status bedah dhita

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


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


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


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


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:


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


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


8/15

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


9/15


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+>


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


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.


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


14/15


15/15

status bedah dhita

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