STATUS ILMU PENYAKIT DALAM SMF PENYAKIT DALAM RUMAH SAKIT UMUM DAERAH KOJA Nama Mahasiswa : Gatot

Triwono Tan a tan!an : NIM : ""#"$$$#%%& Do't(r P(m)im)in! : Dr* S+,anna N raha- s.PD IDENTITAS PASIEN Nama /(n!'a. T(m.at tan!!a/ /ahir Stat+s .(r'awinan P('(r3aan A/amat A. ANAMNESIS Diam)i/ ari : A+toanamn(sis Keluhan utama : 8a) 4arna hitam s(3a' " hari smrs* Riwayat penyakit sekarang : S(3a' & tah+n s()(/+m mas+' r+mah sa'it os m(n!a'+ s(rin! m(n!a/ami )(n!'a' an n9(ri .a a s(n i /+t+tn9a* K(ti'a itan9a a.a'ah rasa sa'itn9a t(ta. ata+ s(ma'in )(rtam)ah os m(n!ata'an )iasan9a rasa sa'itn9a t(r+s )(rtam)ah sam.ai '((so'an harin9a rasa sa'it t(rs()+t ti a' )(rtam)ah /a!i t(ta.i t(rsa san!at sa'it s('a/i sam.ai os ti a' a.at )(r iri ata+.+n )(r3a/an* Os 3+!a m(n!ata'an 3i'a s( an! 'am)+h- s(/ain )(n!'a' an n9(ri- /+t+tn9a 3+!a m(rah an t(ra)a .anas* Os s(rin! min+m o)at : o)at r(mati' 9an! i)(/i os i war+n!* Os ti a' in!at nama o)atn9a* Os m(n!a'+ s(rin! m(n!a/ami m+a/- m+ntah- s+'ar m(n(/an an n9(ri .(r+t )a!ian t(n!ah s(3a' 0 )+/an s()(/+m mas+' r+mah sa'it* Os 3+!a m(rasa t+)+hn9a s(ma'in hari s(ma'in /(mas- 6(.at /(/ah an .an an!ann9a )(r'+nan!#'+nan! s(3a' " )+/an s()(/+m mas+' r+mah sa'it* OS m(n!a'+ .(rnah irawat ina. i s()+ah r+mah sa'it s(/ama "" hari 'ar(na m+a/- m+ntah- an n9(ri .(r+t )a!ian t(n!ahn9a 0 min!!+ s()(/+m mas+' r+mah sa'it ini* Os )+an! air )(sar )(rwarna hitam- 3+m/ah )an9a' s(3a' " hari s()(/+m mas+' r+mah sa'it* Riwayat penyakit dahulu : Tan!!a/ : 0&#"%#0%%2 Jam: "%*%% : : : : : Tn* K K()+m(n- 0% no1 "$2& M(ni'ah 4iraswasta J/* 5i/in6in! Pa!i I No: 07 J(nis '(/amin S+'+ )an!sa A!ama P(n i i'an : La'i#/a'i : In on(sia : Is/am : STM

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;#< 6a6ar air ;#< i=t(ri ;#< )at+' r(3an ;#< 6am.a' ;#< in=/+(n,a ;#< tonsi/itis ;#< 'ho/(ra ;#< (mam r(+mati' ;#< .n(+monis ;#< ./(+ritis ;#< t+)(r'+/osis ;#< ma/aria Riwayat keluarga H+)+n!an Ka'(' N(n(' A9ah I)+ Sa+ ara Ana'#ana' +m+r # # &% &% 2? 7 oran!

