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LAPORAN KASUSSEORANG PRIA USIA 39 TAHUNDENGAN SESAK DAN BENGKAKSELURUH TUBUH
Ranny Setia Ramadhanti
406151010
ILMU PENYAKIT DALAM
RS. !AYAN"KARA
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Identitas Pasien
Nama Pasien Tn. P A
Umur 39 tahun
Alamat Semarang Tengah
Jenis Kelamin Pria
Pekerjaan Wiraswasta
Agama Islam
Status Pernikahan Menikah
N. !M 14#0$#106%$$
Tanggal Masuk "3 Mei #"$%
Nama &kter d&. 'idi (diant) S*.PD
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Anamne+i+
Ke,(han Utama -
Se+a
Ri/ayat Penyait Sea&an
Pa+ien datan denan e,(han +e+a +ea +ema,am SMRS2
+e+a di&a+aan 3e&tam3ah 3e&at dan tida mem3aietia i+ti&ahat
Pa+ien (a mena,ami *em3enaan dan a( di+e,(&(h t(3(h 6 3(,an ini2 3(,an ini tida 3i+a a,an2 $3(,an ini tam3ah mem3e&at2 1 3(,an ini ,(a di aime,e*(h2 m(a, dan m(ntah di+ana,
Pem3enaan di m(,ai da&i ai +e3e,ah i&i $ 3(,an yan,a,( dan $ min( em(dian mena,a& e ai +e3e,ahanan di i(ti +&)t(m em(dian ,enan +e3e,ah anan dani&i
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Riwayat Penyakit Dahulu
Ri/ayat enin mani+ +ea 10 tah(n dan tida te&)nt&),2
&i/ayat da&ah tini di+ana,
Riwayat Penyakit Keluara
Ri/ayat enin mani+ ada dan teanan da&ah tini
di+ana,
A!u"an nutri!i #an ke$ia!aan
Na7+( maan men(&(n
Me&)) dan min(m )*i 89: Pa+ien +(a maan maanan mani+2 7a+t 7))d
Tida +(a ),ah&aa dan min(m )3at dm tida te&at(&
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Peme&i+aan ;i+i
Pe%erik!aan U%u% -
Keadaan Um(m - Tam*a +ait+edan
Ke+ada&an - <)m*)+ menti+ Tanda#tanda =ita,
Teanan Da&ah - 1$0>?0 mm!
Nadi - 11%@> menit2&e(,e&2i+i ((* Pe&na7a+an - @> menit2 &e(,e&
Sat(&a+i - ?B
S(h( A@i,,a - $625
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Pe%erik!aan Si!te% &
Ke*a,a - n)&m)he*a, Ram3(t - 'a&na hitam2 *e&+e3a&an me&ata2 dan tida m(dah
dia3(t Mata - K)n(ntiCa anemi+ 9>92 +,e&a ite&i 9>9
!id(n - Simet&i+2 +e&et #>#2 deCia+i +e*t(m 8#:2 na7a+ (*in hid(n8#:
Te,ina - N)&m)tia2 +e&et #>#
M(,(t dan Ten)&) - i3i& - +imet&i+
Lidah - +imet&i+ UC(,a - di tenah
T)n+i, - ((&an T1>T12 tenan2 tida hi*e&emi+
;a&in - tida hi*e&emi+
Lehe& -Simet&i+2 DeCia+i t&ahea 8#:2 a( (d( 8#:
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K" - D3N
A3d)men- <em3(n2 S(*e,2 U 8#:2 A+ite+89:
Pa&( - In+*e+i- +imet&i+
Pa,*a+i - tida te&a3a 3en),an2 +tem7&emit(+ +ama (at
Pe&(+i - *ea *ada ed(a ,a*an *a&(
A(+(,ta+i - Ce+i(,e& 89>9:2 3&)nia, 89>9:2/heein 8#>#:2 &)ni 89>9:
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E+t&emita+-
Lenan - a&a, dinin 8#>#:2 edem 89>9:
T(nai - a&a, dinin 8#>#:2 edem 89>9:
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Peme&i+aan Pen(nan
La3)&at)&i(m 8hemat),)i2 (&ina,i+a2im(n)#+e&),)i2 imia ,ini:
Radi),)i
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!emat),)i
NA'A PE'ERIKSAAN HASIL ANGKA NOR'AL SATUAN
HEMATOLOGI
!emat)&it #9'" 40#50 B
M<= 626 0#?% m$
M<! 21 625#$$25 *
M<!<$24
$125#$520 >d,
RD' 142$ 1020 +.d 1520 B
MP= ('9 625 +.d 1120 m$
PD' )') 1020 +.d 120 B
!em),)3in ?24 * 1$20 F 120 >d,
E&it&)+it $2$5* 4.5#5.5 G(ta>mm$
T&)m3)+it ?$.000 1502000#4002000 >mm$
Le()+it 5.100 4.000#11.000 >mm$
$ Mei 016
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$ mei 016
I'UNOLOGI(SEROLOGI
Ha!il Anka n)r%al Satuan
!3+A Neati7 Neati7 #
KIMIA KLINIK
U&e(m ?521 10#50
K&eatinin 2$ 026#12$
* 'ei +,-.
