Tugas Kkd Anamnesis Bab Hitam IPD

7/25/2019 Tugas Kkd Anamnesis Bab Hitam IPD

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ANAMNESIS, PEMERIKSAAN FISIK, DAN

PEMERIKSAAN PENUNJANG BAB HITAM

DELA ASRIVIA BUANA

030.10.071

KETERAMPILAN KLINIK DASAR

DEPARTEMEN ILMU PENYAKIT DALAM

FAKULTAS KEDOKTERAN UNIVERSITAS TRISKATI

SENIN, 10 AGUSTUS 2015


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ANAMNESIS

Dokte ! Se"#$#t %#&', ('"#)k#* $#(+k Peke*#"k#* (#-# .okte $+.# De"# A('/'# -#*&

et+( %#.# %#&' )#' '*' M## .e** #%#k I+ ('#%# (#-# e'##3

P#('e* ! P#&' .ok, (#-# Mo44# .ok

Dokte ! B#'k + Mo44# ('"#)k#* .+.+k A.# -#*& '(# (#-# #*t+ +3

P#('e* ! Be&'*' .ok, BAB (#-# #*# )'t#$ .ok

Dokte ! BAB '+ e#*# )'t#$ -#3 B#'k (ee"+$ (#-# et#*-# .#* $e"#k+k#* %e$e'k(##*

'4'*k#* (#-# +*t+k $e"e*&k#%' '.e*t'*t#( '+ -#

P#('e* ! S'"#)k#* .ok

A. IDENTITAS PASIEN

Pertanyaan Jawaban pasen

N#$# "e*&k#% '+3 Mo44# M#+"'.-#), .ok

U('# I+ e#%#3 65t#)+*, .ok

A"#$#t '+ .'$#*#3 D' J#"#* T##k#" 7 No 10

I+ (+.#) $e*'k#)3 S+.#) .ok

Pe*.'.'k#* te#k)' *-# #%# +k3 SMA .ok

Peke8##* '+ #%# -#3 I+ +$#) t#*&A$# '+3 I("#$

B. !ELU"AN UTAMA

Pertanyaan Jawaban

I+ ke"+)#* +t#$# *-# #%# +3 BAB (#-# e#*# )'t#$ .ok

Se8#k k#%#* BAB '+ e#*# )'t#$3 Se8#k 9 )#' -#*& "#"+ .ok

#. RI$A%AT PEN%A!IT SE!ARAN&

Pertanyaan Jawaban

See"+$ ke#.##* I+ (e%et' '*', #'$#*#

ko*.'(' '+3

S#-# #'k : #'k (#8# .ok

Sek##*& #'$#*# ko*.'(' '+ (ete"#) '+

$e#(#k#* ke"+)#* (e%et' BAB '+ e#*#

S#-# $e#(# e%#t #%ek, "e$#(, .#* t'.#k

(e"## $#k#* .ok


3/12

)'t#$3

S+.#) e#%# "#$# '+ $e*"#$' #%ek,

"e$#( .#* t'.#k (e"e# $#k#*3

S+.#) 2 $'*&&+ -#*& "#"+ .ok

A%#k#) '+ %e*#) $e*"#$' )#" (e%et' '*'

#%# #+ %et#$# k#"'3

I*' #+ %et#$# k#"' .ok

B#'$#*# #*# .#' BAB '+3 ;#*#*-# )'t#$ .ok, (e%et' ko%'

BAB *-# ke#(, "+*#k, #t#+ #'3 Ak "e$ek .ok

Be#%# k#"' '+ BAB .#"#$ (e)#'3 1 : 2 k#"' .ok .#"#$ (e)#'

P#.# (##t BAB #%#k#) #.# #(# *-e' (##t I+

$e*&e.#*3

T'.#k #.# .ok

I+ #.# $e#(# %e+t '+ ke$+*&3 A.#k .ok, (e'*& te#(# ke$+*&

A%#k#) '+ e%#t $e#(# ke*-#*&3 I-# .ok (#-# $e#(# e%#t ke*-#*& %#.#)#"