;#< is(ntri ;#< h(.atitis ;#< ti=+s a) omina/is ;#< s'ro=+/o (rma ;#< si=i/is ;#< !onor( ;#< hi.(rt(nsi ;#< +/'+s .(.ti'+m ;1< !astritis ;#< )at+ (m.( + ;#< )at+>in=('si sa/+ran '(mih ;#< h(rnia

;#< .rostat ;#< wasir ;#< ia)(t(s ;#< a/(r!i ;#< asthma ;#< t+mor ;#< h(mo=i/ia ;#< (.i/(.si ;#< stro'( ;#< .si'osis ;#< o.(rasi ;#< '(6(/a'aan

K(a aan '(s(hatan m(nin!!a/ m(nin!!a/ m(nin!!a/ m(nin!!a/ m(nin!!a/ s(hat

P(n9()a) '(matian t+a t+a t+a t+a sa'it #

Adakah kera at yang menderita : P(n9a'it Ya A/(r!i # Asthma # T+)(r'+/osis # R(mati' # Hi.(rt(nsi # Dia)(t(s # E.i/(.si # T+mor>Kan'(r # 4asir # Jant+n! # Gin3a/ # Lam)+n! # ANAMNESIS SISTIM Ti a' H+)+n!an @ # @ # @ # @ # @ # @ # @ # @ # @ # @ # @ # @ #

5atatan '(/+han tam)ahan .ositi= i sam.in! 3+ +/#3+ +/ 9an! )(rsan!'+tan Kulit ;#< )is+/ ;#< .i!m(ntasi ;#< '+'+ Kepala ;#< tra+ma ;#< 1(rti!o Mata ;#< n9(ri ;#< s(6r(t ;#< /+'a ;#< '(rin!at ma/am ;1< ram)+t ;#< sin'o. ;#< mi!rain( ;#< !ata/ ;#< '+nin!>i't(r+s ;#< sianosis ;#< '+nin!>i't(r+s

;#< n9(ri ;#< ma'ro>mi'ro6(.ha/ ;#< ra an! ;1< !an!!+an .(n!/ihatan ;.r(s)io.i< ;#< tinnit+s

Telinga ;#< n9(ri ;#< s('r(t ;#< !!n .(n (n!aran ;#< !ata/ !idung ;#< tra+ma ;#< (.ista'sis Mulut ;#< )i)ir ;#< stomatitis ;#< sa/i1asi Tengg"r"kan ;#< n9(ri #eher ;#< )(n3o/an Dada ;#< n9(ri ;#< )at+' A d"men ;1< '(m)+n! ;#< h(mat(m(sis ;#< 'o/i' ;#< m(n6r(t ;1< tin3a warna t(r ;#< n9(ri ;#< .(n9+m)atan ;#< !+si ;#< !!n .(n!(6a.

;#< s('r(t ;#< !!n .(n6i+man ;#< s(/a.+t ;#< trism+s

;#< .(r+)ahan s+ara ;#< n9(ri ;#< )(r ()ar ;#< h(ma.to( ;1< m+a/ ;#< is=a!ia ;#< .(r+t m(m)(sar ;1< m(/(na ;#< )(n3o/an

;#< )is+

;#< s(sa' ;#< orto.no( ;1< m+ntah ;1< n9(ri .(r+t ;#< wasir ;#< st(atorro(

Kemih$kelamin ;#< is+ria ;#< '(n6in! )at+ ;#< 'o/i' ;#< an+ria ;#< .rostat( Katamenia ;#</(+'or(a

;#< .o/a'is+ri ;#< in'ontin(ntia ;#< o/i!+ria ;#< r(t(ntion

;#< h(mat+ria ;#< .9+ria ;#< o/i!o+ria ;#< '(n6in! m(n(t(s

;#< .(r arahan

;#< /ain#/ain ;#< n9(ri ;#< .ost m(no.a+s(

!aid ;#< hai t(ra'hir ;#< t(rat+r>ti a' ;#< 3+m/ah>/aman9a ;#< m(nar6h( ;#<!(3a/a '/ima't(ri+m Sara% dan "t"t ;#< an(st(sia ;#< '(3an! ;#< s+'ar m(n!in!at ;#< .in!san Ekstremitas ;1< )(n!'a' ;#< sianosis &ERAT &ADAN Rata#rata : # T(rtin!!i : # Saat ini : 2? T+r+n>nai'>t(ta. RI'A(AT !ID)P Riwayat kelahiran ;#< .ar(st(si ;#< a=asia ;#< ata'sia ;#< '( +tan ;1< n9(ri s(n i

