responsi syaraf vonny

8/18/2019 Responsi Syaraf Vonny

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RESPONSI KASUS BAGIAN NEUROLOGI

RSU HAJI SURABAYA

FAKULTAS KEDOKTERAN

UNIVERSITAS MUHAMMADIYAH MALANG

Pembimbing : dr Di!" H!ri# S$S

O%e" : V&nn' Ri()! R!"m!*!+i ,-./0-.1././//2-3

A. IDENTITAS PASIEN

/ N!m! : Tn Im!m S&e"!di

- Um4r : 52 +!"4n

2 Jeni( Ke%!min : L!)i6L!)i

1 A%!m!+ : P!7!r)emb!ng 18 BLK

0 Ag!m! : I(%!m5 S4)4 : J!*!

8 Pendidi)!n : SMA

9 Pe)er!!n : Ped!g!ng

; N& regi(+er : 80.898

/. T!ngg!% MRS : /- M!re+ -./5 $4)4% -.28

// T!ngg!% Pemeri)(!!n : /8 M!re+ -./5 $4)4% /...

B. ANAMNESA (Autoanamnesa)

• Ke%4"!n U+!m! : Lem!" b!d!n (ebe%!" )!n!n mend!d!)

• Ri*!'!+ Pen'!)i+ Se)!r!ng ,RPS3

P!(ien d!+!ng )e UGD $!d! "!ri (!b+4# /- m!re+ -./5 $!d! $4)4% -.28 deng!n )e%4"!n

+ib!6+ib! %em!" b!d!n (ebe%!" )!n!n# )e!d!!!n ini +er!di mend!d!) (e)i+!r $4)4% /;..

)e+i)! $!(ien (ed!ng meng&br&% deng!n )e%4!rg!n'! Ke%4"!n +er(eb4+ di(er+!i $4(ing

ber$4+!r di(er+!i m4!% (e!) -"r (ebe%4mn'! Tid!) !d! ri*!'!+ +r!4m!# +id!) !d! )e!ng#

d!n +id!) di(er+!i dem!m P!(ien meng!)4 +id!) $ern!" meng!%!mi ge!%! (e$er+i ini

(ebe%4mn'!

• Ri*!'!+ Pen'!)i+ D!"4%4 ,RPD3

-DM : ,


2/12


3/12

1 S!r!6(!r! O+!) ,Ner4( r!ni!%i(3

! N O%!7+&ri4( ,N I3

K!n!n Kiri

Hi$&(mi!>An&(mi! 6 6

P!r&(mi! 6 6H!%4(in!(i 6 6

b N O$+i74( ,NII3

K!n!n Kiri

Vi(4( Dbn

L!$!ng P!nd!ng Dbn

Membed!)!n *!rn! Dbn

F4nd4(7&$' Dbn

7 N O74%&m&+&ri4( ,N III3# N Tr&7"%e!ri( ,N IV3# N Abd47en( ,N VI3K!n!n Kiri

Ked4d4)!n B&%! M!+! Di+eng!" di+eng!"

