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LAPORAN KASUSPASIEN
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IDENTITAS PASIEN
• Nama : Tn. S
• Umur : 42 tahun
• Jenis kelamin : Laki-laki
• Alamat : Karantenah ! "in#nan -Pasuruan
• Peker$aan : S%asta
• Status &erka%inan : 'enikah
• Aama : Islam
• (ansal : )al 'elati
• N# *' : 2+-2,-2
• Tanal 'asuk : /kt#0er 2,1
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ANA'NESA
• KELUAN UTA'A: 'untah
• *i%a3at &en3akit sekaran :
&asien atan ke I5D enan keluhan muntahtia& kali makan an minum le0ih ari +67 8air7
arah 9-7 mual 9;7 (A( seikit an 8air7 selain itu
&asien meneluh n3eri &aa selankanan kiri
karena tim0ul 0en$#lan ; 4 0ulan 3an lalu anmun8ul 0en$#lan i &erut kanan atas an tenah
atas ; < 0ulan 3an lalu.
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*I"A=AT PEN=AKIT
DAULU• *i%a3at i&ertensi : isankal
• *i%a3at Dia0etes 'ellitus : isankal
• *i%a3at sesak : isankal
• *i%a3at 0atuk lama : isankal
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*I"A=AT S/SEK/ 5I)I
• (ia3a kesehatan itanun #leh (PJS
P(I.
• (e0era&a hari terakhir7 se$ak sakit na>su
makan &asien menurun7 makan alam
$umlah seikit.
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DATA /(JEKTI?
Keaaan umum : Tam&ak lemah
Kesaaran : K#m&#smentis7 5@S E4'1
Tana Bital
T : ,C, mm 90er0arin
N : ,6Cmenit7 reuler7 Isi an teanan 8uku&
** : 2 6 C menit
t : <71 F@ 9aksiler
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PE'E*IKSAAN ?ISIK
• Ke&ala:
aC iC 8C : -C-C-C-
• Leher: &em0esaran K5( 9-
&eninkatan JP 9-
eBiasi trakea 9-
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PE'E*IKSAAN ?ISIK• Th#ra6
Ins&eksi : 0entuk simetris7 $e$as 9-7 s&3er naB3 9-7&ererakan aa simetris
Pal&asi :
• Pulm#: >remitus suara menurun &aa sisi kiri7 >remitus ra0a
menurun &aa sisi kiri• @#r: kuat ankat7 i8tus 8#ris tera0a 2 8m meial i I@S 1
linea mi8laBikula sinistra7 &ulsus &arasternal 9-7 &ulsus
e&iastrium 9-
Perkusi :
• Pulm#: reu& &aa l#0us in>eri#r sinistra
• @#r: alam 0atas n#rmal
Auskultasi :
• Pulm#: suara na>as menurun &aa l#0us in>eri#r sinistra
• @#r: S S2 tunal7 murmur 9-7 all#& 9-
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Pemeriksaan Penun$anPemeriksaan Hasil Nilai Normal
Lek#sit <,71 <7+,-,7
Eritr#sit 174 47,-47
em#l#0in <74 27-472
emat#krit 45,4 <+7+-1<7+
'@ <7, 7-7,
'@ 247 2+7,-<72
'@@ 271 <7-<174
*D" <7< 71-471
Tr#m0#sit 2 11-<
'P 72, 7,-,7
Neutr#>il 27 7<-7
L3m>#sit 7 7,-27
'#n#sit ,7<2 ,724, ! ,7+,
E#sin#>il ,7,<4 ,7,<, ! ,744,
(as#>il ,72<, ,7,,-,7,,
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Pemeriksaan Penun$an
Pemeriksaan Hasil Satuan Harga normal
S5/T 2 UCL G<
S5PT < UCL G4
(UN 'CDl -2,
SK ,7 'CDl G7<
Natrium <7 m.m#lCl <-44
Kalium 472 m.m#lCl <7-17
@hl#ria 7 m.m#lCl +-,<
i@alsium .,4 7-7<1
5DA 93 'Cl G2,,
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Th#ra6 ?#t#
@/* : N#rmal
Pulm#: tum#r
metastase &aru an
e>usi &leura sinistra
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?#t# PelBis
