Lapjag bangsal 15-01-2016+EKG
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Laporan Jaga Bangsal Jumat, 15 Januari 2016
PPDS Jaga: dr. PutriKoas Jaga : Giavanny dan Nima Ulya
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– Lantai 3 : 0– Lantai 4 : 0– Lantai 5 : 0– Lantai 6
• Tn. J KAD + VES Trigemini + HT grade II
Rekapitulasi Pasien
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Nama : Tn. JJK : Laki-lakiUmur : 50 TahunAgama : IslamAlamat : Komp. Cimanggis, DepokPekerjaan : PNS Angkatan DaratNo RM : 436700Tgl MRS : 15 Januari 2016, pk. 16.30 WIB
I. IDENTITAS PASIEN
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1. ANAMNESIS (Autoanamnesis)
Keluhan Utama : Mual sejak 1 jam SMRS
II. DATA DASAR
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• Pasien datang ke IGD dengan keluhan mual sejak 1 jam SMRS. Mual tanpa muntah.
• Keringat dingin (+), lemas (+), nyeri kepala (+), nyeri tengkuk hingga ke pundak kiri. Nyeri perut (+). Nyeri dada (-), sesak (-), demam (-), batuk (-)
• Pasien mengeluh sering lapar, minum, dan sering BAK. BAK malam bisa >5x.
• Penurunan BB (-), kaki baal (-), pandangan kabur (-).• Pasien merasa lebih cepat lelah• BAB tidak ada keluhan.• Pasien baru mengetahui dirinya DM saat di IGD
RPS :
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RPD• Hipertensi (+)• Asam urat (+)• Kolesterol (+)• Riwayat pasang ring ± 8 bulan• Asma (-)• Alergi (-)
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RPK• HT (+) Ayah pasien• DM (-)• Asma (-)
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RPO• Clopidrogel 75 mg 1x1• Bisoprolol 2,5 mg 1x1• Amlodipin 10 mg 1x1• Micardis 80 mg 1x1• Aspilet 80 mg 1x1• Atorvastatin 20 mg 1x1• Allopurinol 300 mg 1x1
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Riwayat kebiasaan:• Makan makanan manis• Merokok (-)• Konsumsi alkohol (-)• Jarang olahraga
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2. PEMERIKSAAN FISIK
PEMERIKSAAN UMUM–Keadaan Umum : Tampak sakit sedang–Kesadaran : Compos mentis–BB : 75 kg–TB : 170 cm–IMT : 26.0–Keadaan Gizi : Overweight–Tekanan Darah : 150/100 mmHg–Nadi : 86 x/mnt, ireguler–RR : 20 x/mnt–Suhu : 36,5 ⁰C
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STATUS GENERALIS
Kepala : NormocephalRambut : warna hitam, distribusi merataWajah : simetris, deformitas (-)Mata : konjungtiva pucat -/-, sklera ikterik -/-,
mata cekung (-/-), pupil isokor THT : normotia, discharge (-), deviasi septum
nasi (-)Leher : JVP 5-2 cmH2O, KGB tidak membesarMulut : mukosa mulut pucat (-), mukosa kering (-)
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ThoraksParuInspeksi : bentuk dada normal, gerak dada simetris
saat statis dan dinamis, , retraksi intercostal (-)Palpasi : taktil fremitus kedua paru simetris, chest
expansion simetris, nyeri tekan (-), massa (-)Perkusi : sonor pada kedua paruAuskultasi : suara nafas vesikuler (+/+),
wheezing (-/-), ronkhi (-/-)
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JantungInspeksi : iktus kordis tidak terlihatPalpasi : iktus kordis teraba di ICS V Linea
midclavicularisPerkusi
Batas kanan jantung : ICS V linea parasternalis dextra
Batas kiri jantung : ICS V linea axillaris anterior sinistra
Batas pinggang jantung : ICS III linea parasternal kiri Auskultasi : BJ I/II irreguler, murmur (-) gallop (–)
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AbdomenInspeksi : tampak buncitAuskultasi : bising usus (+) normalPalpasi : nyeri tekan (+) epigastrium,
turgor baikPerkusi : timpani pada seluruh kuadran
abdomen
Ekstremitas : akral hangat, CRT < 2 “, edema (-)
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3. PEMERIKSAAN PENUNJANGJenis
Pemeriksaan
Hasil Nilai Rujukan15/01/2016
Hemoglobin 12.6 13-18 g/dL
Hematokrit 36 40-52 %Eritrosit 4.3 4,3-6,0 juta/μLLeukosit 14050 4.800-
10.800/μLTrombosit 212000 150.000-
400.000/μLMCV 84 80-96 fLMCH 29 27-32 pgMCHC 35 32-36 g/dL
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KIMIA KLINIK 15/01/2016 Nilai Rujukan
Ureum 103 20-50 mg/dL
Creatinin 1.6 0.5-1.5 mg/dL
GDS 317 <140 mg/dL
Natrium 133 135-147/mmol/L
Kalium 5.1 3.5-5.0/mmol/L
Clorida 100 95-105/mmol/L
Aseton + -
Troponin 0.14 < 0.02 ng/mL
CPK 29 38-172 U/L
CK-MB 15 7-25 U/L
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KIMIA KLINIKAGD
15/01/201612.32
15/1/201613.14
Nilai Rujukan
pH 7.302 7.357 7.37 – 7.45
pCO2 20.7 33.8 33-44 mmHg
pO2 52.3 112.5 71 – 104 mmHg
HCO3 - 10.3 19.1 22 – 29 mmol/L
BE -13.9 -5.0 (-2) – 3 mmol/L
Saturasi O2 83.8 98.1 94-98%
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EKG: VES Trigemini
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• Pasien laki-laki 50 tahun datang dengan keluhan mual sejak 1 jam SMRS. Mual tanpa muntah. Keringat dingin (+), nyeri kepala (+), nyeri tengkuk hingga pundak kiri tanpa nyeri dada.