Kimia K,ini !a+i, Ana n)&ma,
T)ta, P&)tein 5215 62 +.d 24
A,3(min 25 $25#525
",)3(,in 26$ 12$ +.d $2$
"(,a da&ah
+e/at(
6? %0#115
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& na +ama&)+)*i+05 mei
016/arna Kunin Kunin
Kee&(han Ke&(h Ge&nih
P! 5.0 42#%24
e&at Geni+ 1.00 1.015 +.d 1.05
",()+a Neati7 Neati7
Ket)n Neati7 Neati7
i,i&(3in Neati7 Neati7
U&)3i,in)en Neati7 Neati7
E&it&)+it 5#10 0#1
Le()+it 4# 0#$
Nit&it Neati7 Neati7 K&i+ta, Neati7 Neati7
ate&i Neati7 Neati7
Gam(& Neati7 Neati7
P&)tein $9 Neati7
E*ite, S(am)+ #4 Neati7
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Kimia K,ini 05 Mei 016
K)le!ter)l -,9 01+,,
"(,a da&ah+e/at(
61 %0#115
T&i,i+e&ida 6 H00
!DL ),e+te&), ?2 J$5
LDL ),e+te&), 6526 HJ1$0
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!emat),)i
NA'A PE'ERIKSAAN HASIL ANGKA NOR'AL SATUAN
HEMATOLOGI
!emat)&it ##'9 40#50 B
M<= ?21 0#?% m$
M<! 20 625#$$25 *
M<!< $124 $125#$520 >d,
RD' 142 1020 +.d 1520 B
MP= )'# 625 +.d 1120 m$
PD' )'% 1020 +.d 120 B
!em),)3in %2 * 1$20 F 120 >d,
E&it&)+it 25%* 4.5#5.5 G(ta>mm$
T&)m3)+it %.000 1502000#4002000 >mm$
Le()+it %.00 4.000#11.000 >mm$
6 Mei 016
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Kimia ,ini
. 'ei +,-. Ha!il Anka n)r%al
U&e(m 10%2% 10#50
K&eatinin $206 026#12$
"(,a Da&ah Se/at( 15 %0#115
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!emat),)i
NA'A PE'ERIKSAAN HASIL ANGKA NOR'AL SATUAN
HEMATOLOGI
!emat)&it #+'" 40#50 B
M<= %26 0#?% m$
M<! %24 625#$$25 *
M<!< $12$ $125#$520 >d,
RD' 142$ 1020 +.d 1520 B
MP= )'$ 625 +.d 1120 m$
PD' )') 1020 +.d 120 B
!em),)3in %25* 1$20 F 120 >d,
E&it&)+it 2%4* 4.5#5.5 G(ta>mm$
T&)m3)+it %5.000 1502000#4002000 >mm$
Le()+it %.000 4.000#11.000 >mm$
% Mei 016
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Kimia ,ini
2 'ei +,-. Ha!il Anka n)r%al
U&e(m 10%2% 10#50
K&eatinin $206 026#12$
"(,a Da&ah Se/at( 15 %0#115
T)ta, P&)tein 42?4 62#24
A,3(min 26% $25#525
",)3(,in 2% 12$#$2$
M i 016
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!emat),)i
NA'A PE'ERIKSAAN HASIL ANGKA NOR'AL SATUAN
HEMATOLOGI
!emat)&it #,'# 40#50 B
M<= 426 0#?% m$
M<! %2? 625#$$25 *
M<!< $2? $125#$520 >d,
RD' 142$ 1020 +.d 1520 B
MP= )'$ 625 +.d 1120 m$
PD' 9'$ 1020 +.d 120 B
!em),)3in 2$* 1$20 F 120 >d,
E&it&)+it 2?* 4.5#5.5 G(ta>mm$
