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Laporan Kasus
OlehMAYLINNA HAPSARI
PRATAMA, S.Ked
embimbing
dr. Silman Hadori, Sp.Rad,
MH.Kes
DEPARTEMEN RADIOLOGIFAKLTAS KEDOKTERAN NI!ERSITAS MALAHAYATIRS PERTAMINA "INTANG AMIN "ANDAR LAMPNG
#$%&
EFUSI PLEURASINISTRA
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IDENTIFIKASI PASIEN
Nama : Ny. JNo RM : 067208
Umur : 30 tahun
Aamat : M!"ar #ar$ tan%un& raya' M!#u%$
A&ama : I#am
P!"!r%aan : P!tan$
Statu# : M!n$"ah
Su"u (ana : Ja)a
Tan&&a Ma#u" RS : *0 M!$ 20*6 %am:*7.3+ )$,
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ANAMNESIS
ANAMNESIS : Aoanamn!#a
-!uhan Utama : S!#a" naa# yan!ma"$n m!m,!rat #!%a" 2 ,uanyan& au
-!uhan tam,ahan : (atu"' ,!n&"a"'!ma#
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/# atan& "! I1 RSP(A !n&an"!uhan #!#a" naa# yan& #!ma"$nm!m,!rat #!%a" 2 ,uan yan& au./# m!n&a"u #!#a" %$"a #!an&,!ra"t$$ta#. an #!#a" m!m,a$"#aat $#t$rahat. /# m!n&a"u #!r$n&t!r,an&un 4aa maam har$ "ar!na
#!#a". /# %u&a m!n&a"u #u$t untu"t$ur $"ar!na"an #!#a". /#m!n&a"u #!#a" t$a" $4!n&aruh$o!h 5ua5a an !mo#$. /# %u&a
m!nyan&"a aanya m!n&$. /# %u&am!n&a"u ,atu" ,!raha" #!%a" *m$n&&u yan& au. (atu" ,!raha",!r)arna 4ut$h "!nta an t$a"$#!rta$ arah. /# m!n&a"u aam
* "a$ ,atu" #!,anya" * #!no"
R
I'A
YAT
P
ENYAKIT
RI'AYAT PER(ALANANPENYAKIT
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!ma# #!h$n&&a %$"a o# $n&$n,!ra"t$ta# #!r$n& $,antu o!h"!uar&a. /# m!nyan&"a aanya
ny!r$ aa. /# %u&a m!nyan&"aaanya !mam' 4$!"' mua'muntah' 4u#$n&' ny!r$ 4$n&&an&an ny!r$ 4!rut. /# m!n&a"u na#uma"an m!nurun. /# %u&a m!n&a"u
,uan& a$r "!5$ an ,uan& a$r ,!#art$a" aa "!uhan. /# m!nyan&"aaanya 4!nya"$t arah t$n&&$'
%antun&' a#ma an $a,!t!#. /#
%u&a m!n&a"u $ "!uar&a o# t$a"aa yan& m!m$$"$ &!%aa atau4!nya"$t yan& #ama !n&an o#. /#
%u&a m!nyan&"a aanya a!r&$o,at. /# ,!um 4!rnah ,!ro,at#!,!umnya $"ar!na"an rumah o#
R
I'A
YAT
P
ENYAKIT
RI'AYAT PER(ALANANPENYAKIT
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R$)ayat a!r&$ o,at:
/# m!n&ata"an #!ama $n$ o# m$num o,at t$a" m!n$m,u"an
a!r&$.
R$)ayat P!nya"$t ahuu :
S!,!umnya o# ,!um 4!rnah m!n&aam$ "!uhan yan& #ama.
$4!rt!n#$ : 9
$a,!t!# M!$tu# : 9
A#ma : 9Jantun& : 9
R$)ayat P!nya"$t -!uar&a :
M!nurut o# $"!uar&a t$a" aa yan& m!n&!uh"an "!uhan #ama.
