status bedah dhita
Post on 06-Jul-2018
212 Views
Preview:
TRANSCRIPT
-
8/17/2019 Status Bedah Dhita
1/15
FAKULTAS KEDOKTERAN UKRIDA
(UNIVERSITAS KRISTEN KRIDA WACANA)
Jl. Arjuna Utara No. 6 KeonJeru! " Ja!arta #arat
KE$ANITERAAN KLINIK
STATUS ILMU BEDAH
FAKULTAS KEDOKTERAN UKRIDA
RU%A& SAKIT U%U% FA%IL' %EDICAL CENTER
Naa D*+ta A,r+l+a Anjot+ Tan-aTanan
NI% //.01/2./12
Dr. $e++n -r. %ar3ell Ant*on4
IDENTITAS PASIEN
Naa Len!a, N4.N Jen+5 !ela+n $ere,uan
Te,attanal la*+r #oor7 /8 Jun+ /9:0 Su!u an5a Sun-a
Statu5 ,er!a;+nan Su-a* en+!a* Aaa I5la
$e!erjaan Iu rua* tana $en-+-+!an S%A
Alaat Jalan !an-an ro-a RT 11
-
8/17/2019 Status Bedah Dhita
2/15
Keluhan utama :
#enjolan ,a-a ,a4u-ara !anan 5eja! 0 +nu S%RS.
Riwayat Penyakit Sekarang :
$a5+en -atan -enan !elu*an enjolan ,a-a ,a4u-ara !anan ata5 5eja! 0 +nu S%RS .
$a5e+n era5a!an enjolan a;aln4a 5e,ert+ +5ul !eu-+an laa=!elaaan enja-+ e5ar.
#enjolan 4an -+ ra5a!an !en4al7 n4er+7 en!a!7 !eera*an7 *anat -an -a,at -+ era!an
-ar+ -a5arn4a. Ter-a,at -ea -an ,enurunan erat a-an. Na>5u a!an,un er!uran.
T+-a! a-a ,ee5aran !elenjar eta* en+n -+ le*er au,un -+ !et+a!. $a5+en en4u5u+ana!n4a7 ta,+ t+-a! 5a,a+ tunta57 a5+* a-a ASI 4an ter5+5a -an t+-a! ,erna* -+ !eluar!an.
$a5+en t+-a! e,un4a+ r+;a4at aler+. $a5+en t+-a! e,un4a+ ,en4a!+t -ara* t+n+7
!en3+n an+5 atau,un ,en4a!+t ena*un la+nn4a. D+ !eluara ,a5+en t+-a! a-a 4an
en-er+ta tuor atau !eana5an ,a-a ,a4u-ara. $a5+en t+-a! ero!o! -an t+-a! +nu
al!o*ol.
Riwayat Dahulu Tahun! "ii#i $ila ya %&! $ila ti"ak'&&
( = );a5+r*eoro+-
( = )atu +njal5al !e+*
( = )*ern+a
( = )t+>o+-
( = )atu e,e-u
( = )t+>u5 a-o+nal+5
( = )ul!u5 ?entr+!ul+
( = )tuer!ulo5+5
( = )+n?a+na5+
( = ),en4 -eenerat+>
( = )lu!a a!ar
( = )a,,en-+5+t+5
( = )tuor
( = ),en4 ,ro5tat
( = )-+are !ron+5
( = )D%
( = )!ela+nan !onen+tal
( = )!ol+t+5
( = )tetanu5
( = )*e,at+t+5
( = )>+5tel
( = )5trua t+ro+-
( = ),en4a!+t jantun
a;aan
( = ),en-ara*an ota!
( = )a5tr+t+5
( = )*+,erten5+
( = ),en4a!+t ,eulu*
-ara*
( =)ISK
( = )?ol?ulu5
( = )a5e5 *at+
(=)o,era5+
La+n=la+n ( =) o,era5+ (=)!e3ela!aan
-
8/17/2019 Status Bedah Dhita
3/15
Riwayat Hi"u(
R+;a4at !ela*+ran
$artu5 noral7 3u!u, ulan7 erat a-an la*+r 0911 r
Te,at la*+r (=) D+ rua* %& Rumah Ber#alin (=) R.S. #er5al+nD+tolon ole* (=) Do!ter %& Bi"an (=) Du!un (=) la+n = la+n
Ke*+-u,an er!eluara -an ,er!a;+anan
A-a!a* !e5ul+tan
$e!erjaan T+-a! a-a
Keuanan T+-a! a-a
Keluara T+-a! a-a
La+n=la+n .........