;#< otot /(mah ;#< amn(sia ;#< hi.o>hi.(rt(si ;#< isartria ;#< (=ormitas

T(m.at /ahir : r+mah > )i an > r+mah sa'it )(rsa/in > )i an > +'+n > /ain#/ain Dito/on! o/(h : o't(r > )i an > +'+n > /ain#/ain Riwayat imunisasi ;#< h(.atitis ;#< 85G ;#< 6am.a' ;#< DPT ;#< .o/io ;#< t(tan+s

Riwayat makanan 2

Fr('+(nsi>hari J+m/ah>hari @ariasi>hari Na=s+ ma'an K(s+/itan

: : : :

AB" hari Porsi )iasa K+ran! K+ran!

: Ti a' a a

PEMERIKSAAN *ASMANI Pemeriksaan )mum Tin!!i )a an 8(rat )a an T('anan arah Na i S+h+ P(rna=asan K(a aan !i,i K(sa aran Sianosis O (ma +m+m Ha)it+s 5ara )(r3a/an Mo)i/itas P(r'iraan Um+r Aspek ke+iwaan Tin!'ah /a'+ Pros(s .i'ir Kulit 4arna Jarin!an .ar+t P(rt+m)+han ram)+t K(rin!at La.isan /(ma' Lain#/ain : : : : : : : : : : : : : : "2& 2? "%%>?%mmH! ?%B>mnt ACo5 Tora'oa) omina/- "7 B>mnt 5+'+. 5M Ti a' a a Ti a' a a Pi!ni'+s Norma/ Pasi= 7%

: wa3ar> !(/isah> t(nan!> hi.oa'ti=>hi.(ra'ti= : wa3ar> 6(.at> /am)at> waham> =o)ia> o)s(si

: : : : :

5o'/at m+ a Ti a' a a M(rata Um+m> s(t(m.at 5+'+.

(==/or(s(nsi .i!m(ntasi t+r!or i't(r+s sianosis

: Ti a' a a : Ti a' a a : 5+'+. : Ti a' a a : Ti a' a a

: Ti a' a a

&

Kelen+ar getah ening S+)man i)+/a : Ti a' t(ra)a S+.ra'/a1i'+/a : Ti a' t(ra)a Li.at .aha : Ti a' t(ra)a Kepala 8(sar D )(nt+' Sim(tri m+'a Mata EBo.htha/m+s Eno.hta/m+s K(/o.a' Kon3+n!ti1a S'/(ra L(nsa P+.i/ La.an! .(n!/ihatan D(1iatio 6on3+!(( Nista!m+s T('anan )o/a mata G(ra'an )o/a mata Telinga M(m)ran tim.ani G!n .(n (n!aran S(r+m(n P(r arahan S('r(t P(n9+m)atan : Norma/ : Sim(tri

/(h(r '(tia'

: Ti a' t(ra)a : Ti a' t(ra)a

E's.r(si wa3ah .(m)+/+h arah t(m.ora/

: Norma/ : T(ra)a

: : : : : : : : : : : :

Ti a' a a Ti a' a a Ptosis #># o (m #># )(n3o/an #># An(mis E>E ra an! #># I't(ri' #># 8(nin!> '(r+h Mi riasis> norma/> miosis >.in .oint Iso'or> non iso'or R(=/(' .+.i/ /an!s+n! E>E ti a' /an!s+n! E>E Norma/ Ti a' a a Ti a' a a M(nin!'at> norma/> m(n+r+n A'ti=> .asi=

: : : : : :

Inta'> ti Ti a' a Ti a' a Ti a' a Ti a' a Ti a' a

a' inta' a a a a a

Mulut 8i)ir Li ah S(/a.+t /(n ir Farin! Tonsi/ 8a+ .(rna=asan

: : : : : :

Ti a' sianosis- '(rin!> /(m)a)Ti a' 'otor Norma/ Hi.(r(mis> non hi.(r(mis m(m)(sar> ti a' Ti a' 'has

