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7/24/2019 230827386 Laporan Kasus Chf
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Pembimbing : dr. Toton Suryotono, Sp.PD
JUNI 2014 JUNI 2014
CLINICLCLINICL ST!" #$ INT"%NST!" #$ INT"%N%SUD CINJU%%SUD CINJU%
LAPORAN KASUS
rmi N&'i&tirmi N&'i&ti200( )*0 12)200( )*0 12)
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n&mne+i+ d&n Pemeri+&&n
$i+i
T&ngg&- 04 Juni 2014 Puu-
0.*0 /I
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Identit&+ P&+ien
Ny S, ** t&un, +eor&ng perempu&n beer3& di +&&.Ny S +ud& meni& +e3& 14 t&un y&ng -&-u , d&nte-& mempuny&i 2 or&ng &n&. Ny S bertemp&ttingg&- di Ci3u-&ng de+& P&+&r d&-&m &bup&ten
Ci&n3ur.
Ny S +e&ri5&riny& beer3& d&ri puu- 0).00 p&gi+&mp&i deng&n puu- 12.00 +i&ng. Sore +&mp&i
m&-&m &ri Ny S &ny& di rum&. Peer3&&n inidi-&u&n o-e Ny S +e3& 2 t&un y&ng -&-u, tet&pi+e3& +&it +eit&r 1 bu-&n y--, Ny S tid& beer3& -&gi,di&ren&&n +&itny& ini.
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6e-u&n Ut&m&
Se+& n&p&+ +e3& 7 1 bu-&n y&ng -&-u
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TimelineTimeline
Sesak
Mudah lelah
Sesak napas makinberatJantung berdebar-debarNyeri dadaNyeri uluhati, mualBengkak pada kaki
Mudah lelah
1996 2005 2011 Keluhan saat
datang ke RS
1 bulan
SMRS
Hamil anak 1
Sesak berat
Batuk
Hamil anak 2
Sesak berat
Batuk
Lemas
Sesak napasJantung berdebar-debarBengkak pada kakihilang timbulMudah lelah
Nyeri uluhati
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%i&y&t Peny&it D&u-u
P&+ien mu-&i menge-u +e+& n&p&+ +e3& u+i& 18t&un, +e+& y&ng dir&+&&n i-&ng timbu-, +e+&m&in bert&mb& eti& p&+ien &mi- &n& pert&m&d&n edu&, emudi&n +e+& berur&ng eti& p&+ien
me-&ir&n. 9enurut peng&u&n ibu p&+ien, eti&p&+ien m&+i ei- tid& pern& menge-u +e+&n&p&+ &t&upun nyeri d&d&. P&+ien ber&ti;it&+ +epertitem&n5tem&nny&, d&n p&+ien +ering iut o-&r&g&&+ti d&n -&ri, tet&pi tid& &d& e-u&n +&m& +e&-i.
%i&y&t d&r& tinggi di+&ng&-
%i&y&t gu-& d&r& di+&ng&-
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Riwayat Penyakit Keluarga
%i&y&t peny&it 3&ntung di+&ng&-
%i&y&t &+m&di+&ng&-
%i&y&t iperten+idi+&ng&-
%i&y&t D9 di+&ng&-
Riwayat Pengobatan
Seti&p +e+& n&p&+p&+ien +e-&-u minumneon&p&+in, +e+&berur&ng.
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%i&y&t P+io+o+i&-
P&+ien m&&n ter&tur *< +e&ri. ti;it&+ p&+ien+emen3& 1 bu-&n be-&&ng&n ini +em&in berur&ng&ren& p&+ien mud& -e-&. Seingg& &ti;it&+ dirum& -ebi b&ny& berb&ring, tidur d&n ur&ng
o-&r&g&. P&+ien tid& meroo, tid& +u& minumopi d&n tid& mengon+um+i &-oo-.
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Pemeri+&&n $i+i
Ny. S u+i& ** t&un deng&n e&d&&numum p&+ien t&mp& +&it +ed&ng, -em&,
e+&d&r&n p&+ien Compo+ menti+ d&n
ooper&ti= +&&t di &n&mne+i+.
TD 120!90 mmHg
N : 126x/ menitRR 26"!menit
Suhu #6$%
Tanda-tanda vital
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6ep&-& : Normoep&-
9&t& : 6on3ungti;& &nemi+ 5>5, S-er&iteri 5>5, %e?e< pupi- @>@, pupi-
bu-&t, i+oor
Aidung:De;i&+i +eptum n&+i 5>5, Seret5>5 "pi+t&+i+ 5>5, Pern&p&+&n
uping idung B5 9u-ut : Si&no+i+ B5, ibir ering B5,
Stom&titi+ B5, Lid& otor B5
StatusGeneralis
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L&n3ut&n. . .