• Pasien sering lapar, minum dan BAK (malam >5x)• Pasien lebih cepat lelah dan pasien tidak mengetahui
menderita DM• Riwayat HT(+), asam urat (+), kolesterol (+), riwayat pasang
ring 8 bulan lalu.• Pasien mengkonsumsi obat dari cardiolog CPG, bisoprolol,
atorvastatin, amlodipine, micardis, aspilet, allopurinol
III. RINGKASAN
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• KU: TSS, kesadaran CM• TV: TD 150/100, HR 86x/mnt, RR 20x/mnt, Suhu 36,5 ⁰C• PF jantung: BJ I/II irregular, murmur (-), gallop (-)• PF abdomen: NT (+) epigastrium• Px. Lab: penurunan Hb, Ht, leukositosis dan peningkatan Ur,
Cr, aseton (+)AGD: asidosis metabolik
• EKG: VES Trigemini
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1. Ketoasidosis diabetikum 2. VES Trigemini3. Leukositosis reaktif DD infeksi4. HT grade II5. AKI DD Acute on CKD
IV. DAFTAR MASALAH
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V. PENGKAJIAN
1. Ketoasidosis diabetikum Atas dasar :
Anamnesis: mual dan nyeri perutPF : NT (+) epigastrium Px Lab : GDS 317, Aseton (+), penurunan pH, PCO2 dan HCO3
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Rencana Terapi : - Management KAD
- Hidrasi & perbaikan elektrolit NaCl 0.9% 1500 cc, lanjut NaCl 0.9% 500 cc/6 jam lihat respon
- Perbaikan glukosa darah Insulin 3 U/jam- Diet 1900 kalori
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Monitoring - Cek diuresis didapatkan urine di pispot ±
1000 ml selama 9 jam urine output 1,48 mL/kg/jam
- Cek GDS perjam (krn keterbatasan di bangsal) cek GDS/4 jam:- 02.15 : 209- 05.00 : 133
- Cek elektrolit & AGD/ 6 jam
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2. VES TrigeminiAtas dasar:• Pemeriksaan EKG
Rencana diagnosis :• Cek elektrolit
Rencana terapi: Control rate EKG serial Medikamentosa
Antiaritmia amiodarone Beta adrenergic blocker bisoprolol
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3. Leukositosis reaktif DD/ infeksiAtas dasar:
₋ Ax : demam (-), batuk (-)₋ PF : suhu 36,5 ⁰C₋ Px. Lab: Leukosit 14050 (>>)
Rencana diagnosis :– Cari tahu etiologi awal– Cek diffcount dan morfologi darah tepi
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4. HT grade IIAtas dasar
₋ Ax : Nyeri tengkuk₋ PF : TD 150/100
Rencana terapi : Edukasi:
Modifikasi gaya hidup tekanan darah <130/80 krn menderita DM Diet DASH (Dietary Approaches to Stop Hypertension) buah, sayur, produk
susu rendah lemak, << sodium Kurangi BB normoweight (BMI= 18,5-24,9)
Medikamentosa: Bisoprolol 1x 2,5 mg Amlodipin 1x 10 mg
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5. AKI DD Acute on CKDAtas dasar
₋ Ax : terdapat hipertensi, baru mengetahui menderita DM₋ PF : TD 150/100, Nadi 86x/menit irreguler₋ Px. Lab: Ureum 103, Creatinin 1.6 GFR 58.59 (menurun)
GDS 317
Rencana diagnosis Pemeriksaan urinalisis Pemeriksaan ureum & kreatinin pasca rehidarasi tentukan GFR
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Dapat disebabkan :1. Dehidrasi e.c KAD2. Nephropati DM
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VII. PROGNOSIS
Quo ad vitam : Dubia ad bonam Quo ad sanationam : Dubia ad malamQuo ad functionam : Dubia
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TERIMA KASIH