#+ $#k#* (e.'kt .ok

D' %e+t '+ #.# te#(# *-e'3 K#"#+ #.#

.'#&'#* $#*# -# +3

A.# .ok, *-e'*-# .' .' %e+t (ee"#) k#*#*

#t#( .ok

A%#k#) '+ (e'*& $e#(# $+#" #t#+ $+*t#)

+3

S#-# $e#(# $+#" .ok t#%' t'.#k $+*t#)

A%#k#) .'(et#' .e$#$$3 J'k# '-#, (+)+*-#

#'$#*#3 D' +k+ .e** #%# '+ 3

I-# .ok, (#-# (e'*& $e'#*& e"#k#** '*'

(e%et' (+$e*& &'t+ .ok, .' +k+ .e**

t#** #8# (' .ok

A%#k#) #k)' : #k)' '*' k+"'t '+ e+#)

$e*8#.' k+*'*&3 M+*+" #*# k+*'*& *-#

%e"#)#* #%# $e*.#.#k '+ 3

I-# .ok, k+"'t (#-# te"')#t ,"e') k+*'*&

.#' '#(#*-# e&'t+ 8+ .e** $#t# (#-#

.ok M+*+" *-# (' $e*.#.#k .ok $+"#o$%o( $e*t'(

St#t+( &'4' B#'k

H#'t+( A(te*'k+(

T#('#* +$+ T#$%#k "e') t+# .#' +$+ (ee*# *-#

>## e8#"#* No$#"

Ke"#'*#* (+## .#* ## e'## No$#"A.# t'.#k*-# !

# D-(%*oe De)'.#('

E.e$#

. A('te(e Ke8#*&

Ge#k#* '*/o"+*te

T'.#k te.#%#t .-(%*oe, .e)'.#(', #('te(,

ke8#*&, koe#, te.#%#t e.e$# %#.# ke.+#

ek(te$'t#( ##) .#* te$o %#.#

ekte$'t#( #t#(

S'k# %e*.e't# >oo%e#t'/e

Ko*.'(' $e*t#" %#('e* T#$%#k k)##t'

Pe*#$%'"#* %#('e* R#%') .#* e(')

>##t t++) T'.#k t#$%#k

B. PEMERI!SAAN TANDA VITAL DAN ANTR+P+METRI

Pe(er)saan "as*

Tek#*#* .##) 120=?0 $$H&

N#.' @0=$e*'t, e&+"e, /o"+$e +k+%

Pe*##(#* 15=$e*'t, te#t+, t'%e %e*##(#*

to#ko#.o$'*#"

S+)+ 9,5C>

Be#t #.#* 65 k&

T'*&&' #.#* 1@0 $


7/12

BMI 1? &'4' k+#*&

#. PEMERI!SAAN !EPALA DAN LE"ER

Pe(er)saan "as*

Ke%#"# No$o)e%#"', e*t+k +"#t, t'.#k te.#%#t

.eo$'t#(, #$+t )'t#$, "e#t, .'(t'+('

$e#t#, t'.#k $+.#) .'#+t

;#8#) Ek%e(' #8#) t#$%#k k)##t' ,('$et'(,

t#$%#k 'kte'k, t'.#k ke$e#)#*, %+#t,

t'.#k ('#*o('(

M#t# Ske"e# 'kte'k, ko*8+*&t'/# #*e$'(

H'.+*& T'.#k te.#%#t ke"#'*#* e*t+k, t'.#k #.#

.e/'#(' .e%t+$, ko*k# *o$#", t'.#k)'%ee$'(, t'.#k #.# (eet #t#+ .##)

B''

G'&' .#* &+('L'.#)

M+ko(# $+"+t .#* %#"#t+$

U/+"#, #'*&, .#* to*('"