Te-ing& : Normoti&, Tid& &d& +erumen y&ng e-u&r
Leer : Pembe+&r&n 6! B5, Pembe+&r&n e-en3&rtiroid B5, Leer nyeri te&n B5, JVP meningkat
Tor&< : Normoe+t, 3&ring&n p&rut B5
Pu-mo : In+pe+i +imetri+, penggun&&n ototb&ntu n&p&+ B5, retr&+i dinding d&d& B5, b&gi&nd&d& y&ng tertingg&- B5
P&-p&+i ;o&- =remitu+ +&m& edu& -&p&ng p&ru
Peru+i +onor p&d& edu& -&p&ng p&ru
u+u-t&+i ;e+iu-&r @>@, crackles !"ee'ing 5>5
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L&n3ut&n...
Cor: In+pe+i ictus cor#is tam$ak $a#a V%
P&-p&+i ictus cor#is teraba #i %&S V% ke ara'lateral Linea a(illaris anterior sinistra
Peru+i b&t&+ 3&ntung &n&n p&d& ICS II -ine&p&r&+tern&-i+ de<tr&, b&t&+ 3&ntung iri &t&+ p&d& ICS II-ine& p&r&+tern&-i+ +ini+tr&, batas kiri bawa'$a#a %&S V% lateral linea a(illaris anteriorsinistra
u+u-t&+i J I d&n II norm&-, regu-er, gallo$ )*" murmur sistolik )e+ection systolic*
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L&n3ut&n...
bdomen :
In+pe+i cembung , 3&ring&n p&rut B5u+u-t&+i bi+ing u+u+ +u-it dini-&i
P&-p&+i Nyeri tekan )*,
,e$ar teraba - +ari bac" te$i tum$ul" $ermukaanrata" nyeri tekan )*
Lien tid& ter&b&, nyeri te&n B5
Peru+i re#u$ )*" s'i.ting #ullness )*
Punggung :
P&-p&+i ;o&- =remitu+ +&m& edu& punggung
Peru+i +onor p&d& edu& -&p&ng p&ru, CE 5>5
u+u-t&+i Ee+iu-&r @>@, crackles !, roni 5>5, ee'ing 5>5
"+tremit&+ : &r&- &ng&t, e#ema //! , C%T F 2 deti
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A&+i- Pemeri+&&nL&bor&torium t&ngg&- 2( 9ei
2014
HEMATOLOGI Hasil Nilai rujukan Satuan
Hematologi Rutin
Hemoglobin 13. 1! " 1# g$%L
Hematokrit &'.( 3( ) &( *
Eritrosit &.+& &.! " +.& 1',#$-L
Leukosit 11.1 &. " 1'. 1',3$-L
Trombosit 1(( 1+' " &+' 1',3$-L
M/ 0.# ' " 0& L
MH 3'.& !( " 31 2gMH 33.0 33 " 3( *
R4)S +1.1 3( ) +& L
54 1!. 0 " 1& L
M5/ 1'.1 " 1! L
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Lanjutan6HEMATOLOGI Hasil Nilai rujukan Satuan
differential
LYM % 35! !" # 3" %
M$ % &!' ( # && %
N)* % 5!' '( # +( %
bslutLYM . !5 &(( # &'3 &(/301L
M$ . &" ( # &! &(/301L
N)* . "+ &2 # +" &(/301L
/ /
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Lab tanggal 31/0/1!
&D' 90
S&'T 210
(reum #5)#
Kreatinin 1*0
(R+,
-arna .ingga
Ke/ernihan .ernih
Berat /enis 1*020
H 6*0
,itrit ,egati
'rtein 25!13
&luksa ,rmalKetn ,egati
(rbilingen 1!13
Bilirubin 1!13
4ritrsit 10!13
Leuksit ,egati
"ikr#sk#$is urin 31/0/201!
