Lapjag 7 Maret Devia

8/18/2019 Lapjag 7 Maret Devia

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LAPORAN JAGA7 MARET 2016


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KASUS 1


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IDENTITAS

• Nama : Nn. M

• Usia : 18 !

Anamn"sa #i$a%&%an s"'a(a a&)anamn"sa #i IGD

RSUS *&%&$ 1+.00 ,I-


4/29

ANAMNESA

• KU : N"(i *"(& %anan /aa! s"a% 1 !a(i

SMRS.

• RPS : N"(i *"(& %anan /aa! s"a% 1 !a(iSMRS aa$na #i(asa%an #i s"$&(&! $a*an3

*"(& %"mian /"(*in#a! %" *"(& %anan

/aa!. D"mam 45 m&a$ 45 m&na! 4

s"/ana% 2. -A-9-AK i#a% a#a %"$&!an.

• Riaa a$"(3i 45 )*"(asi 45


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PEMERIKSAAN ISIK

• K"a#aan &m&m : am*a% sa%i s"#an3

• K"sa#a(an : ')m*)s m"nis

• Tan#a ; an#a 9m"ni

RR : 1+9m"ni

S&!& : ?6.6)@S*O2: +8


6/29

STATUS GENERALIS

• K"*a$a : #/n

• Maa : is)%)( ?mm9?mm. R@ 9 @A595 SI 595

• Jan&n3 : S1S2 ("3&$"(

• Pa(& : B"s 9

• E%s("mias : a%(a$ !an3a @RT C2 #"i%.


7/29

STATUS LOKALIS

• a9( a/#)m"n :

Ins*"%si : am*a% #aa(

A&s%&$asi : -U 4

Pa$*asi : S&*"$. N"(i "%an #i RU M'-&(n"

4 *s)as 45 )/&(a)( 45

P"(%&si : im*ani


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LA-ORATORIUM

Result Reference Range

Full Blood Count

="m)3$)/in 1?.?0 11.7051>.>0

="ma)'(i ?8.6 ?>.0057.00

E(!()'" .6+ ?.805>.20

,!i" /$))# '"$$ 21.6> ?.60511.00

P$a"$" ')&n ?61.80 1>0.0050.00

PT 10.+0 +. ; 11.?

APTT ?1 ?157MCV, MCH, MCHC

M@B 81.>0 80.005100.00

M@= 28.80 26.005?.00

M@=@ ?.60 ?2.005?6.00


9/29


Biochemistry

SGOT 4AST 1 >5?

SGPT 4ALT 7 05>>

U("&m 17 C>0

@("ainin" 11.1 0.>51.1

U(i' A'i# ?.00 2.656.0

-$))# Ran#)m G$&')s" +2 C200

Electrolyte

Na 1?8 1?751>

K ?.+ ?.65>.0

@$ 101 +85107


10/29

T=ORAF

K"san :

@)( #an *&$m) i#a%

am*a% %"$ainan


11/29

USG A-DOMEN

K"san :

Tam*a% s(&%&( &/&$"(

/&n& #i ("3i) M'-&(n"

#"n3an &%&(an 95

0.+'m #"n3an #in#in3

m"n"/a$ #an "#"ma

#is"%ia(na s&33"si

a**"n#i'iis a%&H )(3an

in(a/#)m"n $ainna#a$am /aas n)(ma$.


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DIAGNOSIS

• A**"n#isiis a%&


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TATA LAKSANA

• IBD RL >00m$ 9 8am

• K)ns&$ S*- :

• @"(ia)n" 2 3(

• A**"n#"')m


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TEMUAN OPERASI

• Di"m&%an :

A**"n#i $"a% ("()'a"'a$ "#"ma)&s !i*"("mis

"(&ama #i #isa$ #"n3an i/(in ; i/(in #is"%ia(

a**"n#i "'a$i! 19? "n3a! *&s 45.