1(si'(/ ti a' a a

#eher T('anan 1(na 3+!+/aris ;J@P<: Norma/ K(/(na3ar tiroi : Ti a' t(ra)a .(m)(saran K(/(n3ar !(tah )(nin! : Ti a' t(ra)a .(m)(saran Dada 8(nt+' 8+ah a a Paru$paru Ins.('si Pa/.asi P(r'+si : Kiri Kanan : Norma/> )arr(/ 6h(st> .i't+s 6arinat+s : Sim(tris> ti a' ra an! Depan Sim(tris a/am '(a aan Statis D inamis &elakang Sim(tris a/am '(a aan Statis D inamis n9(ri ti a' a a

: =r(mit+s 'iriD'anan sama: Kiri Kanan Sonor .a a '( +a /a.an! .ar+

)(n3o/an ti a' a a-

Sonor .a a '( +a /a.an! .ar+

A+s'+/tasi

: 8+n9i .ar+ )ron'o1(si'+/(r Ron'i : Ti a' a a 4h((,in! : Ti a' a a Kr(.itasi : Ti a' a a : i6t+s 6or is ti a' tam.a' : i6t+s 6or is ti a' t(ra)a : 8atas atas : s(/a i!a II !aris .arast(rna/is 'iri 8atas )awah : s(/a i!a @ !aris mi 6/a1 'iri 8atas 'iri : s(/a i!a @ 0 3ari !aris mi 6/a1 'iri 8atas 'anan : s(/a i!a I@ " 3ari /at(ra/ !aris st(rna/is 'anan : 8+n9i Jant+n! I- II- r(!+/ar- '+at an!'at M+rm+r # Ga//o. #

*antung Ins.('si Pa/.asi P(r'+si

A+s'+/tasi

A d"men Ins.('si Pa/.asi : sim(tris- )(n3o/an ti a' a a- D(=ans m+s'+/ar ti a' a a : s+.(/ 8(n3o/an ti a' a a H(.ar ti a' t(ra)a Lim.a ti a' t(ra)a Gin3a/ ti a' t(ra)a N9(ri t('an (.i!astri+m : tim.ani C

P(r'+si

A+s'+/tasi

Shi=tin! +//n(ss n(!ati= N9(ri '(to' 'osto 1(rt()ra/ ti a' a a : 8isin! +s+s E m(n+r+n> norma/> m(nin!'at

Anus , Re-tum R(6ta/ to+6h( : Ton+s s.hin!t(r ani )ai' Am.+/a ti a' 'o/a.s it(m+''an =(s(s 6air )(rwarna hitam Ti a' it(m+'an arah

Angg"ta gerak L(n!an Otot Ton+s Massa S(n i K('+atan Lain#/ain T+n!'ai an 'a'i L+'a @aris(s Ton+s otot Massa otot S(n i K('+atan O (ma Lain#/ain : : : : : Normoton+s E+tro.i N9(ri ti a' a a- .(r!(ra'an )ai'Norma/ Ti a' a a

ra an! ti a' a a

: Ti a' a a : Ti a' a a : Norma/ : E+tro.i : T(r a.at ra an!- .(m)(n!'a'an- an n9(ri .a a arti6+/atio !(n+ sinistra : Norma/ : Ti a' a a : Ti a' a a

Re%leks ?

'anan T(n on 8is(. Tri6(. Pat(//a A6hi/(s Kr(mast(r K+/it Pato/o!is E E E E E

ti a' i/a'+'an ti a' i/a'+'an

'iri E E E
ti a' i/a'+'an

E
ti a' i/a'+'an ti a' i/a'+'an

#A&.RAT.RI)M Darah H) : &-2 Ht : "7 Trom)osit : A"$*%%% L(+'osit : CC%% LED : 2% Ur(+m : "70 Kr(atinin : 7-0 Asam +rat : ""*2