Perger!)!n B&%! M!+! Ke N!(!% Dbn dbn

Ke Tem$&r!% Dbn dbn

Ke A+!( Dbn dbn

Ke B!*!" Dbn dbn

Ke Tem$&r!% B!*!" Dbn dbn

Ke N!(!% A+!( Dbn dbn

E?&$"+"!%m4( 6 6

e%!" M!+! ,P+&(i(3 6 6P4$i% Ben+4) B4%!+ (ime+ri(

Leb!r 2 mm 2 mm

Perbed!!n Leb!r I(&)&r

Re!)(i !"!'! L!ng(4ng < <

Re!)(i !"!'! K&n(en(4!% < <

Re!)(i A)&m&d!(i < <

Re!)(i K&nergen(i < <

d N Trigemin4( ,N V3

K!n!n Kiri!b!ng M&+&ri) O+&+ M!((e+er Dbn dbn

O+&+ Tem$&r!% Dbn dbn

O+&+ P+er'g&ide4( e?+>in+ Dbn dbn

!b!ng Sen(&ri) I Dbn dbn

II Dbn dbn

III Dbn dbn

Re%e) K&rne! L!ng(4ng < <

Re%e) K&rne! T!) L!ng(4ng < <

e N F!7i!%i( ,N VII3

K!n!n Kiri

2


4/12

!)+4 Di!m Ker4+!n d!"i Sime+ri(

Tinggi !%i( Sime+ri(

S4d4+ m!+! Sime+ri(

Li$!+!n n!(&%!bi!% Sime+ri(

!)+4 ger!) Menger4+)!n d!"i Sime+ri(

Men4+4$ m!+! Sime+ri(Ber(i4% dbn

Meringi( Sebe%!" )!n!n

+er+ingg!%

Penge7!$!n ->2 de$!n %id!" Dbn

Hi$er!)4(i( 6 6

Se)re(i !ir m!+! Dbn dbn

N Ve(+ib4%&7&7"%e!ri( ,N VIII3

K!n!n KiriVe(+ib4%!r Ver+ig& 6

N'(+!gm4( )e 6 6

Tinni+4( 6 6

Te( )!%&ri Sde

&7"%e!r eber < <

S7"*!b!7" Dbn

Rinne Dbn

T4%i )&nd4)(i 6 6

T4%i $er(e$(i 6 6

g N G%&((&$"!ringe4( ,N I3# N V!g4( ,N 3

B!gi!n M&+&ri) S4!r! Bi!(!

Mene%!n Dbn

Ked4d4)!n !r74( Dbn

Ked4d4)!n 44%!>$"!r'n? Dbn

Perger!)!n !r74( $"!r'n?>44%! Dbn

Verne+6Rede!4 $"en&men Dbn

De+!) !n+4ng Reg4%!r

Bi(ing 4(4( Dbn

B!gi!n Sen(&ri) Penge7!$!n />2 be%!)!ng %id!" Dbn

Re%e) M4n+!" Dbn

Re%e) P!%!+4m M&%%e <

" N A77e((&ri4( ,N I3

K!n!n Kiri

Meng!ng)!+ b!"4 < <

Mem!%ing)!n )e$!%! < <

i N Hi$&g%&((4( ,N II3

K!n!n KiriKed4d4)!n %id!" *!)+4 i(+ir!"!+ )e Di+eng!"