R$)ayat So#$a E"onom$ :
/# t$n&&a $ "am4un& ,!r#ama #uam$nya' o# ,!"!r%a #!,a&a$
4!tan$. Statu# !"onom$ : "uran&
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-!aaan Umum : Tam4a" #a"$t #!an&-!#aaran : ;om4o# m!nt$#
1;S : E
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STATUS 1ENERALIS
-!4aa
(!ntu" : Normo5!4ha$Ram,ut : $tam' t$a" muah ronto"
Mata : S"!ra norma "a>"$' "on%un&t$a an!m$# "a>"$
T!$n&a : Normot$a "a>"$
$un& : Normona#$' #!"r!t t$a" aa' !a#$ t$a" aaMuut : ($,$r norma' #$ano#$# t$a" aa' 4!o t$a"
aa
L!h!r
P!m,!#aran -1( : t$a" aa 4!m,!#aran
P!m,!#aran T$ro$ : t$a" aa 4!m,!#aran
J=P : t$a" aa 4!n$n&"atan
Tra5h!a : t$a" aa !$a#$
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Thora@
9 ;or
In#4!"#$: $5tu# 5or$# t$a" t!r$hat
Pa4a#$ : $5tu# 5or$# t$a" t!ra,aP!r"u#$
(ata# "anan ata# : I;S II $n!a 4ara#t!rna#$# !@tra
(ata# "$r$ ata# : I;S II $n!a 4ara#t!rna$# #$n$#tra
(ata# "anan ,a)ah : I;S I= $n!a 4ara#t!rna$# !@tra
(ata# "$r$ ,a)ah : I;S = $n!a m$5a$"uar$# #$n$#tra
Au#"uta#$ : (J I an II norma' r!&uar' murmur an &ao4 t$a"aa
Pumo
In#4!"#$: #tat$#' $nam$#' #$m!tr$# "anan an "$r$
Pa4a#$ : r!m$tu# #uara "anan norma' "$r$ m!!mah
P!r"u#$ : "anan #onor' "$r$ r!u4
Au#"uta#$ : #uara naa# !#$"u!r "anan norma' "$r$ !#$"u!rm!!mah' ron"$ 9 "anan an "$r$' )h!!B$n& 9 "anan an "$r$
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A,om!n
In#4!"#$ : atar' a5$t!# t$a" aa' ma##a
an %!%a# t$a" $t!mu"anAu#"uta#$ : ,$#$n& u#u# 4o#$t$
Pa4a#$ : Ny!r$ t!"an t$a" aa' h!4aran$!n t$a" t!ra,a
P!r"u#$ : t$m4an$ #!uruh a4an& a,om!n
E"tr!m$ta#
Su4!r$or : a"ra han&at an !!ma t$a"aa
In!r$or : a"ra han&at an !!ma "ananan "$r$
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IA1N/SIS -ERJA
Eu#$ P!ura S$n$#tra
IA1N/SIS (ANIN1
T( 4aru
PENATALA-SANAANFarma"oo&$ :
I RL C &tt>t4m
/2 3 $t!r > m!n$t
Am,ro@o #yr 3 @ * 5Furo#!m$ 2 @ * > $
L!oDo@a5$n * @ *
N!uro,$on * @ * > r$4
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PEMERI-SAAN PENUNJAN1
US1
Tora"o#$nt!#$#
S4utum (TA
PR/1N/SAuo a =$tam: u,$a a ,onam
uo a Fun&t$onam : u,$a a ,onam
uo a Sanat$onam : u,$a a ,onam
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PEMERIKSAAN PENN(ANGEMAT/L/1I
PEMERI-SAAN ASIL N/RMAL
!mo&o,$n ).*
L": *
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URINE
PEMERI-SAAN ASIL N/RMAL
Garna -un$n& -un$n&
-!%!rn$han J!rn$h J!rn$h
(!rat J!n$# *.020*.00+9*.030
4 6 +98
L!u"o#$t>!#$# 9 N!&at$ *0 !u"o>u
N$tr$t 9 N!&at$
Prot!$n %$$ N!&at$ H 30 m&>
1u"o#a 9N!&at$ H 30 m&>
-!ton 9 N!&at$ H +0 m&>
Uro,$$no&!n 9 N!&at$ H * m&>
($$ru,$n 9 N!&at$ H 2 m&>
arah Samar *$ N!&at$ H *0 !ry>
S!$m!n L!u"o#$t +96 *0 > LP(
Er$tro#$t %$-%# + > LP(
E4$t! (!,!ra4a
(a"t!r$ S!$"$t
-r$#ta 9
S$$n!r 9
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-IMIA ARA
PEMERI-SAA
N
ASIL N/RMAL
