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FAKULTAS KEDOKTERAN UKRIDA

(UNIVERSITAS KRISTEN KRIDA WACANA)

Jl. Terusan Arjuna No. 6 Keon Jeru! " Ja!ar#a $ara#

KE%ANITERAAN KLINIK

STATUS IL&U %EN'AKIT DALA&

FAKULTAS KEDOKTERAN UKRIDA

ar * Tan++al Ujan * %resen#as Kasus, -----

S&F %EN'AKIT DALA&

RU&A SAKIT, RSUD Tara!an

Naa

NI&

, Dee Cn#/a De0

, 112314154

Tana Tan+an

---------

Dr. %en+ , r. S/rl7 S8.%D

---------

IDENTITAS PASIEN

Naa Len+!a8, Tn. K No.R&, 3129:6;3

Jens Kelan, La! en7ea!an 8asen sul# a!an> sul# uan+ ar esar se/n++a enja leas.

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B. PEMERIKSAAN FISIK

Pemeriksaan umum

Keaaan Uu , Ta8a! sa!# sean+

Kesaaran , Co8os en#s

Te!anan ara/ , 113*:3 +

Na , =3*en#

Su/u , ;6>:oC

%erna8asan (@re!uens an #8e) , 22*en# #8e aono#ora!al

Ke8ala , Noro?e8/al> s#rus rau# era#a.

&a#a , Konjun+#Ba anes (*)> s!lera !#er! (*).

Teln+a , Noro#a> seruen ( se!re# ( @arn+ #a! /8eres> se!re# ( #a! aa !ares en#s.

Le/er , Kelenjar +e#a/ enn+ an #ro #a! #eraa eesar.

2

De8an $ela!an+

Ins8e!s Kr

Kanan

Se#rs

Se#rs

Se#rs

Se#rs

%al8as Kr

Kanan

$enjolan ( n7er #e!an (


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T/ora , Ta! #eraa enjolan a#au assa.

%aru ,

Dada:

Jantung

Ins8e!s Ta! #erl/a# ?#us ?ors

%al8as I?#us ?ors #eraa lnea ?laB?ulars !r sela

+a 4%er!us $a#as a#as jan#un+ #erle#a! lnea s#ernals !r sela

+a 2

$a#as 8n++an+ jan#un+ #erle#a! lnea 8aras#ernal

!r sela +a ;

$a#as !r jan#un+ #erle#a! 2 jar la#eral lnea

?laB?ulars sela +a 4

$a#as !anan jan#un+ #erle#a! lnea s#ernals !anan

sela +a 4

Aus!ul#as Ka#u8 #ral #eren+ar re+ular urn> $J1$J2> #a!

aa urur> #a! aa +allo8

Ka#u8 #r?us8 #eren+ar re+ular urn> $J1$J2>

#a! aa urur> #a! aa +allo8

Ka#u8 8ulonal #eren+ar re+ular urn> $J2$J1>

#a! aa urur> #a! aa +allo8

Ka#u8 aor#a #eren+ar re+ular urn> $J2$J1> #a!

aa urur> #a! aa +allo8

Perut

Ins8e!s , Da#ar> #a! aa e!as o8eras> #a! aa enjolan.

%al8as , N7er #e!an () e8+as#ru an /8o!onru !anan> ur8/7

s+n ( n7er CVA (


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Aus!ul#as , $sn+ usus ()> #a! enn+!a#.

E!s#re#as , A!ral /an+a#> e!s#re#as a#as an a0a/ #a8a! !#er!.

Kul# , I!#er! ().

Kes8ulan %eer!saan Fs!,

S!lera !#er!> !ul# #uu/ !#er!> e!s#re#as a#as an a0a/ #a8a! !#er!> n7er #e!an

() 8aa e8+as#ru an /8o!onru !anan.

LABORATORIM DAN PEMERIKSAAN PENNJAN! LAINN"A

#emat$%$gi &'()*+

Dara, Rutin

eo+lon 14.4 +*L 1;.3


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#emat$%$gi &' Okt$4er '()*+

Dara, Rutin

eo+lon 14.3 +*L 1;.3


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&a!ros!o8s Urn

Warna

Kejern/an

$era# Jens

8

%ro#en Urn

Reu!s

Ke#on

Dara/ Saar

$lrun

Urolno+en

N#r#

Leu!os#

Kunn+

Jern/

1.339

:.3

Ne+a#@ (


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Kalu (K) /* EH*L ;.6


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Kes8ulan %eer!saan La,

, 1;.3 +*L> #, ;:.6G> Er#ros#, 4.:= ju#a*µL> Leu!os#, 12.333*;> Troos#

;62.333*;> DS, 144 +*L> Ureu, 19 +*L> Krea#nn, 3.59 +*L> AST (SOT) 43

U*L> ALT (S%T) =6 U*L> $lrun To#al 15.12 +*L> $lrun Dre! 1=.4: +*L> $lrun

Inre! 3.21 +*L> Alun ;.=1 +*L> aa T 264.3 U*L> Al!al Fos@a#ase 14= U*L> Na

1;9 EH*L> K ;.= EH*L> Klora 55 EH*L> Warna urn !unn+> Kejern/an urn a!.

