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Weekly Report CA. Mamae1 Tgl 26

Mar 05, 2016

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Page 1: Weekly Report CA. Mamae1 Tgl 26

7/21/2019 Weekly Report CA. Mamae1 Tgl 26

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WeeklyReport

Page 2: Weekly Report CA. Mamae1 Tgl 26

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IDENTITAS PASIENNama : Ny. Herlina

Umur : 38 Tahun

 JK : Perempuan

 Tanggal masuk : 26 Agustus 20!

"uangan : #aru$a atas

"umah %akit : "%U AnutapuraPalu

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ANAMNESIS Keluhan utama  :

  Payudara membesar sebesar bola sepak.

 Anamnesis terpimpin/ Alloanamnesis :

Pasien masuk RSU anutapura dengan keluhan payudara

membesar sebesar bola sepak. Keluarga mengaku

payudara semakin membesar 2 bulan terakhir dan

mengeluarkan darah dan nanah. Awalnya benjolan sudah

ada sekitar satu tahun yang lalu, namun pasien tidak mau

berobat dan hanya diobati dengan obat herbal. emam

!"# selama 2 bulan terakhir. $yeri !"# sampai di daerah

pundak.

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PEMERIKSAAN

FISIK 

Status generalisata :

Sakit berat%&omposmentis

Tanda vital :

' : (2)%*) +mg

R : 2) - %menit $ : *) -%menit

S : /,2 0&

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&'ntinue.........Kepala:

Konjungtiva anemis (+/+)

Sklera ikterik (-/-)

Leher :

Perbesaran KGB (-), Tiroid (-)

Thorax :

Paru-paru

Inseksi ! "ormo#$est, retraksi (-), tamak massa eritema (+)

sebesar bola seak ada dada kiri dan ada ermukaan

terdaat nodul% &ritema samai ada ba$u kiri%

Palasi ! n'eri tekan (+), remitus taktil kesan normal%

Perkusi ! Sonor

 uskultasi ! Bun'i vesikular, *$(-/-),$(-/-)

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Jantung

1nspeksi : 1tus &ordis sulit dinilaiPalpasi : 1tus &ordis sulit dinilai

Perkusi: sulit dinilai

Auskultasi : 34 1%11 murni reguler,

bunyi tambahan !5#Abdomen

1nspeksi : Kesan datar

Auskultasi: Peristaltik usus !"# kesan normal

Perkusi : 'impaniPalpasi : $yeri tekan !"# epigastrium, organomegali !5#

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 Genitalia : 'idak ditemukan kelainan

 Ekstremitas :

Superior : Akral hangat, 6dem!5#

  1n7erior : Akral hangat,6dema !5#

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Status Lokalis

Regio : +ammae sinistra

1nspeksi :  tamak massa eritema (+) sebesar

bola seak ada dada kiri dan ada ermukaan

terdaat nodul% &ritema samai ada ba$u kiri

Palpasi : teraba tumor, berbatas tegas, padat,

permukaaan tidak rata, $yeri tekan !"#.

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(a)'rat'rium

Parameter Hasil %atuan "ange

N'rmal

"*&

Hem'gl')in

+H),

Hemat'krit

P(T

-*&

Neutr'l

lim/'sit

1

18

3

326

012

1

16

064mm3

gr4$l

5

034mm3

0

3

4mm

3

5

5

3180!120

1!1!

31010

!0!00

100100

8

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RESME

  Pasien masuk *S anutaura Palu dengan kelu$ana'udara membesar sebesar bola seak% emam (+),

n'eri (+)%Pada Pemeriksaan isik, ditemukan status lokalismassa eritema (+) sebesar bola seak ada dada kiridan ada ermukaan terdaat nodul% &ritema samai

ada ba$u kiri% teraba tumor, berbatas tegas, adat,ermukaaan tidak rata, "'eri tekan (+)%

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7A#N9%% K(N%

&a.ammae

An;uran pemeriksaan:

/'t' th'ra< PA

=NA*

U%# a)$'men

Pemeriksaan (a): $arah lengkap1 &T1*T1 %#9T1%#PT1#7%1H)sag1ureum1>reatinin.

P?NATA(AK%ANAAN

 persiapan mastekt'mi Persiapan 2 kantung $arah -*

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