RIN/KASAN $

Anamn(sis T(/ah i.(ri'sa Pasi(n )(rnama T+an* K 9an! m(n!a/ami m(/(na s(3a' " hari Os s(oran! .ria )(r+m+r &$ tah+n atan! (n!an m(/(na " hari smrs* Os m(rasa t+)+hn9a s(ma'in hari s(ma'in /(mas an ti a' )(rt(na!a s(3a' " )+/an smrs* Os s(rin! m(n!a/ami '(m)+n!- m+a/- m+ntah- n9(ri (.i!astri+m - is=a!ia s(3a' 0 )+/an smrs* Os m(m.+n9ai riwa9at ra an! s(n i s(3a' & tah+n smrs 9an! 3i'a 'am)+h rasa sa'itn9a t(r+s )(rtam)ah sam.ai '((so'an harin9a rasa sa'it t(rs()+t ti a' )(rtam)ah /a!i t(ta.i t(rasa san!at sa'it s('a/i sam.ai os ti a' a.at )(r iri ata+.+n )(r3a/an* Os 3+!a m(n!ata'an 3i'a s( an! 'am)+h- s(/ain )(n!'a' an n9(ri- /+t+tn9a 3+!a m(rah an t(ra)a .anas* P(m(ri'saan 3asmani Tin!!i )a an 8(rat )a an T('anan arah Na i S+h+ P(rna=asan K(a aan !i,i Kon3+n!ti1a Pa/.asi A) om(n S(n i : : : : : : : : : : "2& 2? "%%>?%mmH! ?%B>mnt ACo5 Tora'oa) omina/- "7 B>mnt 5+'+. An(mis E>E N9(ri t('an (.i!astri+m T(r a.at ra an!- .(m)(n!'a'an- an n9(ri .a a arti6+/atio !(n+ sinistra

P(m(ri'saan .(n+n3an! H) : &-2 Ht : "7 LED : 2% Ur(+m : "70 Kr(atinin : 7-0 Asam +rat : ""*2

Diagnosis kerja

"%

"* 0* A* 2*

M(/(na (6 !astritis (rosi=a (6 o)at#o)at NSAID An(mia (6 m(/(na GGK (6 n(=ro.ati +rat Go+t Arthritis

Diagn"sis anding
"*a* )* 6* )* M(/(na (6 1aris(s (so.ha!+s .(6ah (6 6irhosis h(.atis M(/(na (6 !astro.ati (6 sirosis h(.atis M(/(na (6 (so=a!itis M(/(na (6 t+mor sa/+ran 6(rna

0*a* An(mia (=isi(nsi )(si )* An(mia (=isi(nsi asam =o/at 6* An(mia .(rni6iosa A*a* GGK (6 PN5 )* GGK (6 GNA 2*a* Rh(matio arthritis )* Ost(oartrosis

Pemeriksaan an+uran
"* En os'o.i 0* La)oratori+m: # Monitor H) an Ht s(tia. hari # Monitor (/('tro/it arah # Ana/isa !as arah # Kimia arah .rot(in s(r+m ;a/)+min- !/o)+/in D Ko/in (st(ras(< # F+n!si /i1(r SGPT- SGOT # Urin( /(n!'a. # P(m(ri'saan mor=o/o!i s(/ arah m(rah # TI85- S(r+m Iron A* As.irasi 6airan s(n i +nt+' .(m(ri'saan 'rista/ asam +rat 2* Foto Ront!(n AP an /at(ra/ arti6+/atio !(n+ sinistra

Penatalaksanaan
# Istirahat i t(m.at ti +r # P+asa 02 3am .(rtama- s(/an3+tn9a )(ri'an i(t /am)+n! "- har+s r(n ah .rot(in an .+rin # I@FD na6/ %-$F )(r!antian (n!an (Btros( "%F masin!#masin! 73am>'o/= # Pasan! ow(r 6ath(t(r +nt+' monitor )a/an6( 6airan ""

# Tran=+si PR5 sam.ai H) "%!ramF ata+ /()ih # In3('si D(Bam(thason( AB& m! i*1 # Ji'a s(ran!an a'+t !o+t s+ ah hi/an! )(ri'an +ri'ostati' A//o.+rino/ 0#AB "%%m!>hari

Pen-egahan
Unt+' m(n6(!ah t(r3a in9a !astritis (rosi=a '(m)a/i- ( +'asi .asi(n +nt+' ti a' s(m)aran!an m(min+m o)at NSAID*

Pr"gn"sis
A @itam A F+n!siona/ A sanationam : D+)ia a ma/am : Ma/am : Ma/am

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