Leksit 12
4ritrsit 2#
4itel 5Kristal ,egati
Silinder ,egati
Lainlain ,egati
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Pemeri+&&n "6!B*1 9ei 2014
1* +rama /antung 7ritmia) Heart Rate 166"
dm2* Segmen 'R 8 0*2) kmlek RS 80*12)
+nter:al T ; 0*
#* 7"is abnrmal right a"is de:iatin
* atlgis) ST ele:asi dan T in:erted
negati
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Datar Masalah
CA$ = III e.
tri&- $ibri-&+i e
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1. CA$
d&-& +u&tu e&d&&n p&toG+io-ogi+ dim&n&
3&ntung g&g&- mempert&&n&n +iru-&+i &deu&t
untu ebutu&n tubu me+ipun te&n&n
pengi+i&n uup.
!&g&- 3&ntung p&-ing +ering di+eb&b&n o-e g&g&-
ontr&ti-it&+ mio&rd, +eperti y&ng ter3&di p&d&
in=&r mio&rd, iperten+i -&m&, &t&u &rdiomiop&ti.
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Diagnsis dari gagal /antung daat
didasarkan atas kriteria Framingham
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%lasi&ikasi Ne' (#rk Heart )ss#*iati#n
+H,
Der&3&t I T&np& eterb&t&+&n p&d&
&ti;it&+ G+i. ti;it&+G+i bi&+& tid&
menyeb&b&n e-eti&n,p&-pit&+i, +e+&, &t&u
nyeri d&d&
Der&3&t IId& -imit&+i &tiGt&+
G+i, timbu- +e+& n&p&+,r&+& -e-&, p&-pit&+i,deng&n &tiGt&+ G+ibi&+& n&mun ny&m&n
deng&n i+tir&&t
Der&3&t IIItiGt&+ G+i +&ng&t
terb&t&+. tiGt&+ G+iur&ng d&ri bi&+& +ud&
menimbu-&n ge3&-&,
tet&pi ny&m&n +e&tu
0era+at %VKeti#akmam$uanuntuk men+alani
akti1itas 2sik a$a$unSetia$ akti1itas 2sik
#ilakukan" maka rasa
Harrison’s principles of Internal Medicine 17th Edition Volume II
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%lasi&ikasi +H,
agal .antung %iri
is$neu
<rthneu ar#ksimal
N#kturnal s$neu
atuk "uda lela
&elisah dan %emas
agal .antung %anan
itting edema
He$at#megali )sites
)n#reksia
,kturia kelemaan
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'emeriksaan enun/ang
'ada 4K& ditemukanhiertri :entrikel kiri)kelainan gelmbang STdan gel#mbang TDari t traks terdaat
$embesaran jantungdan bendungan $aru4'ada ekhkardigrai
terlihat embesaran dandisungsi :entrikel kiri)kelainan bergerak katumitral saat diastlik*
'ada 4K& asienditemukan hiertri:entrikel kanan dan
right a"is de:iasi Dari t traks
asien terdaat
embesaran /antungdan bendungan aru*
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7lgrithm r Treatment =H>
Harrison’s principles of Internal Medicine 17thEdition Volume II
Di&gno+i+ o= A$ onGrm
++e++ =or ?uid retention
No ?uid retention?uidretention
Diureti
C"inibitorHet& b-oer
%
-do+terone &nt&goni+tAydr&-&'ine>i+o+orbide
digo<in
NA I5IE
Per+i+tent+ymptom+or +pei&-
popu-&tion
H% i= C"5into-er&nt
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'enatalaksanaan
1. Diureti ter&py .urosemi# 34 5 634 mg! 'r
2. Inibitor+ o= te %enin5&ngioten+in5-do+teron +y+tem
5 C" inibitor+ ca$to$ril 7839mg 6(!'ari
5 ngioten+in II reeptor b-oer E&-+&rt&n 10 mg tie & d&y
5 Spirono-&tone 28 mg>r
*. et& -oer B &;erdi-o-, metopro-o- +uin&te, bi+opro-o-
4. Digit&-i+ g-yo+ide+
8. E&+odi-&tor+
. Combin&tion o= medi&- ter&py). Po+iti;e ionotropi &gent+ B dobut&min
. C&-ium &nne- b-oer+ B &m-odipin
(. ntio&gu-&tion B &r=&rin
