6niai' 4*ate6ri A5: )enin*atan risi*6 +e)at6t6*sisita
Ri8a(isin 4*ate6ri C5: )a'a se(ester tia *e+a(i-an(en9e1a1*an +i)6)r6tr6(ine(ia
Eta(1ut6- 4*ate6ri A5
Piraina(i' 4*ate6ri ti'a* terse'ia5: 1e-u( a'a -a)6ransa()in
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%+an* Y6u