1


5/12

Ked4d4)!n %id!" *!)+4 berger!) )e 6 6

A+r&i 6

F!(i)4%!(i 6

Ke)4!+!n %id!" mene)!n b!gi!n d!%!m $i$i < <

0 Si(+im M&+&ri) ! Be(!r

A+r&i : 6

P(e4d&!+r&i : 6

b P!%$!(i

N'eri : 6

K&n+r!)+4r : 6

K&n(i(+en(i : $!d!+# )en'!%

7 Per)4(i

N&rm!% : <

Re!)(i m'&+&ni) : 6

d T&n4(

Leng!n T4ng)!i

K!n!n Kiri K!n!n Kiri

Hi$&+&ni 6 6 6 6

S$!(+i) 6 6 6 6

Rigid 6 6 6 6

Reb&4nd $"en&men 6 6 6 6

e Ke)4!+!n

K!n!n Kiri

T4b4" O+&+ $er4+ Dbn

O+&+ $ingg!ng Dbn

Ked4d4)!n di!r!gm! Sime+ri(

Leng!n M De%+&id - 0

M Bi7e$( - 0

M Tri7e$( - 0

F%e?i (endi $erge%!ng!n +!ng!n - 0

E?+en(i (endi $erge%!ng!n

+!ng!n

- 0

Memb4)! !ri6!ri +!ng!n - 0

Men4+4$ !ri6!ri +!ng!n - 0

T4ng)!i F%e?i !r+i767&?!e 2 0

E?+en(i !r+i767&?!e 2 0

F%e?i (endi %4+4+ 2 0

E?+en(i (endi %4+4+ 2 0

F%e?i $%!n+!r )!)i 2 0

E?+en(i d&r(!% )!)i 2 0

Ger!)!n !ri6!ri 2 0

0


6/12

Ger!)!n in&%4n+er

Trem&r : *!)+4 i(+ir!"!+ ,63 *!)+4 ger!) ,63

"&re! : 6

A+"e+&(e : 6

T&r(i&n ($!(me : 6

F!(i)4%!(i : 6g K&&rdin!(i

K!n!n Kiri

J!ri +!ng!n6!ri +!ng!n Dbn dbn

J!ri +!ng!n6"id4ng Dbn dbn

T4mi+6%4+4+ Dbn dbn

Pr&n!(i6(4$in!(i Dbn dbn

T!$$ing !ri6!ri +!ng!n Dbn dbn

T!$$ing !ri )!)i Dbn dbn

" G!i+ S+!+i&nJ!%!n di!+!( +4mi+ : (4%i+ die!%4!(i

J!%!n di!+!( !ri )!)i : (4%i+ die!%4!(i

T!ndem *!%)ing : (4%i+ die!%4!(i

J!%!n %4r4( %!%4 $4+!r : (4%i+ die!%4!(i

J!%!n m4nd4r : (4%i+ die!%4!(i

Berdiri deng!n (!+4 )!)i : (4%i+ die!%4!(i

Hemi$%egi7 g!i+ : (4%i+ die!%4!(i

erebe%%!r g!i+ : (4%i+ die!%4!(i

T!be+i7 g!i+ : (4%i+ die!%4!(i

P!r)in(&n g!i+ : (4%i+ die!%4!(i

R&mberg +e(+ !+4" )e : (4%i+ die!%4!(i5 Si(+im Sen(&ri)

Leng!n T4ng)!i T4b4"

R!(! E)(+er&7e$+i: K! Ki K! Ki K! Ki

• R!(! n'eri (4$eri7i!% < < < < < <

• R!(! (4"4 ,$!n!(>dingin3 < < < < < <

• R!(! r!b! ring!n < < < < < <

R!(! Pr&$i&(e$+i

• R!(! ge+!r < < < < < <

• R!(! +e)!n < < < < < <• R!(! n'eri +e)!n < < < < < <

• R!(! ger!) $&(i(i < < < < < <

R!(! En+er&(e$+i: reered $!in ,63

R!(! )&mbin!(i

• S+ere&gn&(i( : d!%!m b!+!( n&rm!%

• B!r&gn&(i( : (de

• Gr!$"e(+e(i! : d!%!m b!+!( n&rm!%

• T*& $&in+ +!7+i% : d!%!m b!+!( n&rm!%

• Sen(&r' e?+in7+i&n : d!%!m b!+!( n&rm!%

5


7/12

• L&(+ & b&d' im!ge: d!%!m b!+!( n&rm!%

8 Re%e?6re%e?

Re%e) K4%i+ S4$eri7i!%: K!n!n Kiri

Re%e) dinding $er4+ 6 6Re%e) in+er(7!$4%!r Dbn

Re%e) 7rem!(+er Sde

Re%e) g%4+e!% Dbn

Re%e) !n!% Sde

Re%e) Tend&n

Re%e) bi7e$(


8/12

K'$"&(i( : 6

K'$"&(7&%i&(i( : 6

Gibb4( : 6

- Ger!)!n 7eri7!%6er+ebr!e :

F%e?i : dbn

E?+en(i : dbnL!+er!% dei!(i : dbn

- Ger!)!n d!ri +4b4":

Memb4ng)4) : (de

E?+en(i : (de

L!+er!% dei!(i : dbn

S)&r (+r&)e Sirir! ,-#0? der!!+ )e(!d!r!n3 < ,-?m4n+!"3 < ,-?n'eri )e$!%!3 < ,.#/?

