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LAPORAN KASUS DOKTER JAGA RUANGAN RS GRAND MEDISTRA - CHF fc IV ec CAD + CKD stage IV + DM type 2

Jul 07, 2018

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  • 8/19/2019 LAPORAN KASUS DOKTER JAGA RUANGAN RS GRAND MEDISTRA - CHF fc IV ec CAD + CKD stage IV + DM type 2

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    dr. Ade Irmadr. Annisa Irnita Siregar

    dr. Martin Susantodr. Novita Pangaribuandr. Pelangi Windarinidr . Winda Pardede

     

    NarasumberDr. 'err(anto L Tobing,S)PD *"GE',+INASIMDr. R. Arie !anu Pradi)ta,S)PD

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    Nama - S enis "elamin- La/i*la/i

    mur - ta0unAgama - ProtestanSu/u - !ata/

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    ANAMNESAKeluhan Utama: Dada

    sebela0 /iri terasa )anasRiwayat Penyakit sekarang:

     Tela0 dialami se1a/ % 0ari(ll. antung berdebar dgn2e)at, ter/adang normal.3s )ost P4I #ta0un lalu diRS 'ara)an "ita

    RPO: +urosemide,4lo)idogrel, Atorvastatin,!iso)rolol, Novomi5

    RPT: DM

    PEMERI"SAAN +ISI" Vital Sign-

     Tensi - %6$78$ mm'gNadi - 9# 7 menit

    Naas - #& 7 menit Tem) - *Status Localis: -Pemeriksaan Penunjang:

    DR, R+T, E"GDiagnosa wal: AnginaPe/toris : Post P4I

    Pengo!atan: I;+D RL8gtt7i

  • 8/19/2019 LAPORAN KASUS DOKTER JAGA RUANGAN RS GRAND MEDISTRA - CHF fc IV ec CAD + CKD stage IV + DM type 2

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  • 8/19/2019 LAPORAN KASUS DOKTER JAGA RUANGAN RS GRAND MEDISTRA - CHF fc IV ec CAD + CKD stage IV + DM type 2

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    Seorang la/i*la/i, ta0un, diba, D3E =:>, 3P=:> N(eri dada /iri =:> dialami os se1a/ # 0ari SMRS, n(eri

    terasa se)erti tertim)a benda berat, men1alar /e ba0u /iri.

    Durasi n(eri dada @#$ menit. N(eri ber/urang /eti/a

    beristira0at. Ri se1a/

    ta0un lalu.

    Ri

  • 8/19/2019 LAPORAN KASUS DOKTER JAGA RUANGAN RS GRAND MEDISTRA - CHF fc IV ec CAD + CKD stage IV + DM type 2

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    Ri

  • 8/19/2019 LAPORAN KASUS DOKTER JAGA RUANGAN RS GRAND MEDISTRA - CHF fc IV ec CAD + CKD stage IV + DM type 2

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    Ri

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    Status Presens* Sens - 4om)os mentis * Sianosis - =*>*  TD- %6$78$ mm' * 3rto)nea - =:>* 'R- 9# 57menit * Dis)nea - =:>

    * RR- #& 57menit * Edema - =:>*  Tem) - ?9,9 4 * Pu2at - =*>

    Status Lokalisata

    "e)ala -%ata : /on1un2tiva )al)ebra inerior )u2at =*>, i/teri/ =*>,

    iso/or, diameter )u)il- #*? mm, R4 =:7:>%ulut : bibir sianosis =*>

    Le0er - T; R:? 2m '#3, Pembesaran /elen1ar =*>

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     T0ora5 anterior - I - Simetris usiormis  P - Stem remitus /a /i, /esan mengeras  P - Sonor  A - SP - bron/ial

      ST - Ron/i basa0 =:> )ada seluru0 la))aru

       antung - I - I2tus 2ordis terli0at  P- I2tus 2ordis teraba

      P- !atas atas- I4S III sinistra  batas /iri -

    #2m lateral LM4S  A- S% =:>, S# =:> normal  gallo) =*> murmur =*>

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     T0ora5 Posterior- I - Simetris usiormis  P - Stem remitus /a /i, /esan mengeras  P - Sonor  A - SP - bron/ial

      ST - Ron/i basa0 =:>)ada seluru0 la))aru

    Abdomen- I - Simetris  P - Soe)el, '7L7R - ttb

      P - Tim)ani  A - Peristalti/ =:>N E/stremitas - Pitting oedem =:7: >, sianosis =*>,

    'R 9#57i, reg, t7v 2u/u), a/ral 0angat

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    Diagnosa : 4'+ 2 I; e2 4AD

    Pengobatan : !ed Rest semi +o

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    Sinus Rythm, QRS rate 75x/i, axis Normal, P mitral (+), di

    lead I, II, V4,V5,V, PR inter!al" #,$#%, QRS duration"

    #,#&%, S'' han*e" (), V (), V-S ()

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    'b - %$.# g7dL't - ?#.$ FW!4 - %#6$$7mm?

    PLT - ##8$$$7mm?

    4"*M! - ?.% Tro)onin*T - $*%$$

    "GD ad random - %6$ mgFreum - 98 mgF4reatinine - ?. mgF

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    Tanggal S O A P

    .. aret Sesa0 na1as22

    Sens" 3'".#/R" 76 x/iRR" $4 x/i'" ,73ata" 8on9:;al;e

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    Tanggal S O A P

    .$ aret Sesa0 na1as(+), nyeridada ()

    Sens" 3'".54/75R" 75x/iRR" $7 x/i'" ,73ata" 8on9:;al;e

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    "GD ad random - %89 mgF

    Natrium - %6 mEH"alium - . mEH40lorida - %%? mEH

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    Tanggal S O A P

    . aret Sesa0 na1as(+) , nyeridada ()

    Sens" 3'".4#/6#R" x/iRR" $ x/i'" ,63ata" 8on9:;al;e

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    )' - 9.?&P43# - ?$

    P3# - %$6!E - *9,9'43? - %9.Sat. 3# - 9

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    Tanggal S O A P

    .4 aret Sesa0 na1as(+) , nyeridada ()

    Sens" 3'".5#/&R" 6# x/iRR" $ x/i'" ,43ata" 8on9:;al;e

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    "GD )uasa - %%& mgF"GD ad random - % mgF

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    Tanggal S O A P

    .5 aret Sesa0 na1as(+) , nyeridada ()

    Sens" 3'".5#/.##R" .## x/iRR" $4 x/i

    '" ,63ata" 8on9:;al;e

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    SE"IAN

     TERIMA "ASI'