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IDENTITAS PASIEN
Nama : Ny. T
Umur : 47 th
Jenis kelamin : Perempuan
Agama : Islam
No. Medical Record : 100!1"
Alamat : #enu$ Sar% &T 00'(001) #enu$) Semaran*
Ruang raat : Ba%tul I++ah 1
Tgl masuk : 0 N,-emer /01'
Tgl keluar : Desemer /01'
Status Care : N N,n PBI
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ANAMNESIS
Pas%en 2atan* $e P,l% Penya$%t Dalam &SI Sultan
A*un* pa2a tan**al 0 N,-emer /01' 2en*an $eluhan
mual pus%n* 2an lemas. Pus%n* 2an mual 2%rasa su2ah
se3a$ har% yan* lalu. emu2%an pas%en merasa lemas
se3a$ / har% yan* lalu. Pas%en merasa nyaman $et%$a
t%2uran 2an terasa pus%n* saat er3alan.
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!elu"an Utama # mual
$nset # se3a$ har%
!ualitas dan !uantitas # 5ual 2an %n*%n muntah h%lan* t%mul
%aktor mem&er'erat dan mem&eringan #
ertamah pus%n* saat an*un 2an er3alan.
(e)ala lain # Pus%n* 2an terasa lemas.
ANAMNESIS
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&%6ayat Penya$%t
RPD
&%6ayat D5 :
&%6ayat 8%pertens% :
&%6ayat #astr%t%s : 9
&%6ayat antun* : 9
&%6ayat aler*% ,at : 9
RP!
&%6ayat 8%pertens% :
&%6ayat D5 :
&%6ayat #astr%t%s : 9
&%6ayat antun* : 9
Ria*at Sosial Ekonomi
Pas%en merupa$an pas%en N N,n PBI
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PE5E&ISAAN ISI
Umum : Pas%en terl%hat sa$%t
!ulit : *atal ;9<) lu$a ;9<) $un%n* ;9<) pu=at;9<.
!e&ala : mes,=ephal) pus%n* ;<
Mata : mata merah;9<) $,n3un*t%-a anem%s ;<) s=lera %$ter%$ ;9<) mata $aur ;9<
Telinga : er2en*%n* ;9<) $uran* pen2en*aran ;9<
+idung : s%metr%s) septum 2e-%as% ;9<) na>as =up%n* h%2un* ;9<) m%m%san ;9<) se=ret ;9<
Mulut : s%metr%s) s%an,s%s ;9<) %%r pu=at;9<) %%r $er%n* ;9<) mu$,sa h%perem%s ;9<) 2e-%as%
l%2ah ;9<) l%2ah trem,r ;9<) l%2ah $,t,r ;9<) *us% er2arah ;9<) st,mat%t%s ;9<
Tenggorokan : nyer% ten**,r,$an ;9<) sera$ ;9<) nyer% telan ;9<
,e"er : 2e-%as% tra=hea ;9<) pemesaran thyr,%2 ;9<) pemesaran $elen3ar l%m>e ;9<
Dada : sesa$ na>as ;9<) nyer% 2a2a ;9<
Sistem (I : mual ;<) muntah ;<) nyer% ep%*astr%$ ;9<
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-ital Sign
Te$anan 2arah : 10("0 mm8*
Na2% : ! ?(men%t
Suhu : ),
= && : // ?(men%t
Status (ii
BB : ' $*
• TB : 10 =m ;1. m<@
• B5I : '(/)' /0)7 ;n,rm,6e%*ht<
PE5E&ISAAN ISI
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PE5E&ISAAN DADA
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Ins&ection : I=tus =,r2%s t%2a$ terl%hat.
Pal&ation : thr%ll ;9<) ep%*astr%= pulse ;9<) parasternal pulse ;9<)
sternal l%>t ;9<.
Percussion : 2ull s,un2
Upper ,r2erl%ne ,> heart : ICS II le>t sternal l%ne
a%st ,> heart : ICS III le>t parastern l%ne ,6er r%*ht ,r2erl%ne ,> heart : ICS r%*ht sternal l%ne
,6er le>t ,r2erl%ne ,> heart : ICS le>t m%2 =la-%=le l%ne
PE5E&ISAAN ANTUN#
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...CONT
Aus=ultat%,n
A,rtal -al-e : S1 F S/ stan2ar2) a22%t%,nal s,un2 ;9<
Pulm,nary -al-e : S1 F S/ stan2ar2) a22%t%,nal s,un2 ;9<
Tr%=usp%2 -al-e : S1 F S/ stan2ar2) a22%t%,nal s,un2 ;9<
5%tral -al-e : S1 F S/ stan2ar2) a22%t%,nal s,un2 ;9<
Intepretasi : normal
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PE5E&ISAAN ABDO5EN
Ins&ection : symetr%=) sy=atr%=;9<) str%ae;9<)enlar*ement ,> -ena ;9<)
=aputme2usa ;9<.
