Cbd Daksha

download Cbd Daksha

of 21

Transcript of Cbd Daksha

  • 7/23/2019 Cbd Daksha

    1/21

    GEDE

    CASE BASED

    DISCUSSION

    I GEDE KRISHNAMAHAYAYANA1102005153DAKSHAYANI VIJAYAN1102005194

  • 7/23/2019 Cbd Daksha

    2/21

    Identitas Pasien

    Nama I!P!

    "m#$ %9 &a'#n

    Jenis Ke(amin )a*i+(a*i

    Ke,a$-ane-a$aan Ind.nesia A(amat Ja(an -#n#n- !at#$ G-/Sa(a i N. 1

    ds$

    A-ama Hind#

    Pendidi*an +

    Stat#s Pe$*a,inan Meni*a'

    a*t# MRS 1053015

    &-( Peme$i*saan 1052015

  • 7/23/2019 Cbd Daksha

    3/21

    Anamnesis

    Ke(#'an "tama Ne$i dada

    Ri,aat Pena*it Se*a$an-

    Pasien $#6#*an da$i $#ma' sa*it ,an-aa men-e(#' ne$i dada ada di 7a'a-ian *i$i Ke(#'an te$se7#t di$asa*an se6a* 5 6am se7e(#m mas#*

    $#ma' sa*it semasa asien sedan- tid#$

    ne$i dada di$asa*an te$tindi' 7enda 7e$at

    Ne$i di$asa*an men6a(a$ *e (en-an *i$i dan $a'an- asien

    Ke(#'an 7e$de7a$8+: *e$in-at din-in8+: m#a( m#nta'8+:sesa* 8;/

    Ke(#'an sesa* tida* mem7ai* den-an e$#7a'an .sisi/

  • 7/23/2019 Cbd Daksha

    4/21

    Anamnesis

    Riwayat Penyakit Terdahulu

    Pasien memi(i*i ena*it 6ant#n- den-an $i,aat e$a,atan di$#ma' sa*it 1/5 7#(an an- (a(# *a$ena *e(#'an ne$i dada an-sama see$ti saat ini /Pasien 6#-a memi(i*i $i,aat 'ie$tensise6a* 5 ta'#n an- (a(#

    Riwayat Pengobatan

    Di R#ma' Sa*it an-aa :asien tida* mendaa$*an en-.7atan

    Riwayat Penyakit Keluarga

    'ie$tensi: *en

  • 7/23/2019 Cbd Daksha

    5/21

    &anda Vita(Keadaan #m#m sa*it sedan-

    Gi=i .m.s Mentis

    G>S 15

    &e*anan Da$a'150100 mmH-

    S#'# a*si(a 3% >

    Nadi ?@menit

    Resi$asi 20 @menit

    Sat#$asi *si-en 100B ada 2nasa( *an#( 2 (m

    !e$at 7adan 50 *-

    &in--i 7adan 1%0

  • 7/23/2019 Cbd Daksha

    6/21

    Pe!erikaan U!u!

    Mata >.n6#n

  • 7/23/2019 Cbd Daksha

    7/21

    Thora#

    Pe$-e$a*an dada simet$is

    $antung

    In%eki I*t#s *.$dis n.$ma( 8tida* te$(i'at:#(sasiae@

    Pal%ai I*t#s *.$dis n.$ma(: &'$i(( 8+

    Perkui !atas Atas I>S II !atas !a,a' I>S V

    !atas Kanan PS) De@t$a

    !atas Ki$i 3

  • 7/23/2019 Cbd Daksha

    8/21

    Paru

    Inse*si simet$is saat statis dandinamis: $et$a*si 8+

    Pa(asi ta*ti( C$emit#s n.$ma(

    Pe$*#si s.n.$s.n.$ A#s*#(tasi esi*#(e$: $'.n*i 8++:

    ,'ee=in- 8++

    +

    +

    +

    +

    +

    +

    -

    -

    -

    -

    -

    -

  • 7/23/2019 Cbd Daksha

    9/21

    Abdo!en

    Inse*si Distensi 8+

    A#s*#(tasi !isin- #s#s 8; n.$ma(

    Pe$*#si &imani: s'iCtin-d#((ness 8+

    Pa(asi Ne$i *et.* >VA 8+:7a((.tement 8+: 'ati: (ien tida*te$a7a

    Ektre!ita a*$a( 'an-at: .dema8+: 6a$i ta7#'8+

  • 7/23/2019 Cbd Daksha

    10/21

    PE&ERIKSAAN PENUN$AN'

