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Laporan kasus

7/21/2019 Laporan Kasus Put

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Identitas Pasien :

Nama : Ny. S

Umur : 60th

Jenis Kelamin : ♀

No RM : !""#

$an%%al Masuk RS :

0! &esem'er (0) pkl : 6.00*i'

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+namnesis Keluhan Utama :

Perut kem'un% "hari SMRS

Ri*ayat Penyakit Sekaran%:

Nyeri perut kanan atas "hari SMRS ,Nyeri

dirasakan hilan% tim'ul dan mem'erat hariSMRS,perut mem'esar -/ seak min%%u.

Mual -/ Muntah -1/ 2+K -/ 2+2 -1/seak hari

SMRS ,demam-/naik turun #hari SMRS.

RP&: Ri*ayat 3$ -/ minum o'at tidak

teratur. Ri*ayat &M disan%kal. Ri*ayat

'ero'at alan di 2idan.

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Pemeriksaan 4isik

Keadaan umum

Keadaan sakit : sakit sedan%

Kesadaran : 5ompos mentis

ital si%n :

$ekanan &arah : !0780 mm3%

Perna9asan : (07menit

Nadi : (07menit

Suhu : !8,6 ;

22 : ")k%

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Keadaan Spesi9ik

Kepala : konun%ti<a anemis171, skeleraikterik -7 /

Leher : JP )1( 5m3(=, pK>2 -1/

$horak :

;or: SS( re%uler, murmur-1/, %allop -1/.

Pulmo <esikuler, *he?in% 171, ronkhi171

+'domen : distensi a'domen -/, 2U -/

N, Undulasi -/ Shi9tin% dullness -/

+sites-/ , 3 tera'a ari 'a5, Lien tt' ,

ena Kolateral -1/ spider ne<i-/

@kstremitas : akral han%at kerin% merah,

edema -171/ pittin%

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Pemeriksaan Penunan%

-!7(7(0)/

&+R+3 3emo%lo'in : 0,6 %rA

Leukosit : (0.B!07mm!

$rom'osit: "##.0007mm!

3;$: )."A

2S@7L@& : !)mm7am/

>ol &arah : 2 Rhesus : -/

Urin rutin

Protein : Sedimen Urin

Reduksi : 1 Leu: -/ 81!07LP2

Uro'ilin : @ry: -/ ()1!07LP2

2iliru'in : 1 Kristal: -1/7LP2

Keton : 1 @pitel: -/ 7LP2

Nitrit : Silinder: Sil. Leuko -/ 01

P3 : 6.0 2akteri -/

2erat enis urine : .0)

S>=$:6(,(

S>P$:"!,(

+l'umin: ,"B%r7dl

2SS : "# m%7dl

Ureum : "B," m%7dl

;reatinin (,(8 m%7dl

+s. Urat:

;holestrol total : B0 m%7dl

$>: !# m%7dl

3'sa% -1/

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@K>

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&ia%nosis sementara:

sirosis hepatis dekompensata dd

hepatoma

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Penatalaksanaan

I<9d RL %tt 7i mikro Spironolakton ( ta'

In 4urosemid ( ampul i<

In para5etamol ! C 9ls

In kanamisin ()00m% -st/

La5tulosa syr !(5

+ntasida !

Pasan% kateter urin

Propanolol 0m%

3itun% input dan output

MRS Daal +

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$erima kasih