10.nti&rritmi ter&py B &miod&rone
11.St&tin ter&pyCMDT 2013
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2. tri&- $ibri-&+i
tri&- Gbri-&+i &d&-& +u&tu t&i&ritmi&
+epr&;entriu-er deng&n &r&teri+ti &ti;it&+
&trium y&ng tid& teroordin&+i deng&n
on+euen+i ter3&diny& perburu&n =ung+i
me&ni &trium
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4tilgi
? =H>
? H@ertensin
? 7ge ; A5 @ears? Diabetes melitus
? Strke
? =ardim@ath@
CMDT 2013
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Diagnsis
Irregu-&r-y irregu-&r e&rt rytm
U+u&--y t&y&rdi
#=ten &++oi&ted it p&-pit&tion+ or=&tigue
"C! +o+ err&ti &tri&- &ti;ity it
irregu-&r ;entriu-&r re+pon+e Aig inidene &nd pre;&-ene in te
e-der-y popu-&tion
CMDT 2013
l
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Tanggal S O A P
02>0>14 P&+ienmeng&t&&n+e+& n&p&++ud&
berur&ng,tet&pi +e+&+em&inbert&mb&eti&ber&ti;it&+p&+ien 3&-&n e
toi-et, m&+imenge-u
3&ntungberdeb&r5deb&r,nyeri d&d&+ebe-& iriy&ng i-&ng
timbu-, perutembung, mu&-B@, beng&p&d& edu&tung&i
TD : 110>0 mmAgN : 124<>mS: *8,(KC%%: 22<>mnt
C 5>5, JEPmening&t
Cor:&rdiomeg&-i @, J I II regu-er, g&--opB5 murmur +i+to-i
pu-mo: ;e+iu-er,r&-e+@>@, / 5>5
bdo: NT +e-uru-&p&ng &bdomen,U @, +i=ting
du--ne++ @, ep&rter&b& 2 3&ri b.&.,permu&&n -iin,tid& bebrben3o-5ben3o-, tepi tumpu-
"+tremit&+ :dingin, edem& @>@,
1. CA$ = III e.C&rdiomyop&ty
2. tri&- Gbri-&+ideng&n %&pid
Eentriu-&r%e+pon+e
1. "6! u-&ng2. $oto
%ontgent Tor&< P
*. US! Aep&r4. IE$D N&C-8. $uro+emid
*<20 mg. C&ptopri-
*<,28).
Sirnlaktn #"100 mg
). #mepr&'o-1<1
1. "6! u-&ng
2. Digo+in1<1
T l S O A P
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Tanggal S O A P
0*>0>14 P&+ien m&+i+e+& n&p&+tet&pi +ud&berur&ng,
m&+imenge-u 3&ntungberdeb&r5deb&r,nyeri d&d&+ebe-& iriy&ng i-&ng
timbu-, perutembung, mu&-B@, beng&p&d& edu&tung&i mu-&iberur&ng
TD : 110>0 mmAgN : 11<>mS: *KC%%: 20<>mnt
C 5>5, JEPmening&t
Cor:&rdiomeg&-i @, J I II regu-er, g&--opB5 murmur +i+to-i
pu-mo: ;e+iu-er,r&-e+@>@, / 5>5
bdo: NT +e-uru-&p&ng &bdomen,U @, +i=ting
du--ne++ @, ep&rter&b& 2 3&ri b.&.,permu&&n -iin,tid& bebrben3o-5ben3o-, tepi tumpu-
"+tremit&+ :dingin, edem& @>@,
1. CA$ = III e.C&rdiomyop&ty
2. tri&- Gbri-&+ideng&n %&pidEentriu-&r%e+pon+e
1. "6! u-&ng2. $oto
%ontgent Tor&< P
*. IE$D N&C-4. $uro+emid*<20 mg
8. C&ptopri-*<,28
.Sirnlakt
n #"100 mg. #mepr&'o-
1<1
1. "6! u-&ng2. Digo+in
1<1
T l S O A P
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Tanggal S O A P
04>0>14 Se+& n&p&++ud&berur&ng,&d&ng 3&ntung
berdeb&r5deb&r,nyeri d&d&+ud&berur&ng,perut embung,mu&- B@,beng& p&d&
edu& tung&iberur&ng
TD : 120>0 mmAgN : 11<>mS: *KC%%: 20<>mnt
C 5>5, JEPmening&t
Cor:&rdiomeg&-i @, J I II regu-er, g&--opB5 murmur +i+to-i
pu-mo: ;e+iu-er,r&-e+ @>@, / 5>5
bdo: NT +e-uru-&p&ng &bdomen,U @, +i=ting
du--ne++ @, ep&rter&b& 2 3&ri b.&.,permu&&n -iin,tid& bebrben3o-5ben3o-, tepi tumpu-
"+tremit&+ :dingin, edem& @>@,
1. CA$ = III e.C&rdiomyop&ty
2. tri&- Gbri-&+ideng&n %&pidEentriu-&r
%e+pon+e
1. "6! u-&ng2. Tunggu
&+i- $oto%ontgent
Tor&< P*. IE$D N&C-4. $uro+emid
*<20 mg8. C&ptopri-
*<,28.