Ur!a 3* *09
;r!at$n$n *.2
L" : 0.?9*.+
m&>
Gn : 0.79*.3
m&>1ua arah
S!)a"tu*27
H 200 m&>
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Thora PA
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ECPERTISEPo#$#$ tra"!a $ t!n&ah
M!$a#t$num #u4!r$or t$a" m!!,arJantun& #u$t $n$a$' ,ata# "$r$ t!rtutu4 4!r#!u,un&an
S$nu# 5o#to4hr!n$5u# "anan norma' "$r$ t!rtutu44!r#!u,un&an
S$nu# 5ar$o4hr!n$5u# "anan norma' "$r$ t!rtutu4
4!r#!u,un&an$ara&ma "anan norma' "$r$ t!rtutu4 4!r#!u,un&an
Pumo:$u# "anan an "$r$ norma
;ora"an ,ron"oa#"u!r ,!rtam,ah
Tam4a" 4!r#!u,un&an o4a" homo&!n $ h!m$thora@ "$r$ ,a)ah-ran$a$#a#$ 9
S"!ta : aam ,ata# norma
KESAN /
E0us1 pleura 21r1
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RESUME
/# atan& "! I1 RSP(A !n&an "!uhan #!#a" naa# yan& #!ma"$n m!m,!rat #!%a" 2 ,uan yan& au. /#m!n&a"u #!#a" %$"a #!an& ,!ra"t$$ta#. an #!#a" m!m,a$" #aat $#t$rahat. /# m!n&a"u #!r$n& t!r,an&un 4aamaam har$ "ar!na #!#a". /# %u&a m!n&a"u #u$t untu" t$ur $"ar!na"an #!#a". /# %u&a m!n&a"u ,atu",!raha" #!%a" * m$n&&u yan& au. (atu" ,!raha" ,!r)arna 4ut$h "!nta an t$a" $#!rta$ arah. /# m!n&a"uaam * "a$ ,atu" #!,anya" * #!no" ma"an. /# m!n&a"u "!ua "a"$nya ,!n&"a". an o# %u&a m!n&a"u ,aant!ra#a !ma# #!h$n&&a %$"a o# $n&$n ,!ra"t$ta# #!r$n& $,antu o!h "!uar&a. /# m!n&a"u na#u ma"an
m!nurun. /# %u&a m!n&a"u ,uan& a$r "!5$ an ,uan& a$r ,!#ar t$a" aa "!uhan. . /# %u&a m!n&a"u $"!uar&a o# t$a" aa yan& m!m$$"$ &!%aa atau 4!nya"$t yan& #ama !n&an o#. /# ,!um 4!rnah ,!ro,at#!,!umnya $"ar!na"an rumah o# ,!raa $ "am4un& yan& $#ana t$a" aa o"t!r #!rta %auh ar$ "ota.
ar$ 4!m!r$"#aan #$" $a4at"an "!aaan umum 4a#$!n tam4a" #a"$t #!an&' "!#aaran 5om4o# m!nt$#!n&an 1;S *+.
Tana =$ta:
T!"anan arah: *?0 mm&' P!rnaa#an: 26 @>m!n$t' Na$: 6? @>m!n$t' Suhu: 36'30;.
Statu# "!4aa' !h!r' 5or' a,om!n !"#tr!m$ta# #u4!r$or aam ,ata# norma
Mata : -on%un&t$a an!m$# "a>"$
PumoIn#4!"#$: #tat$#' $nam$#' #$m!tr$# "anan an "$r$
Pa4a#$ : r!m$tu# #uara "anan norma' "$r$ m!!mah
P!r"u#$ : "anan #onor' "$r$ r!u4
Au#"uta#$ : #uara naa# !#$"u!r "anan an "$r$' ron"$ 9 "anan an "$r$' )h!!B$n& 9 "anan an "$r$
E"#tr!m$ta# $n!r$or : !!m > "anan an "$r$
a#$ a,orator$um :
,: 8'+
L!u"o#$t : *3200Mono#$t : *m!n$t' Na$: 6? @>m!n$t'Suhu: 36'30;.
Statu# "!4aa' !h!r' 5or'a,om!n !"#tr!m$ta##u4!r$or aam ,ata#normaMata : -on%un&t$a
an!m$# "a>"$PumoIn#4!"#$ : #tat$#' $nam$#'
#$m!tr$# "anan an "$r$Pa4a#$ : r!m$tu# #uara"anan norma' "$r$m!!mahP!r"u#$ : "anan #onor'"$r$ r!u4Au#"uta#$: #uara naa#!#$"u!r "anan an "$r$'
ron"$ 9 "anan an "$r$')h!!B$n& 9 "anan an
-!aaan umum : Pa#$!ntam4a" #!#a" naa#
T$n&"at "!#aaran :;om4o#m!nt$#
TT=RR : Ta"h$4n!aN : Ta"h$"ar$aS : J$"a aa $n!"#$ ,$#ah$4!rt!rm$a
T : ($#a h$4ot!n#$a
-!4aa : M!#o5h!4aMata : ;on%un&t$a an!m$#$un& : S!#a" naa#'5u4$n& h$un&aa : 1!ra"an4!rnaa#an ,!r"uran&Pumo 4aru94aru In#4!"#$ : T!r$hat !"#4an#$