T'.#k #.# ke"#'*#* e*t+k, '' %+#t,t'.#k

#.# ('#*o('(G+(' e#*# %+#t .#* t#$%#k #.#

%e.##)#* L'.#) *o$o&"o('#, e*t+k

*o$#", e#*# %+#t, t'.#k #.#

.eo$'t#(,"'.#) t'.#k ke'*& M+ko(#

$+"+t t#$%#k %+#t To*('" .#* +/+"#*o$#",t'.#k )'%ee$'(, +/+"# "et#k

.'te*), t'.#k t#$%#k %+"(#(', .'*.'*&

#'*& *o$#", t'.#k )'%ee$'( .e**

+k+#* T1=T1

Te"'* T'.#k #.# ke"#'*#* e*t+k, t'.#k #.# .##),

t'.#k #.# (eket, "'#*& te"'* "#%#*&,

$e$#* t'$%#*' t#$%#k '*t#k

B#+ *##( Feto )e%#t'k+$Le)e T'.#k te.#%#t ke"#'*##* e*t+k .#* +k+#*

KGB No$#", t'.#k #.# %e$e(##*

JVP 5 6 $ H2O

D. PEMERI!SAAN T"+RA!S


8/12

Pe(er)saan "as*

INSPE!SI

Be*t+k t)o#k( T#$%#k *o$#", ('$et'(, %#.# %oto**

$e"'*t#*& ee*t+k e"'%( .e**

%e#*.'** .'#$ete #*te'o %o(te'o.e** "#te#" 5!

T#$%#k (#$%'*& t'.#k te.#%#t k'o('(,

"o.o('(, .#* &'+(

T#$%#k e"#k#*& t'.#k t#$%#k (ko"'o('(

.#* &'+(

D'*.'*& .#.# K+"'t (#o $#t#*&, t#$%#k 'kte'k t#$%#k

(%'.e *e/', %#.# .#.# (ee"#) k'' te.#%#t

+"+ : +"+ )#"+( %#.# .#.# .#* ket'#k

Pe&e#k#* .'*.'*& .#.# (##t e*##( No$#", ('$et'(, t'.#k #.# )e$'t)o#k(

-#*& tet'*&", t'%e %e*##(#*

to#ko#.o$'*#"

B+#) .#.# B+#) .#.# $e*&e'"", t'.#k #.# e*8o"#*,

(e%#(#*& .#* ('$et'(

PALPASI

Pe&e#k#* *##( S'$et'( k#*#* .#* k'', t'.#k #.# -#*&

tet'*&"

Vo#" e$'t+( No$#", ('$et'( k#*#* .#* k'' (#$ k+#t

#'k .#.# $#+%+* %+*&&+*&

Ikt+( ko.'( Te## (et'*&&' I>S 51 $ $e.'#" "'*e#

$'. "#/'+"#'( k''

T)'"" T'.#k te## t)'"" .' 6 #e# k#t+% 8#*t+*&

S+.+t #*&+"+( (+o(t#e Me$e*t+k (+.+t 70C

PER!USI

Pe#*.'** ke.+# "#%#*& %#+ P#.# ke.+# "#%#*& %#+ .'.#%#tk#* +*-'

(o*o

B#t#( %#+ .#* )e%# T'.#k .#%#t .'te*t+k#* k#e*# )e%#

$e*&e'"

Pe#*8#k#* T'.#k .#%#t .'te*t+k#*

B#t#( %#+ .e** 8#*t+*& k#*#* Set'*&&' I>S 9


9/12

B#t#( %#+ .#* 8#*t+*& k'' Set'*&&' I>S 51 $ $e.'#" "'*e#

$'."#/'+"#'( k''

B#t#( #t#( 8#*t+*& Set'*&&' I>S 9 "'*e# %##(te*#"'( k''

.e** (+## e.+%

AUS!ULTASIP#+ S+## *##( t#ke#" %e#*.'** '*(%'#('

ek(%'#(' 1 ! 9, (+## *##( o*k'#" #'k

.#.# $#+%+* %+*&&+*& '*(%'#(' .#*

ek(%'#(' 1 ! 2, (+## *##( (+ o*k'#" #'k

.#.# $#+%+* %+*&&+*& '*(%'#(' .#*

ek(%'#(' 1 ! 1, (+## *##( /e('k+"e #'k

.#.# $#+%+* %+*&&+*& '*('%#(' .#*

ek(%'#(' 9 ! 1 T'.#k .#%#t (+## *##(

t#$#)#* (e%et' o*k', )e44'*&, (t'.o,

.#* #$o'k

J#*t+*& I#$# e&+""e, ek+e*(' @0=$e*+'t, +*-'

