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7/23/2019 Cbd Daksha
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GEDE
CASE BASED
DISCUSSION
I GEDE KRISHNAMAHAYAYANA1102005153DAKSHAYANI VIJAYAN1102005194
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Identitas Pasien
Nama I!P!
"m#$ %9 &a'#n
Jenis Ke(amin )a*i+(a*i
Ke,a$-ane-a$aan Ind.nesia A(amat Ja(an -#n#n- !at#$ G-/Sa(a i N. 1
ds$
A-ama Hind#
Pendidi*an +
Stat#s Pe$*a,inan Meni*a'
a*t# MRS 1053015
&-( Peme$i*saan 1052015
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Anamnesis
Ke(#'an "tama Ne$i dada
Ri,aat Pena*it Se*a$an-
Pasien $#6#*an da$i $#ma' sa*it ,an-aa men-e(#' ne$i dada ada di 7a'a-ian *i$i Ke(#'an te$se7#t di$asa*an se6a* 5 6am se7e(#m mas#*
$#ma' sa*it semasa asien sedan- tid#$
ne$i dada di$asa*an te$tindi' 7enda 7e$at
Ne$i di$asa*an men6a(a$ *e (en-an *i$i dan $a'an- asien
Ke(#'an 7e$de7a$8+: *e$in-at din-in8+: m#a( m#nta'8+:sesa* 8;/
Ke(#'an sesa* tida* mem7ai* den-an e$#7a'an .sisi/
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Anamnesis
Riwayat Penyakit Terdahulu
Pasien memi(i*i ena*it 6ant#n- den-an $i,aat e$a,atan di$#ma' sa*it 1/5 7#(an an- (a(# *a$ena *e(#'an ne$i dada an-sama see$ti saat ini /Pasien 6#-a memi(i*i $i,aat 'ie$tensise6a* 5 ta'#n an- (a(#
Riwayat Pengobatan
Di R#ma' Sa*it an-aa :asien tida* mendaa$*an en-.7atan
Riwayat Penyakit Keluarga
'ie$tensi: *en
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&anda Vita(Keadaan #m#m sa*it sedan-
Gi=i .m.s Mentis
G>S 15
&e*anan Da$a'150100 mmH-
S#'# a*si(a 3% >
Nadi ?@menit
Resi$asi 20 @menit
Sat#$asi *si-en 100B ada 2nasa( *an#( 2 (m
!e$at 7adan 50 *-
&in--i 7adan 1%0
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Pe!erikaan U!u!
Mata >.n6#n
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Thora#
Pe$-e$a*an dada simet$is
$antung
In%eki I*t#s *.$dis n.$ma( 8tida* te$(i'at:#(sasiae@
Pal%ai I*t#s *.$dis n.$ma(: &'$i(( 8+
Perkui !atas Atas I>S II !atas !a,a' I>S V
!atas Kanan PS) De@t$a
!atas Ki$i 3
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Paru
Inse*si simet$is saat statis dandinamis: $et$a*si 8+
Pa(asi ta*ti( C$emit#s n.$ma(
Pe$*#si s.n.$s.n.$ A#s*#(tasi esi*#(e$: $'.n*i 8++:
,'ee=in- 8++
+
+
+
+
+
+
-
-
-
-
-
-
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Abdo!en
Inse*si Distensi 8+
A#s*#(tasi !isin- #s#s 8; n.$ma(
Pe$*#si &imani: s'iCtin-d#((ness 8+
Pa(asi Ne$i *et.* >VA 8+:7a((.tement 8+: 'ati: (ien tida*te$a7a
Ektre!ita a*$a( 'an-at: .dema8+: 6a$i ta7#'8+
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PE&ERIKSAAN PENUN$AN'
EK'
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EKG
Inter%retai (I$ama Sin#s HR 0@menit:a@is n.$ma(: -e(.m7an- P n.$ma(: inte$a(PR 0:20 di ii:iii:aVF:V4 : *.m(e*s RS 0:12 s : RSR V1: RV5: SV1 35
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T)ORA* P)OTO +,-./0.1/,02
F.t. &'.$a@ AP
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>.$ 7esa$ dan 7ent#* esan n.$ma( :tama**a(si*asi a.$ti< *n.7
P#(m. ta* tama* in(t$ate
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3aboratoriu!
Para!eter )ail Satuan NilaiRu4ukan Re!ark
5BC %/?0 103) 4:10 11:0
6Ne ?0/3 B 4? 0
63y 14:5 B 13 40
6&o 9:?4 B 2:0 11:0
6Eo 3:30 B 0 5:0
6Ba 2:25 B 0 2:0
RBC 3:99 10%) 4:5 5:9 Renda'
)'B 12:? -d) 13:5 1?:5 Renda'
)CT 3?: B 41 53 Renda'
&C7 94:? C) 0:0 100:0&C) 31: -d) 2%:0 34:0
&C)C 33:5 -d) 31:0 3%:0
P3T 23% 103) 150 440
Darah 3engka% +,-.0.1/,02
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KI&IA K3INIK +,-./0.,02
3aboratoriu!
Para!eter )ail Satuan Nilai Ru4ukan Re!ark
Natriu! +Na2 135 mm.() 13%+145 Renda'
Kaliu! +K2 4:4 mm.() 3:5+5:10
S'OT 35:2 ") 11+33 &in--i
S'PT 24:1 ") 11:00+50:00
Albu!in 3:5% -d) 3:40+4:0
BUN 12 m-d) :00+23:00
Creatinin 1:2 m-d) 0:?0+1:20 tin--i
CK&B &aa :41 I"m) 0+5:00 &in--i
Tro%onin T 50+100 n-m)50Lne-atiC: 50+100L(.,:
100LAMI
&in--i
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)e!otai +,-.0.,02
3aboratoriu!
Para!eter )ail Satuan NilaiRu4ukan Re!ark
PTT 10:3
n.$ma(+Le$7edaan den-an
*.nt$.( 2 deti*
INR 0/95 deti*
Kotrol PTT 9:9 deti*
APTT 41:9 deti*N.$ma(Le$7edaan den-an
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Diagnoi
S&EMI InCe$i.$ Ki(i 1
1/&IMI 514
2/nset 5 6am Hie$tensi st 1
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&e$ai
IVFD NS tm
2 nasa( *an#( (m
Aset.sa( 1 @ 0 m-
>(.id.-$e( 1 @ ?5 m-
Simastatin 1 @ 20 m- !is.$.(.( 1 @ 2:5 m-
>at.$i( 3 @ 12:5 m-
Dia=eam 3 @ 5 m-
)a@adn s$ 3 @ >I ISDN 5 m- S)
St$etase 1:5 6#ta #nit
Hea$in 7.(#s 3000 #nit Ld$i %00 #nit6am
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P(annin-
)iid $.(e
E.$.na$ an-i.-$a'M.nit.$in- *e(#'an /ita( si-n dan
7a(an