Auscultation : per%stalt%= ;<
Pal&ation :
Super>%s%al : t%*ht ;9<) mass ;9<
Deep : a2,m%nal pa%n ;9<) l%-er) $%2ney) an2 spleen
6erenGt palpale) 5urphyGs s%*n ;9<
Percussion : tympan%) s%2e ,> 2ea> ;9<) sh%>t%n* 2ullness ;9<
%-er : 2ea>;<) r%*ht l%-er span 10 =m) le>t l%-er span
=m
Spleen : Thr,e spa=e per=uss%,n ;< tympan%
Intepretasi : normal
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E$strem%tas super%,r %n>er%,r
• Oe2ema 9(9 9(9
• C,l2 9(9 9(9
• aun2%=e 9(9 9(9
PE5E&ISAAN EST&E5ITAS
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PE5E&ISAAN ABO&ATO&IU5
Interpretasi :Anemia
HiperglikemiaAzotemia
&ematoloi &asil
H !"! g#$l
Ht 2!"6 %
&e'ko(it 10"! ri'#'&
Tromo(it )1* ri'#'&
'imia &asil
+D, 410 mg#$l
-re'm 12) mg#$l
reatinin $ara/ 2"68 mg#$l
atri'm 1)0 mmol#&
Kali'm 4.2! mmol#&
/lori$e 10).*mmol#&
Imunoloi &asil
H(AgK'alitati
on Reakti
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ABNO&5AITAS DATA
Anamnesis
1. Mual dan muntah
2. Kepala terasa
pusing
3. Badan terasa
lemas
Pemeriksaan fisik
4. Konjungtiva
anemis5. Tekanan darah
tinggi
Lab
Hematology
. !" #$# g%dl
Chemistry
&. '() 41*
+. ,reum 123 mg#$l
#. -reatinin serum
2$+ mg#$l
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P()B*EM *IS+
DM TIP3 II*5
HIP3RT3,I+RAD3 1 2 $an 5
A3MIA) " 4 $an 65
A7OT3MIA8 $an !5
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DM tipe IIAss : makroangiopati pen9 :ant'ng koroner" pen9akit
arteri perier"
pen9 ;erero<a(;'ler5
mikroangiopati retinopati $iaetik" neropati
$iaetik"
ne'ropati $iaetik5
IP D, : ='n$'(kopi" angiograp/9 arteri ;oroner
mikroal'min'ria" T
(;an ;rani'm" API
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Ip +, :
> -armaoloi
o<omi? 2 ? 2 'nit5
+li@'i$one 1 0 15
=l'narizin mg 2 ? 15
> /on farmaoloi
Meng'rangi kon('m(i karo/i$rat a(i" roti" kentang5
Diet ren$a/ g'la
IpM, B +'la $ara/ (eCakt' (etiap /ari" HA1;" +DPP" +DP
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(umus BrocaBB Ideal !0% ? 1601005 ? 1
0"! ? 60 4 kg
'alori Basal 4 ? 2
1)0 ;al
Ativitas 10% ? 1)0 1)
Istirahat
!mur 40 60 ta/'n
% ? 1)0 6*"
+otal 1)0 E 1) 6*" 141*" kalori per /ari
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Ass:
1.Maligna /9pertention
2.enigna /9pertention
IP D, : 'n$'(kopi" Mi;roal'min'riaIP +, :
1. =armakologi( B
Amlo$ipin 10 mg 1 ? 15
2. on armakologi( B
Diit loC (alt
Hiperten(i gra$e I
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Ass B KD" neropat9
Ip D, B -rin R'tin" T ,A A$omenIp +,B
/on -armaoloy B Diet loC protein 0"60"8g#kg#/ari
Diet loC (alt 1 gram Diet F'i$ 00;; E /oC m';/ 'rine m&#/ari
-armaoloy B
aO) ) ? 00mg to pre<ent /ipero(atemia
i;nat ) ? 00mg to pre<ent a;i$o(i( metaoli;on$an;entron ) ? 4mg to (top na'(ea
Keto(teril 2 ? 1 protein ('plement
Hemo$iali(a C/en ;reatinin ;learen;e toleran;e
$e;re(e 'ntil G1
Azotemia
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Ip M, B alan;e o F'i$" $i're(i(" <ital (ign" aCarene((" ;/emi;al loo$ te(t("
o<er/i$ro(i( (ign
Ip E, B 3?palin ao't $i(ea(e 3?plain ao't Hemo$iali(a
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#&(#140 age5 ? eig/t ? 0"8
*2 ? ;reatinin pla(ma
140 4*5 ? ) ? 0"8 *2 ? 2.68
418!"6 21"*1 ml#mnt#1"*)m
1!2"!6
Interpretation B KD
,tage IJ5
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Kriteria $iagno(i( KD
ker'(akan gin:al lei/ $ari ) 'lan aik (tr'kt'ral
ma'p'n 'ng(ional $engan ata' tanpa pen'r'nan
+=R $an a$a kelainan patologi(" kelainan 'rin"
kelainan $ara/" kelainan te( pen;itraan
la:' ltra(i glomerol'( k'rang $ari 60 ml # menit#1"*)
(elama ) 'lan $engan ata' tanpa ker'(akan gin:al
A i
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Ass : Anemia /ipokrom mikro(iter
Anemia normokrom normo(iter
Anemia makro(iter
IP.D, : MJ" MH" MH" TI" =eritin" retik'lo(it" olat.
IP.+, :
1. on =armakologi B
3at <egetale (pina;/" et;.5
2. =armakologi B
,'la( =ero('( )00mg ) ? 15
Anemolat 1mg ) ? 15
IP.M, : <ital (ign" H" Anemi; ,ign
IP.E, : 3at more <egetale( (pina;/" et;.5
De;rea(ing /ar$ a;ti<it9
Anemia
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