Riwayat makanan
Fre!uen5+*ar+ < !al+ 5e*ar+
Var+a5+*ar+ er?ar+a5+ (na5+ ,ut+*7 5a4uran7 te,e)
Riwayat imuni#a#i :
(@ ) #C (@ )D$T 8 !al+ (@)$ol+o7 2 !al+
(@ )&e, # < !al+ (@)Ca,a! ( )La+nn4a7 .....
Riwayat Keluarga
&uunan Uur (Ta*un) Jen+5 Kela+n Kea-aanKe5e*atan
$en4ea%en+nal
#a,a! 8/ ta*un La!+=la!+ Su-a*
en+nal
D+aete5
Iu 81 $ere,uan Se*at
$a5+en
-
8/17/2019 Status Bedah Dhita
4/15
A"akah keluarga)kera$at yang men"erita :
$en4a!+t 'a T+-a! &uunan
Aler+ @
A5a @
Tuer!ulo5+5 @
&+,erten5+ @
D+aete5 @ #a,a!
Jantun @
+njal @
ANAMNESIS SISTEM RE*IE+ ,- S.STEM&
Hara( "ii#i: $ila ya%&! $ila ti"ak'&
Kulit:
( = )+5ul
( = )!u!u
( = )raut
( = )!un+n+!teru5
( = )turor
( = )!er+nat ala
( = )5+ano5+5
Ke(ala:
( = )traua
( = )5a!+t !e,ala
( = )!onjunt+?a
-
8/17/2019 Status Bedah Dhita
5/15
( = )n4er+ ,a-a 5+nu5
Mata:
( = )era*
( = )5e!ret
( = )traua
( = )n4er+
( = )!un+n+!teru5
( = )!etajaan ,enl+*atan
Telinga:
( = )n4er+
( = )5e!ret
( = )anuan ,en-enaran
( = )t+n+tu5
Hi"ung:
( = )r*+nnor*ear*+nora+
( = )n4er+
( = )5e!ret
( = )traua
( = )ter5uat
( = )anuan ,en3+uan
( = )e,+!ta5+5
( = )en-a a5+n
Mulut:
-
8/17/2019 Status Bedah Dhita
6/15
( = )++r
( = )u5+
( = )anuan enelan
( = )l+-a*
( = )u!o5a
Tengg/r/kan:
( = )n4er+ tenoro!an
( = ),erua*an 5uara
Leher:
( = )enjolan
( = )n4er+ le*er
Th/ra0 1antung "an (aru'(aru&:
( = )5e5a! na>a5
( = )atu!
( = )n4er+ -a-a
( = )en+
( = )atu! -ara*
( = )er-ear=-ear
Payu"ara :
%& $en1/lan
%& merah
%& hangat
%& nyeri
-
8/17/2019 Status Bedah Dhita
7/15
%&$engkak
A$"/menlam$ung)u#u#&:
( = )ual
( = )-+are
( = )n4er+ e,+a5tr+u
( = )t+nja er-ara*
(=)enjolan
( = )unuta*
( = )!on5t+,a5+
(=) n4er+ !ol+!
( = ) t+nja er;arna -e,ul
Saluran kemih)alat kelamin:
( =) -+5ur+a
( = ) *e5+5ten5+
( = ) !en3+n atu
( = ) *eatur+a
( = ) no!tur+a
( = ) uren5+
( = ) !ol+!