T&)m3)+it $.000 1502000#4002000 >mm$
Le()+it %.000 4.000#11.000 >mm$
Mei 016
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G(m,ah (&ine yan e,(a&
. %ei +,-. .,, 4 5,, 4*,,
-5,,
% mei 016 600 F 500 F 400
1500
mei 016 600 F $50 F 400
1$50 >4 am
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Dian)+i+ Ke&a
<KD
Edema ana+a&a
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Dian)+i+ andin
Ne7&)*ati DM
Sind&)m Ne7&)ti
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Renana Te&a*i N)n#;a&ma),)i+
I+ti&ahat yan ((*
!em)dia,i+a
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Peme&i+aan US" a3d)men
<h),e+i+t),ithia+i+ 8((&an +eita& 124m:
Ne7&),ithia+i+ anan 8+eita& 12m:
Peninatan e)eni+ita+ )&te+ *ada ed(a
ina, 8+e+(ai &en3&ide 1:
am3a&an*&)+e+ &)ni+
Si+titi+
A+ite+
E7(+i *,e(&a d(*,e+ Ta tam*a e,ainan *ada +)n)&a )&an
int&aa3d)men diata+
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;)t) th)&a@ AP
<)& 3nt( dan ,eta n)&ma,
"am3a&an edema *(,m)
E7(+i *,e(&a d(*,e+
R T i
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Renana Te&a*i;a&ma),)i+
In7(+ RL a+net
In. <e7t&ia@)n >1am
In.;(&)+emide>1am
In. Om>4am In. Ondan+ent&)n
m>am
Ka,i(m a&3)nat
$@1 I&3e+a&tan
1@50m
ISDN $@10m
A+am 7),at 1@1 Amin)&a, $@1
<anna $@a
In6ek!i Oral
T i di I<U t , 6 ? i
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Te&a*i di I<U t, 6#? mei016
In7(+ a+e&in
a+net In e7t&ia+)n I>1 am
In ;(&)+emid I> am
In Om>4 am
In Ondan m> am
O na+a, $#5 ,*m
Dan t&an+7(+i PR< 1 ),7 P&emed
7(&)+emid 1 am*
7a7O 3 38-
Ir$e!artan -5, % -8-
A!a% )lat -8-
A%in)ral 38-
7anna 38+
Latula! !yru" 38- ISDN -, % 38-
In6ek!i Oral
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Renana ECa,(a+i
K)nt&), dan m)nit)& Tanda#tanda Cita,
Teanan da&ah
;&e nadi
;&e *e&na7a+an
S(h(
Keadaan (m(m - e+ada&an
La3)&at)&i(m 8hemat),)i2 im(n)#+e&),)i2 imia ,ini:
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Ed(a+i
Mem3e&ian in7)&ma+i menenai - I+ti&ahat ti&ah 3a&in
K(&ani maan maanan a+in2 maanan
mani+ dan 7a+t 7))d Menaa e((*an a+(*an ai&an 3ata+i
min(m
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P&)n)+i+
() ad Citam - d(3ia ad ma,am
() ad +anati)nam - d(3ia ad ma,am
() ad 7(nti)nam - d(3ia ad ma,am
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TERIMA KASI!