Kesim&ulan :Kesan &elBis
n#rmal
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US5 A(D/'EN
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? ll t l +C,C2,1
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?#ll#% u& tl +C,C2,1
S N3eri &aa selankanan kiri an &erut atas terutama $ika i&akai
0er$alan7 muntah 6 9;7 mual 9;7 (A( 8air 67 na>su makanmenurun
/ T: ,C+, N: **: 24Status l#kalis: tera&at 0en$#lan ; ,8m &aa e&iastrium7hi&#k#nrium e6tra 8m7 an iinuinal sinitra ; 18m. (en$#lanmelekat &aa asar7 n3eri tekan 9;7 &ermukaan rata7 0atas $elas7
k#nsistensi &aat ken3al
A Tum#r a0#men ; sus&. Lim>aen#&ati T( lim>#ma malina
P In>. LeB#>l#6asin 61,,m iB ri&7 in$. 'er#&enem <67 in$. *anitiin26am&7 in$. Santaesik <6am&7 in$. Neur#san0e 6am&7 ne0ul
&ulmi8#rtC $am7 &#. @#itam 6ta0
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?#ll#% u& tl C,C2,1
S N3eri &aa selankanan kiri an &erut atas terutama $ika i&akai
0er$alan7 muntah 9-7 mual 9-7 (A( 8air 2 67 na>su makan menurun
/ T: ,,C, N: 1 **: 24Status l#kalis: tera&at 0en$#lan ; ,8m &aa e&iastrium7hi&#k#nrium e6tra 8m7 an iinuinal sinitra ; 18m. (en$#lanmelekat &aa asar7 n3eri tekan 9;7 &ermukaan rata7 0atas $elas7k#nsistensi &aat ken3alPittin #eema &aa e6t in>eri#r.
A Tum#r a0#men ; sus&. Lim>aen#&ati T( lim>#ma malina
P In>. LeB#>l#6asin 61,,m iB ri&7 in$. 'er#&enem <67 in$. *anitiin26am&7 in$. Santaesik <6am&7 in$. Neur#san0e 6am&7 ne0ul
&ulmi8#rtC $am7 &#. @#itam 6ta0
P6. ?NA( tunu hasil
? ll t l 2,C,C2,1
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?#ll#% u& tl 2,C,C2,1
S N3eri &aa selankanan kiri an &erut atas terutama $ika i&akai
0er$alan7 muntah <6 9;7 mual 9;7 (A( 8air 67 na>su makanmenurun
/ T: 2,C, N: **: 24Status l#kalis: tera&at 0en$#lan ; ,8m &aa e&iastrium7hi&#k#nrium e6tra 8m7 an iinuinal sinitra ; 18m. (en$#lanmelekat &aa asar7 n3eri tekan 9;7 &ermukaan rata7 0atas $elas7
k#nsistensi &aat ken3alPittin #ema &aa e6tremitas in>eri#r
A Tum#r a0#men ; sus&. Lim>aen#&ati T( lim>#ma malina
P In>. LeB#>l#6asin 61,,m iB ri&7 in$. 'er#&enem <67 in$. *anitiin
26am&7 in$. Santaesik <6am&7 in$. Neur#san0e 6am&7 ne0ul&ulmi8#rtC $am7 &#. @#itam 6ta07 8e>i6ime 26ta07 #me&raH#le26ta0
asil ?NA(: metastase @a m#erate i>>erentiate
? ll t l 2C,C2,1
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?#ll#% u& tl 2C,C2,1
S N3eri &aa selankanan kiri an &erut atas terutama $ika i&akai
0er$alan7 muntah 9-7 mual 9-7 na>su makan menurun/ T: ,,C+, N: **: 2,
Status l#kalis: tera&at 0en$#lan ; ,8m &aa e&iastrium7hi&#k#nrium e6tra 8m7 iinuinal sinitra ; 18m7 an mun8ul0en$#lan 0aru &aa rei# a6ila e6tra ; 8m7 th#ra6 &#steri#rsinistra an e6tra iatas s8a&ula ; 18m an 28m7 th#ra6 &#steri#r
&araBerte0ra e6tra ; +8m7 an th#ra6 anteri#r sinistra I@S ; 28m.(en$#lan melekat &aa asar7 n3eri tekan 9;7 &ermukaan rata7 0atas $elas7 k#nsistensi &aat ken3al
A Tum#r a0#men ; sus&. Lim>aen#&ati T( lim>#ma malina
P TS &aru K*S
&#. @#itam 6ta07 8e>i6ime 26ta07 #me&raH#le 26ta0
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