( =) reten5+o ur+n
Katamenia:
( = )leu!orea
( = ),er-ara*an
( = )la+n=la+n
-
8/17/2019 Status Bedah Dhita
8/15
Hai":
Ka,an *a+- ter!*+rB Kuran le+* / +nu 4an lalu
%&1umlah "an lamanya : 2'3 hari
( = )anuan *a+-
( = )ejala !l+a!ter+u
( = ),a53a eno,au5e
%&teratur
( = )n4er+
Sara4 "an /t/t:
( =)r+;a4at traua
( = )n4er+
( = )en!a!
Ek#tremita#:
( = )en!a!
( = )n4er+
( = )-e>or+ta5
( = )5+ano5+5
Berat $a"an
#erat a-an rata=rata 0 !
#erat a-an tert+n+ 8 !
#erat a-an 5e!aran ( )teta,
( )na+!.....!
%&turun 5 kg
STATUS 6ENERALIS
-
8/17/2019 Status Bedah Dhita
9/15
-
8/17/2019 Status Bedah Dhita
10/15
$er!u5+ t+,an+ -+ 5eluru* la,an ,erut.
$al,a5+ t+-a! ter-a,at n4er+ -an enjolan -+ 5eluru* la,an ,erut
&at+ T+-a! teraa
L+,a T+-a! teraa
+njal T+-a! teraa
Alat kelamin : t+-a! -+la!u!an
9/l/k Du$ur : t+-a! -+la!u!an (t+-a! a-a +n-+!a5+)
Ek#tremita# lengan "an tungkai&:
Angg/ta gerak
Lengan Kanan KiriOtot
Tonu5 norotonu5 norotonu5
%a55a eutro>+ eutro>+
Sen-+ t+-a! a-a !ela+nan t+-a! a-a !ela+nan
era!an a!t+> a!t+>
Ke!uatan @8 @8
La+n=la+n ,alar er+te (=) ,alar er+te (=)
>la,,+n treor (=) >la,,+n treor (=)
Tungkai "an Kaki
Kanan Kiri
Lu!a t+-a! a-a t+-a! a-a
Var+5e5 t+-a! a-a t+-a! a-a
Otot norotonu57 eutro>+ norotonu57 eutro>+
Sen-+ noral noral
era!an a!t+> a!t+>
Ke!uatan @8 @8
E-ea t+-a! a-a t+-a! a-a
La+n=la+n t+-a! a-a t+-a! a-a
Re4lek#
Kanan Kiri
Re>le!5 Ten-on $o5+t+> $o5+t+>
#+5e, $o5+t+> $o5+t+>
$atela $o5+t+> $o5+t+>
A3*+lle5 $o5+t+> $o5+t+>
Re>le! ,r++t+?e Neat+> Neat+>
Re>le!5 ,atolo+5 Neat+> Neat+>
-
8/17/2019 Status Bedah Dhita
11/15
I* STATUS L,KALIS
Regi/MammaeDe0tra
• In5,e!5+Warna !ul+t aae 5aa 5e,ert+ ;arna !ul+t 5e!+tar7 ter-a,at
,enealan !ul+t aae7 !e-ua ,a4u-ara t+-a! 5+etr+57 ta,a! a-an4a
enjolan 7 retra!5+ atau 3e!unan ,a,+lla aae t+-a! a-a7 ,eneluaran
-+53*are 5e3ara 5,ontan t+-a! a-a.
• $al,a5+ Teraa 5eua* a55a ,a-a !ua-ran 5u,erolateral7 entu! ulat
lonjon7 u!uran /0 37 ,eru!aann4a l+3+n7 !on5+5ten5+ luna! !en4al7 mobile7
erata5 jela57 n4er+ te!an (@)7 ,eneluaran -+53*are a-a. T+-a! teraa
,ee5aran K# a!5+la
Regi/MammaeSini#tra
• In5,e!5+ Warna !ul+t aae 5aa 5e,ert+ ;arna !ul+t 5e!+tar7 ,enealan
!ul+t aae t+-a! a-a7 !e-ua ,a4u-ara ta,a! 5+etr+57 ta! ta,a! a-an4a
a55a7 ,eneluaran -+53*are 5e3ara 5,ontan t+-a! a-a.
