42
Pembimbing : dr. Toton Suryotono, Sp.PD  JUNI 2014  JUNI 2014 CLINICL CLINICL ST!" #$ INT"%N ST !" #$ INT"%N %SUD CINJU% %SUD CINJU% LAPORAN KASUS rmi N&'i&ti rmi N&'i&ti 200( )*0 12) 200( )*0 12)

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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.