aa #$m!tr$#' tam4a"#!#a" naa# tam4a"4!n&&unaan otot ,antunaa#Pa4a#$ : =o"a Fr!m$tu#m!nurunP!r"u#$ : P!"a"#"on$un!#' r!u4
Au#"uta#$ : (uny$ naa#m!n&h$an& atau t$a"
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Pas1en Teor1
P!m!r$"#aan P!nun%an& Po#$#$ tra"!a $ t!n&ahM!$a#t$num #u4!r$ort$a" m!!,ar
Jantun& #u$t $n$a$' ,ata#"$r$ t!rtutu44!r#!u,un&anS$nu# 5o#to4hr!n$5u#"anan norma' "$r$ t!rtutu44!r#!u,un&anS$nu# 5ar$o4hr!n$5u#"anan norma' "$r$ t!rtutu44!r#!u,un&an$ara&ma "anan norma'"$r$ t!rtutu44!r#!u,un&anPumo:
$u# "anan an "$r$norma
;ora"an,ron"oa#"u!r,!rtam,ah
Tam4a"4!r#!u,un&an o4a"homo&!n $h!m$thora@ "$r$,a)ah
-ran$a$#a#$ 9S"!ta : aam ,ata#
1am,aran !u#$ 4!ura4aa ra$o&ra tora"#4o#$#$ t!&a" aaah:
* 4!num4uan #$nu#"o#tor!n$"u# ,$a 5a$ran+00 m 4aa Foto PA'an 200 m 4aa otoat!ra2 M!n$#5u# #$&n3 #!rta 4!r#!u,un&anua# yan& mun&"$n$#!rta$ 4!noron&an
%antun& an m!$a#t$num.
a yan& a&a" ,!r,!a$%um4a$ 4aa 4o#$#$#u4$n! !n&an$t!mu"annya tana9
tana ra$oo&$" ,!ru4a:* 4!n$n&"atan !n#$ta#h!m$tora"# yan& t!r"!na2 M!n$#5u# #$&n3 h$an&nya ,ayan&anatau ,ata# h!m$$ara&ma
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A4$5a 5a44$n&
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KESIMPLAN/# atan& "! I1 RSP(A !n&an "!uhan #!#a" naa# yan&
#!ma"$n m!m,!rat #!%a" 2 ,uan yan& au. /# m!n&a"u
#!#a" %$"a #!an& ,!ra"t$$ta#. an #!#a" m!m,a$" #aat$#t$rahat. /# m!n&a"u #!r$n& t!r,an&un 4aa maam har$"ar!na #!#a". /# %u&a m!n&a"u #u$t untu" t$ur $"ar!na"an#!#a". /# %u&a m!n&a"u ,atu" ,!raha" #!%a" * m$n&&uyan& au. (atu" ,!raha" ,!r)arna 4ut$h "!nta an t$a"$#!rta$ arah. /# m!n&a"u aam * "a$ ,atu" #!,anya" *#!no" ma"an. /# m!n&a"u "!ua "a"$nya ,!n&"a". an o#%u&a m!n&a"u ,aan t!ra#a !ma# #!h$n&&a %$"a o# $n&$n,!ra"t$ta# #!r$n& $,antu o!h "!uar&a. /# m!n&a"u na#uma"an m!nurun. /# %u&a m!n&a"u ,uan& a$r "!5$ an,uan& a$r ,!#ar t$a" aa "!uhan. . /# %u&a m!n&a"u $
"!uar&a o# t$a" aa yan& m!m$$"$ &!%aa atau 4!nya"$tyan& #ama !n&an o#. /# ,!um 4!rnah ,!ro,at#!,!umnya $"ar!na"an rumah o# ,!raa $ "am4un& yan&$#ana t$a" aa o"t!r #!rta %auh ar$ "ota.
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ar$ 4!m!r$"#aan #$" $a4at"an "!aaan umum 4a#$!n tam4a" #a"$t #!an&'"!#aaran 5om4o# m!nt$# !n&an 1;S *+.
Tana =$ta:
T!"anan arah: *?0 mm&' P!rnaa#an: 26 @>m!n$t' Na$: 6? @>m!n$t' Suhu:36'30;.
Statu# "!4aa' !h!r' 5or' a,om!n !"#tr!m$ta# #u4!r$or aam ,ata# norma
Mata : -on%un&t$a an!m$# "a>"$
Pumo
In#4!"#$: #tat$#' $nam$#' #$m!tr$# "anan an "$r$
Pa4a#$ : r!m$tu# #uara "anan norma' "$r$ m!!mah
P!r"u#$ : "anan #onor' "$r$ r!u4
Au#"uta#$ : #uara naa# !#$"u!r "anan an "$r$' ron"$ 9 "anan an "$r$' )h!!B$n&9 "anan an "$r$
E"#tr!m$ta# $n!r$or : !!m > "anan an "$r$
a#$ a,orator$um :
,: 8'+
L!u"o#$t : *3200
Mono#$t : *