8#*t+*& I .#* II *o$#", .e** '*te*('t#(

+*-' 8#*t+*& I te.e* "e') k+#t %#.#

.#e#) k#t+% $'t#" .#* t'k+(%'. .#* +*-'

8#*t+*& II te.e* "e') k+#t %#.# k#t+%

#ot# .#* %+"$o*#", t'.#k te.#%#t +*-'

8#*t+*& III .#* IV, o%e*'*& (*#%, e8et'o*

('(to"'k (o+*., ('(to"'k "'k, .#* t'.#k

te.#%#t '('*&

E. PEMERI!SAAN ABD+MEN

P#('e* .'$'*t# +*t+k e#'*& .e** k#k' .'tek+k, 8'k# $e$#k#' 'k#t %'*&*& .'"e%#(k#*

Be+(#)# $e$+#t %#('e* '"ek( See"+$*-# .'t#*-# ke %#('e* #%#k#) (+.#) +#*& #'e(#, +#*& #' ke'" .#* $#k#* Se"#'* 't+ 8+ $e$'*t# %#('e* +*t+k $e$e'k#* e(%o*

%#.# (##t %e$e'k(##*

Pe(er)saan "as*


10/12

INPE!SI

Be*t+k #.o$e* B+*'t, te.#%#t (#&&'*& o t)e "#*k(

D'*.'*& %e+t .#* +$'"'k+( D'*.'*& te*&, k+"'t t#$%#k 'kte'k,

t#$%#k (%'.e *e/', te.#%#t ($'"'*&+$'"'k+(, t#$%#k .'"#t#(' /e*#

Ge#k .'*.'*& %e+t T'.#k .#%#t .'*'"#'

Ge#k %e'(t#"t'k .#* ##) T'.#k t#$%#k

AUS!ULTASI

B'('*& +(+( Me*&)'"#*&

Ate'#" +'t T'.#k #.#

Ve*o+( )+$ Te.e* /e*o+( )+$ %#.# e&'o

)'%oko*.'+$ k#*#*

PER!USI

Kee$%#t k+#.#* #.o$e* D#e#) $e.'#" te.e* t'$%#*', .#e#)

"#te#" te.e* e.+%

B#t#( ##) )e%# T'.#k .#%#t .'te*t+k#*

B#t#( #t#( )e%# T'.#k .#%#t .'te*t+k#*

S)'t'*& .+"*e((

PALPASI

S+%e'('#" $e*-e"++) Te#(# '&'.'t#(, t+&o k+"'t t'.#k .#%#t

.'*'"#'

N-e' tek#* .#* *-e' "e%#( N-e' tek#* %#.# )'%oko*.'+$ k#*#*

He%# T'.#k .#%#t .'"#k+k#*

Ve('# e""e# T'.#k .#%#t .'"#k+k#*

L'e* Me$e(#

G'*8#" #""ote$e*t T'.#k .#%#t .'"#k+k#*

A('te( +*.+"#('


11/12

'. PEMERI!SAAN E!STREMITAS

Pe(er)saan "as*

INSPE!SI E!STREMITAS ATAS

Be*t+k ek(te$'t#( No$#", ('$et'(, %o%o(' +k+#* te)#.#%

t++) %o%o('o*#", t'.#k te.#%#t

.eo$'t#(

K+"'t, k+k+, otot, .#* t+"#*& K+"+t t#$%#k 'kte'k, t#$%#k (%'.e *e/'

%#.# #)+ .#* "e** #t#($ ke.+# te"#%#k

t#** t#$%#k ke$e#)#*

Koo.'*#(' &e#k B#'k

PALPASI E!STREMITAS ATAS

K+"'t S+)+ *o$#" te## )#*t

Otot T'.#k #to', kek+#t#* otot 5=5, "#%%'*&

te$o =, te$o

Tugas Kkd Anamnesis Bab Hitam IPD

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