Sirnlaktn #"100 mg
. #mepr&'o-1<1
1. "6! u-&ng
2. Digo+in1<1
P i "6!
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Pemeri+&&n "6!B4 Juni 2014
1* +rama /antung 7ritmia) Heart Rate 150"
dm2* Segmen 'R 8 0*2) kmlek RS 80*12)
+nter:al T ; 0*
#* 7"is abnrmal right a"is de:iatin
* atlgis) ST ele:asi dan T in:erted
negati
T l S O A P
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Tanggal S O A P
08>0>14 P&+ien +ud&tid& menge-u+e+& n&p&+,m&+i
menge-u 3&ntungberdeb&r5deb&r,nyeri d&d&di+&ng&-, perutembung,,beng& +ud&
tid& &d&
TD : 110>00 mmAgN : 112<>mS: *KC%%: 1<>mnt
C 5>5, JEPmening&t
Cor:&rdiomeg&-i @, J I II regu-er, g&--opB5 murmur +i+to-i
pu-mo: ;e+iu-er,r&-e+ @>@, / 5>5
bdo: NT +e-uru-&p&ng &bdomen,U @, +i=ting
du--ne++ @, ep&rter&b& 2 3&ri b.&.,permu&&n -iin,tid& bebrben3o-5ben3o-, tepi tumpu-
1. CA$ = III e.C&rdiomyop&ty BPerb&i&n
2. tri&- Gbri-&+ideng&n %&pidEentriu-&r%e+pon+e
1. $oto%ontgent
Tor&< P2. IE$D N&C-
*. C&ptopri-*<,28 *
Sirnlaktn #"100 mg
1. Digo+in1<1
P i T P B8 J i
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Pemeri+&&n Tor&< P B8 Juni2014
A&+i-
Cor&&n brono;&+u-ermening&t, ep&-i+&+i B@, i-&r&'e B@, t& t&mp&inG-tr&t>on+o-id&+i>pem&d&t&n-im=&nodi
6edu& +inu+ o+to=reniu+ -&nip
Di&=r&gm& -iin, t& mend&t&r
Cor : CT% -ebi d&ri 0,8
Si+tem& tu-&ng int&t
6e+&n
C&rdiomeg&-i deng&nbendung&n p&ru
Si+tem& tu-&ng y&ngter;i+u&-i+&+i int&t
P i US! U bd
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Pemeri+&&n US! Upper bdomenB8 Juni 2014
6e+&n Li;er onge+tion, urig&
e. %igt +ided e&rt=&i-ure
T& t&mp& e-&in&np&d& p&nre&+, E$, Lien,d&n edu& ren
T& t&mp& met&+t&+ep&d& org&n5org&n
ter+ebut T& t&mp&
-im=&denop&typ&r&&otr&
Tanggal S O A P
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Tanggal S O A P
0>0>14 P&+ien +ud&tid& menge-u+e+& n&p&+,m&+i
menge-u 3&ntungberdeb&r5deb&r,nyeri d&d& B5,perutembung,,beng& +ud&
tid& &d&
TD : 110>00 mmAgN : 112<>mS: *KC%%: 1<>mnt
C 5>5, JEPmening&t
Cor:&rdiomeg&-i @, J I II regu-er, g&--opB5 murmur +i+to-i
pu-mo: ;e+iu-er,r&-e+ @>@, / 5>5
bdo: NT +e-uru-&p&ng &bdomen,U @, +i=ting
du--ne++ @, ep&rter&b& 2 3&ri b.&.,permu&&n -iin,tid& bebrben3o-5ben3o-, tepi tumpu-
1. CA$ = III e.C&rdiomyop&ty
Bperb&i&n
1. tri&- Gbri-&+ie.
*1. IE$D N&C-4. $uro+emid
*<20 mg8. C&ptopri-
*<12,8
1. Digo+in1<1
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Terim& 6&+i
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%i&y&t Peny&it Se&r&ng
P&d& +&&t p&+ien beru+i& 18 t&un, p&+ienbeer3& +eb&g&i pemb&ntu rum& t&ngg&.P&+ien meng&u b&ru pert&m& &-i meng&-&mi
e-u&n +e+& n&p&+. Se+& n&p&+ +em&inbert&mb& eti& p&+ien beer3& -ebi ber&td&n p&+ien +ering menge-u mud& -e-&.