+e)!n!n d!r!" di!(+&%e3 6 ,2? +!nd! !+er&m!3 6 /-

S)&r (+r&)e Sirir! ,-#0?.3 < ,-?/3 < ,-?/3 < ,.#/?;.3 6 ,2?/3 6 /- /2 /0 6-

D. PEMERIKSAAN PENUN&AN'

Laoatu!um (*+,-+,/)

D!r!" Leng)!$:

Hb : /1#- g>d%

Le4)&(i+ : /-10.>mm2

Tr&mb&(i+ : -/2...>mm2

Hem!+&)ri+ : 15#1

Kimi! K%ini):

GDA $4!(! : -;1 mg>d% -JPP : 2/1 mg>d%

BUN : /8 mg>d%

re!+inin (er4m : /.#9? mg>d%

SGOT : 2/ 4>L

SGPT : -- 4>L

A%b4min : 2#- g>d%

T&+!% 7"&%e(+er&% : //9 mg>d%

Trig%i(erid! : //. mg>d%

HDL "&%e(+er&% : 28 mg>d%

LDL "&%e(+er&% : 8/ mg>d%K>N!>%:

K!%i4m : 2#. mm&%>L

N!+ri4m : /20 mm&%>L

"%&ride : ;0 mm&%>L

CT0S1an Ke2a%a (+,-+,/)

9


9/12

E. RESUME

Anamnes!s

• Ke%4"!n U+!m! : Lem!" b!d!n (ebe%!" )!n!n mend!d!)

• Ri*!'!+ Pen'!)i+ Se)!r!ng ,RPS3

P!(ien d!+!ng )e UGD $!d! "!ri (!b+4# /- m!re+ -./5 $!d! $4)4% -.28 deng!n )e%4"!n

+ib!6+ib! %em!" b!d!n (ebe%!" )!n!n# )e!d!!!n ini +er!di mend!d!) (e!) -!m (ebe%4m

dib!*! )e RS )e+i)! $!(ien (ed!ng meng&br&% deng!n )e%4!rg!n'! Ke%4"!n +er(eb4+

;


10/12

di(er+!i $4(ing ber$4+!r di(er+!i m4!% (e!) -"r (ebe%4mn'! Tid!) !d! ri*!'!+ +r!4m!#

+id!) !d! )e!ng# d!n +id!) di(er+!i dem!m

• Ri*!'!+ Pen'!)i+ D!"4%4 ,RPD3

- P!(ien meng!)4 +id!) $ern!" meng!%!mi ge!%! (e$er+i ini (ebe%4mn'!

-

DM : ,;. mmHg

•

N!di ,N3 : 95 ?>meni+@ reg4%!r • Pern!!(!n ,RR3 : -. ?>meni+

• S4"4 b!d!n ,+3 : 25#-&

• BB : 5. )g

• TB : /50 7m

• GiCi : B!i)

S+!+4( In+ern! Sing)!+

K>L : A>I>>D 6>6>6>6

T"&r!? : P4%m&: n&rm&7"e(+# (ime+ri(# e(i74%!r>e(i74%!r# r&n)"i 6>6#

*"eeCing 6>6# re+r!)(i ,63 &r: S/S- +4ngg!%# m4rm4r ,63# g!%%&$ ,63

Abd&men : Bi(ing U(4( ,Lien : +!) +er!b! ,dbn3

E)(+rimi+!( : A)r!%: "!ng!+# )ering# mer!"

Edem!

