Download - 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
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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
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Ri
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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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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'