J&ntung berdeb&r5deb&r d&n nyeri d&d&
di+&ng&-. P&+ien +ering di &nt&r o-em&3i&nny& untu berob&t e doter &ren&e-u&nny& itu. Sete-& beber&p& &-i berob&t,e-u&npun berur&ng.
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%i&y&t Peny&it Se&r&ng
P&+ien beru+i& 24 t&un d&n +ed&ng meng&ndung&n& pert&m&. P&+ien meng&t&&n e-u&n +e+&n&p&+ timbu- emb&-i terut&m& eti& p&+ien &mi-di trime+ter etig&. Se+& n&p&+ di+ert&i deng&n
b&tu ering. Tet&pi +e+& berur&ng 3i& p&+ienberi+tir&&t d&n tidur mem&&i * -&pi+ b&nt&-. P&+ienme-&ir&n &n& pert&m& deng&n -&ir +pont&ndito-ong o-e duun ber&n&, d&n tid& &d& m&+&-&
+e-&m& pro+e+ me-&ir&n. n& p&+ien 3ug& -&irdeng&n e&d&&n +e&t. Sete-& me-&ir&n &n&pert&m& ini p&+ien tid& pern& menge-u +e+&n&p&+ -&gi.
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%i&y&t Peny&it Se&r&ng
P&+ien beru+i& *0 t&un d&n meng&ndung &n& edu&.P&+ien meng&t&&n b&& memi-ii e-u&n y&ng
+&m& +eperti +&&t meng&ndung &n& pert&m&. Se+&n&p&+ timbu- emb&-i terut&m& eti& p&+ien &mi- di
trime+ter etig&. Se+& n&p&+ di+ert&i deng&n b&tu. Tet&pi +e+& berur&ng 3i& p&+ien beri+tir&&t d&ntidur mem&&i * -&pi+ b&nt&-. P&+ien rutinmemeri+&&n e&mi-&nny& di bid&n +etemp&t. P&+ienme-&ir&n &n& edu& deng&n -&ir +pont&n dito-ong
o-e duun ber&n&, d&n tid& &d& m&+&-& +e-&m&pro+e+ me-&ir&n. Sete-& me-&ir&n &n& edu& inip&+ien tid& pern& menge-u +e+& n&p&+ -&gi.
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%i&y&t Peny&it Se&r&ng
P&+ien beer3& +eb&g&i +eor&ng pet&ni, bi&+&ny& p&+ienmu-&i beer3& p&d& puu- 0).00 /I +&mp&i 3&m 12.00/I. Tet&pi +e-&m& 1 bu-&n S9%S ini p&+ien +eringpu-&ng -ebi &&-, di&ren&&n p&+ien +ering menge-u+e+& n&p&+, +e+& n&p&+ +em&in ber&t eti& p&+ienber&ti;it&+ ber&t. D&n +e+& n&p&+ berur&ng eti&p&+ien beri+tir&&t. P&+ien 3ug& +ering terb&ngun &ren&+e+& tib&5tib& p&d& m&-&m &ri. P&+ien 3ug& +ering
menge-u ep&t -e-& d&n &d&ng di+ert&i deng&n 3&ntung berdeb&r5deb&r. Nyeri d&d& di+&ng&-. P&+ien 3ug& +ering menge-u nyeri p&d& u-u &ti, mu&-d&n perutter&+& embung. eng& p&d& &i i-&ng timbu-
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%i&y&t Peny&it Se&r&ng
P&+ien perempu&n beru+i& ** t&un beer3& +eb&g&ipet&ni d&t&ng e U!D %SUD Ci&n3ur deng&n e-u&n+e+& n&p&+. Se+& n&p&+ +em&n ber&t eti&p&+ien ber&ti;it&+, d&n berur&ng 3i& p&+ien
beri+tir&&t d&n mem&&i * b&nt&-. P&+ien 3ug&+ering menge-u ep&t -e-& d&n &d&ng di+ert&ideng&n 3&ntung berdeb&r5deb&r d&n nyeri d&d&+ebe-& iri. P&+ien 3ug& +ering menge-u nyeri p&d&
u-u &ti, perut ter&+& penu d&n mu&- t&pi tid&di+ert&i deng&n munt&. P&+ien d&t&ng deng&nbeng& p&d& edu& tung&i. d&n 6 tid& &d&e-u&n.