&!ro!o8! urn noral.

Fo#o Ron#+en T/ora, (34 O!#oer 2319)

&RI &RC% en+an !on#ras(;1 O!#oer 2319)

• Du!#us lars n#ra/e8a#? !anan an !r> u!#us /e8a#!us !ouns an C$D s!#

elear. Kaler C$D a+an /lus 3>= ?. Kaler C$D a+an s#al #a! elear

en+an #e8 re+uler. Ta8a! les 8aa# loula#e eln+!u8 a+an s#al C$D /n++a

re+on 8er8an!rea#! !a8u# 8an?reas> a#as les rela#Be #e+as en+an u!uran *< 4>= ;>9

6>= ?.

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• Les #a8a! era#asan lan+sun+ en+an !a8u# 8an?reas> naun #a! #a8a! 8elearan

u!#us 8an!rea#!us. Les ju+a #a8a! era#asan lan+sun+ en+an Bena 8or#a.

• Ta8a! as#es 8er/e8a#!a> 8er8an!rea#! an 8ara?ol?a.

•

Ta! #a8a! @lln+ e@e?# 7an+ en?ur+a!an a#u C$D.• Kanun+ e8eu #a! eesar> u!osa l?n> 8er?/ole?7s#? @a# ers/> #a!

en?ur+a!an a#u alan7a.

Len , #a! eesar> 8aren! /oo+en7> V.lenals #a! elear.

%an?reas, noral> 8aren! /oo+en.

njal, $en#u! noral> 8aren! a!. Ta! #a8a! enun+an #r>urnarus> s7s#e

8elBo?al7?es an !eua ure#er #a! elear. Kelenjar 8araaor#al #a! eesar> #a!

#a8a! as?#es.

Laun+ an usus aoen a#as, ala a#as noral> u!osa usus #a! eneal> usus

#a! elear>> #a! #a8a! leus.

Kesan,

• Dla#as u!#us ler n#ra an e!s#ra /e8a#? e?. Les loula#e eln+!u8 s#al C$D

/n++a re+on 8er8an!rea#!. DD* l@aeno8a#

• Ta! #a8a! !e#erla#an ?a8u# 8an?reas.

• Ta! #a8a! la#as u!#us 8an!rea#!us.

• As#es 8er/e8a#!> 8er8an!rea#! an 8ara?ol?a.

• Or+an aoen lann7a ala a#as noral.

US Aoen

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• Laun+, nn+ eneal re+uler

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• e8ar, en#u!> u!uran an s#ru!#ur noral> Les "

• KE, en#u! noral> nn+ re+ular #a! eneal. U!uran a+a! elear. $en#u!

Slu+e

•

Len, noral• Keua njal, Kor#e!s eulla an 8elBo ?al7?es noral> a#u "

• $ul #n+!a# !esaaran> 8eer!saan @s! an #ana alase an l8ase.

%asen 8uasa!an 6 ja 8er#aa se#ela/ #na!an ERC%.

%asen er e# luna! se#ela/ 8asen saar> sua/ @la#us an #a! #eu!an @a!#or !eun+> un#a/ an re@le!s enelan sua/ a!).

%asen on#or /n++a e@e! ar oa# /lan+.

Se#ela/ 8eer!saan> 8asen un+!n a!an en+ala 8erasaan #a! n7aan 8aa

#en++oro!an> !eun+ an nausea.

J!a #era8a# lu!a 8aa #en++oro!an> er!an oa# un#u! en+a#asn7a.

OserBas !o8l!as 7an+ un+!n un?ul se8er# 8an?rea##s> 8er@oras> 8er#on#s> n@e!s>

8enara/an a#au8un rea!s aler+.

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In@oras!an 8aa 8asen un#u! ela8or!an a8ala un?ul ea> n7er 7an+ /ea# 8aa

8eru#> 8eru# enja !eras> a#au8un 8enara/an.

Medika Ment$sa

8 Ura@al! ;1

8 Les?/ol ;1

8 Cur?ua ;1

8 &usn ;1 ?#/

8 La?#ola? ;1?#/

8 KSR 21

8 Ce@o8eraone 21

8 %an#o8raole 243+

8 Onan?en#ron ;=+

!. Pr$gn$sis

uo a B#a, ua a ona

uo a @un+sona, ua a ona

uo a sana#ona, ua a ona

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