• $al,a5+ T+-a! teraa a55a7 t+-a! a-a ,eneluaran -+53*are7 t+-a!
teraa ,ee5aran K# a!5+la
• Regi/ A0illa De0tra
• In5,e!5+ t+-a! ta,a! a-an4a a55aenjolan
• $al,a5+ t+-a! teraa a-an4a a55a enjolan
• Regi/ A0illa Sini#tra
• In5,e!5+ t+-a! ta,a! a-an4a a55aenjolan
• $al,a5+ t+-a! teraa a-an4a a55aenjolan
Benjolan seperti
bisul pada
-
8/17/2019 Status Bedah Dhita
12/15
* PEMERIKSAAN PENUN8AN6
Tanal ,er+!5a /< %aret 01/8
Ultra#/n/gra4i
%aae -etra ta,a! le5+ *+,ere3*o+3 ata5 tea57 te,+ reuler7 ta! ta,a!
,ee5aran K# a+lla -etra
%aae 5+n+5tra ta! ta,a! le5+7 ta! ta,a! ,ee5aran K# a+lla
Ke5an A5e5 aae -etra
*I RIN6KASAN RESUME)SILENT -EATURES&
Anamne#i#
#enjolan ,a-a ,a4u-ara !anan ata5 5eja! 0 +nu 4an lalu. #enjolan a;aln4a 5ee-ar
+5ul7 laa=!elaaan ertaa* e5ar. #enjolan 4an -+ra5a!an !en4al7 n4er+ te!an7
!eera*an7 *anat -an -ea. Ter-a,at na>5u a!an e!uran -an erat a-an
enurun. $a-a ,eer+!5aan >+5+! aae -etra teraa 5eua* a55a ,a-a !ua-ran
!anan ata57 entu! ulat 7 u!uran /0 37 7 !on5+5ten5+ luna! !en4al7 mobile7 erata5
jela57 n4er+ te!an (@)7,eneluaran -+53*are t+-a! a-a. T+-a! teraa ,ee5aran K#
a!5+la. &a5+l US ter-a,at a5e5 aae
*II DIA6N,SIS KER8A
A$#e# mamae "ek#tra
Da5ar -+ano5+5 -ar+ *a5+l anane5+57 ,eer+!5aan >+5+! -an ,eer+!5aan ,enunjan
-+-a,at!an
• #enjolan ,a-a ,a4u-ara !anan ata5 5eja! 0 +nu 4an lalu. #enjolan a;aln4a
5ee-ar +5ul7 laa=!elaaan ertaa* e5ar. #enjolan 4an -+ra5a!an !en4al7 n4er+
te!an7 !eera*an7 *anat -an -ea. Ter-a,at na>5u a!an e!uran -an erat
a-an enurun. $a5+en en4u5u+ ana!n4a t+-a! tunta5 5e*+na a5+* a-a ASI 4an
ter5+5a -an t+-a! -+!eluar!an.
-
8/17/2019 Status Bedah Dhita
13/15
• $eer+!5aan >+5+! aae -etra teraa 5eua* a55a ,a-a !ua-ran !anan ata57
entu! ulat 7 u!uran /0 37 7 !on5+5ten5+ luna! !en4al7 mobile7 erata5 jela57 n4er+
te!an (@)7,eneluaran -+53*are t+-a! a-a. T+-a! teraa ,ee5aran K# a!5+la.
• &a5+l US ter-a,at a5e5 aae
*III DIA6N,SIS DI--ERENTIAL
; Ki#taPayu"ara
• D+,+!+r!an a-an4a !+5ta !arena enjolan 4an ter-a,at ,a-a ,a4u-ara7 n4er+7
-an -a,at -+era!!an
• Da5ar 4an t+-a! en-u!un *a5+l ,eer+!5aan US t+-a! enaar!an
a-an4a !+5ta ,a-a ,a4u-ara 4an +a5an4a ta,a! le5+ -enan entu! un-ar
atau o?al -enan ata5 tea5 -an teratur7 an=e!o+!7 -an a-an4a ,en4enatan
a!u5t+! ,o5ter+or ( $AS )
enaat ta 811
-
8/17/2019 Status Bedah Dhita
14/15
-
8/17/2019 Status Bedah Dhita
15/15
top related