S+!+4( Ne4r&%&gi(:

• GS : 105

• MS : 6• N r!ni!%i( : PBI 2mm>2mm@ R 7!"!'! <

• N r!ni!%i( %!in : P!re(e N VII De)(+r! +i$e (en+r!%

• M&+&ri) : Ke)4!+!n O+&+ :

--- 000

222 000

T&n4( : dbn

• Sen(&ri) : dbn

• Re%e) i(i&%&gi( : BPR


11/12

• Re%e) P!+&%&gi( :

B!bin()i : 6>6

"!dd&7) : 6>6

O$$en"eim : 6>6

S7"!eer : 6>6

G&rd&n : 6>6S+r!n()' : 6>6

G&nd! : 6>6

Mende%6Be7"+re* : 6>6

R&((&%im& : 6>6

H&m!n : 6>6

Tr&mmer : 6>6

• V>ANS : dbn

F. ASSESMENT

D!a"nos!s K%!n!s :L!)i6%!)i# 52+"# "emi$!re(e de?+r!# $!re(e N VII de?+r! +i$e

(en+r!%# "i$er+en(i d!n DM

D!a"nos!s To2!s : AM Sini(+r!

D!a"nos!s Et!o%o"!s : VA In!r) Tr&mb&+i)

Sirir! ()&r:

,,-#0 ? DK3 < ,- ? M3 < ,- ? NK3 < ,.#/ ? TD di!(+&%e3 ,2 ? AT33 /-

,-?.3 < ,-?/3 < ,-?/3 < ,.#/?;.3 6 ,2?/3 6 /-

6- ,S+r&)e n&n Hem&r!gi73

'. PLANNIN'

! Di!gn&(i(

/ L!b&r!+4ri4m :

6 D!r!" Leng)!$ : Hb# Le)&(i+# Tr&mb&(i+# Hem!+&)ri+

6 Kimi! K%ini) :

G4%! D!r!" : GDP# G-PP

Pr&i% Li$id : T&+!% 7"&%e(+er&%# TG# HDL# LDL

F4ng(i Gin!% : BUN# Kre!+inin#

Ser4m E%e)+r&%i+ : K!%i4m# N!+ri4m# K%&rid

- R!di&%&gi : T S7!n Ke$!%! T!n$! K&n+r!(# F&+& T"&r!? AP

2 EKG

b Ter!$i

• Ter!$i 4m4m

/ He!d 4$ -.62.

- N4+ri(i en+er!% : dii+ rend!" g!r!m +inggi $r&+ein

2 Meng4b!" $&(i(i +id4r $!(ien miring )!n!n miring )iri (e7!r! berg!n+i!n

+i!$ (e%!ng *!)+4 beber!$! !m

-K&n(4%+!(i d&)+er S$PD

- Re"!bi%i+!(i Medi) 4n+4) m&bi%i(!(i !)+i

//


12/12

• Ter!$i K"4(4( :

• In4( Ringer L!)+!+ -062. 77 > )gBB -. +$m

• Ine)(i i+i7&%in 2 ? 0.. mg ,/-0mg>m%3

• Ine)(i S&"&bi&n /?/ !m$ IV

• A($i%e+ 9.mg /?/ PO

7 M&ni+&ring

- GS

- Vi+!% (ign ,n!di# TD# RR# (4"43

- Ke%4"!n $!(ien

- BAK d!n BAB

d Ed4)!(i

- Meng!!ri )e%4!rg! $!(ien 4n+4) meng4b!" $&(i(i +id4r $!(ien miring )e )iri

d!n )e )!n!n 4n+4) meng"ind!ri )&m$%i)!(i %!n4+!n

- Memberi+!"4 $!(ien d!n )e%4!rg! $!(ien +en+!ng )e!d!!n $!(ien# d!n $er!%!n!n

$en'!)i+ '!ng dideri+!

- Memberi+!"4 $emeri)(!!n d!n +er!$i '!ng di%!)4)!n )e$!d! $!(ien

- Memberi+!"4 +en+!ng $r&gn&(i( d!n )em4ng)in!n +er!din'! ge!%!6ge!%! (i(!

$!d! $!(ien

- Memberi+!"4 b!"*! $en'emb4"!n d!ri $en'!)i+ '!ng dideri+! $!(ien

memb4+4")!n !ng)! *!)+4 '!ng %!m! (e"ingg! )e%4!rg! $!(ien d!n $!(ien

"!r4( ber(!b!r

3. PR4'N4SIS

D4bi! e+ M!%!m

/-

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