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KASUS 2


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IDENTITAS

• Nama : N. N

• Usia : !

Anamn"sa #i$a%&%an s"'a(a a&)anamn"sa #i IGD

RSUS *% 1+.2> ,I-


17/29

ANAMNESA

• KU : N"(i #i #"%a $&/an3 an&s %anan s"a% 7 !a(i

SMRS

• RPS : n"(i #i #i #"%a $&/an3 an&s %anan s"a% 7!a(i SMRS. N"(i #i(asa "(&s m"n"(&s "(&ama

i%a -A- s%a$a n"(i 8910. D"mam 4 m&a$9m&na!

45 -A- 4 #a(a! 45 $"n#i( 4. -AK 4.

• Sa! *"(na! /"()/a s"/"$&mna %" *)$i /"#a!

#an #isa(an%an &n&% #i$a%&%an USG *"(iana$.


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• Riaa =T 45

• Riaa DM 45

• Riaa an&n3 4 SBT *"(/ai%an

• Riaa )*"(asi 45

• Riaa a$"(3i 45


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PEMERIKSAAN ISIK

• K"a#aan &m&m : am*a% sa%i s"#an3

• K"sa#a(an : ')m*)s m"nis

• Tan#a ; an#a


20/29

STATUS GENERALIS

• K"*a$a : #/n

• Maa : is)%)( ?mm9?mm. R@ 9 @A595 SI 595

• Jan&n3 : S1S2 ("3&$"(

• Pa(& : B"s 9

• E%s("mias : a%(a$ !an3a @RT C2 #"i%.


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STATUS LOKALIS

a9( *"(iana$ #"(a

Ins*"%si : am*a% #a"(a! *"(iana$ #"(a

!i*"("mis "#"ma)&s

Pa$*asi : "(a/a !an3a %"(as NT 4 $&%&asi 45


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LA-ORATORIUM

Result Referece Range

Full Blood Count

="m)3$)/in 1?.0 11.7051>.>0

="ma)'(i ?+.?0 ?>.0057.00

E(!()'" . ?.805>.20

,!i" /$))# '"$$ 22.08 ?.60511.00

-9E9-9S9L9M 0919?97791198

P$a"$" ')&n +?.00 1>0.0050.00

ESR >0 0520MCV, MCH, MCHC

M@B 88.>0 80.005100.00

M@= ?0.20 26.005?.00

M@=@ ?.60 ?2.005?6.00


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Biochemistry

SGOT 4AST 17 >5?

SGPT 4ALT 2 05>>

U("&m 22 C>0

@("ainin" 0.6+ 0.>51.1

PT 11 +.511.?

APTT ?1 ?157

-$))# Ran#)m G$&')s" +7 C200Electrolyte

Na 1?+ 1?751>

K ?.7 ?.65>.0

@$ ++ +85107


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T=ORAF

K"san :@)( #an *&$m)

i#a% am*a%

a#ana

%"$ainan


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USG SOT

TISSUE

USG S) iss&"

*"(iana$ #"(a :

Tam*a% $"si

!i*)"'!)i' !""()3"n

#"n3an in"(na$ "'!)

#i#a$amna /aas

i#a% "3as &%&(an 95

2.72 2.>1 'm.K"san : s"s&ai

#"n3an 3am/a(an

a/s"s *"(iana$ #"(a


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DIAGNOSIS

• A/s"s *"(iana$ #"(a

• S"*sis


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TATALAKSANA

• IBD RL >00m$ 9 8 am

• K")()$a' ?0m3

• K)ns&$ S*- :

@"(ia)n" 23(

M"()ni#a)$" ?>00m3

Insisi #(aina3" #"/(i#"m"n


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=ASIL OPERASI

• Di"m&%an *&s s"/ana% 95 >0'' #"n3an

()n33a a/s"s m"n'a*ai s&*(a$"


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TERIMA KASI=

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Lapjag 7 Maret Devia