    EK'

  • 7/23/2019 Cbd Daksha

    11/21

  • 7/23/2019 Cbd Daksha

    12/21

  • 7/23/2019 Cbd Daksha

    13/21

    EKG

    Inter%retai (I$ama Sin#s HR 0@menit:a@is n.$ma(: -e(.m7an- P n.$ma(: inte$a(PR 0:20 di ii:iii:aVF:V4 : *.m(e*s RS 0:12 s : RSR V1: RV5: SV1 35

  • 7/23/2019 Cbd Daksha

    14/21

    T)ORA* P)OTO +,-./0.1/,02

    F.t. &'.$a@ AP

  • 7/23/2019 Cbd Daksha

    15/21

    >.$ 7esa$ dan 7ent#* esan n.$ma( :tama**a(si*asi a.$ti< *n.7

    P#(m. ta* tama* in(t$ate

  • 7/23/2019 Cbd Daksha

    16/21

    3aboratoriu!

    Para!eter )ail Satuan NilaiRu4ukan Re!ark

    5BC %/?0 103) 4:10 11:0

    6Ne ?0/3 B 4? 0

    63y 14:5 B 13 40

    6&o 9:?4 B 2:0 11:0

    6Eo 3:30 B 0 5:0

    6Ba 2:25 B 0 2:0

    RBC 3:99 10%) 4:5 5:9 Renda'

    )'B 12:? -d) 13:5 1?:5 Renda'

    )CT 3?: B 41 53 Renda'

    &C7 94:? C) 0:0 100:0&C) 31: -d) 2%:0 34:0

    &C)C 33:5 -d) 31:0 3%:0

    P3T 23% 103) 150 440

    Darah 3engka% +,-.0.1/,02

  • 7/23/2019 Cbd Daksha

    17/21

    KI&IA K3INIK +,-./0.,02

    3aboratoriu!

    Para!eter )ail Satuan Nilai Ru4ukan Re!ark

    Natriu! +Na2 135 mm.() 13%+145 Renda'

    Kaliu! +K2 4:4 mm.() 3:5+5:10

    S'OT 35:2 ") 11+33 &in--i

    S'PT 24:1 ") 11:00+50:00

    Albu!in 3:5% -d) 3:40+4:0

    BUN 12 m-d) :00+23:00

    Creatinin 1:2 m-d) 0:?0+1:20 tin--i

    CK&B &aa :41 I"m) 0+5:00 &in--i

    Tro%onin T 50+100 n-m)50Lne-atiC: 50+100L(.,:

    100LAMI

    &in--i

  • 7/23/2019 Cbd Daksha

    18/21

    )e!otai +,-.0.,02

    3aboratoriu!

    Para!eter )ail Satuan NilaiRu4ukan Re!ark

    PTT 10:3

    n.$ma(+Le$7edaan den-an

    *.nt$.( 2 deti*

    INR 0/95 deti*

    Kotrol PTT 9:9 deti*

    APTT 41:9 deti*N.$ma(Le$7edaan den-an

  • 7/23/2019 Cbd Daksha

    19/21

    Diagnoi

    S&EMI InCe$i.$ Ki(i 1

    1/&IMI 514

    2/nset 5 6am Hie$tensi st 1

  • 7/23/2019 Cbd Daksha

    20/21

    &e$ai

    IVFD NS tm

    2 nasa( *an#( (m

    Aset.sa( 1 @ 0 m-

    >(.id.-$e( 1 @ ?5 m-

    Simastatin 1 @ 20 m- !is.$.(.( 1 @ 2:5 m-

    >at.$i( 3 @ 12:5 m-

    Dia=eam 3 @ 5 m-

    )a@adn s$ 3 @ >I ISDN 5 m- S)

    St$etase 1:5 6#ta #nit

    Hea$in 7.(#s 3000 #nit Ld$i %00 #nit6am

  • 7/23/2019 Cbd Daksha

    21/21

    P(annin-

    )iid $.(e

    E.$.na$ an-i.-$a'M.nit.$in- *e(#'an /ita( si-n dan

    7a(an