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8/16/2019 Case 1 Dr. Febie Sp. PD Fix
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8/16/2019 Case 1 Dr. Febie Sp. PD Fix
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Anamnesis
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Identitas Pasien
N"m" : (n. %
)$i" : '1 !"h*n
%eni$ +el"min : Pri" S!"!*$ Per#"in"n : el*m meni#"h
l"m"! : /*m"h S*$*n W"d*#
Pl*i!
Pe#er""n : Peg""i e#$pedi$i
g"m" : $l"m
("ngg"l "$*# : 23 pril 2016 01.00 W
("ngg"l Peri#$" : '0 pril 2016
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Dem"m "!*#
+lini#:• Di"gn$i$
(&phid
+lini#2704• /: ( 9 c"ir"ndi r.ple*r"• b"! 5 *rin mer"h
/S% 2304
1 minggu 1 minggu 1 minggu
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Keluhan Utama
Se$"# $e"# 1 mingg* S/S
Keluhan Tambahan
"!*# $e"# ' mingg* S/S Dem"m $e"# ' mingg* S/S
Ple*ri!ic che$! p"in
Se$"# $""! !id*r ;
d*d*#
Dem"m m"l"m h"ri,
#ering"! dingin
Pen*r*n"n
di$"ng#"l
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Riwayat Penyakit Dahulu
/i"&"! pen&"#i! pern"p"$"n di$"ng#"l
/i"&"! pen&"#i! D, hiper!en$i, #le$!erl di$"ng#"l.
Riwayat Kebiasaan
Riwayat Sosial
er## 1 b*ng#*$ min.h"ri 10 !"h*n
/i"&"! #n$*m$i "l#hl di$"ng#"l
d"n&" "ngg!" #el*"rg" &"ng $"#i! $er*p" di$"ng#"l
Pe#er""n: e#$pedi$i
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Pemeriksaan Fisik
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Pemeriksaan Umum & Tanda ital
+e"d""n *m*m : S"#i! $ed"ng
+e$"d"r"n : Cmp$ en!i$
(e#"n"n d"r"h : 12080 mm
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Status Antro!ometrik
er"! "d"n : 50 #g
(inggi "d"n : 160 cm
( : 13.5'1 #gm
2
S!"!*$ AiBi : Nrm"l en*r*! "$i"-p"$i?i#
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Pemeriksaan Fisik "1#
+ep"l" : nrmceph"li, de?rmi!"$ -
"!" : +n*ng!i" nemi$ --, S#ler" #!eri# --,
p*pil 'mm'mm, re?le#$ c"h"&" 99
(eling" : de?rmi!"$ -, $er*men --, membr"n
!imp"ni in!"#in!"#
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Pemeriksaan Fisik "%#
%"n!*ng
n$pe#$i : #!*$ #rdi$ !id"# !erlih"!
P"lp"$i : #!*$ #rdi$ !er"b" di CS line"
mid#l"i#*l"ri$ #iri Per#*$i :
"!"$ "!"$ : CS line" mid#l"i#*l"ri$ $ini$!r"
"!"$ #i : CS line" mid#l"i#*l"ri$ $ini$!r"
"!"$ #" : CS line" $!ern"li$ de#$!r"
*$#*l!"$i : % 1 d"n % 2 reg*l"r, m*rm*r -, g"llp -
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Pemeriksaan Fisik "#
bdmen
n$pe#$i : !"mp"# r"!"
P"lp"$i : $*pel, !id"# !erd"p"! n&eri !e#"n
Per#*$i : !imp"ni $el*r*h regi "bdmen *$#*l!"$i : ) 9, 1' #"limeni!
E#$!remi!"$ :
#r"l h"ng"!, C/(2 de!i#, edem" ----, !*rgr#*li! b"i#, #e#*"!"n m!ri# 5555
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Pemeriksaan Penun'ang
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Foto Toraks PA
(el"h dil"#*#"n ?! !r"#$ P deng"n h"$il:
("mp"# konsolidasi homogen di hemi!r"#$#"n"n &"ng men*!*pi b"!"$ #"n"n "n!*ng,
$in*$ d"n di"?r"gm" #"n"n.
Cr: $*li! die"l*"$i #"ren" b"!"$ #"n"n
!er!*!*p per$el*b*ng"n.
r!": nrm"l
P*lm: +ed*" hil*$ !id"# meneb"l. ("mp"#
in?il!r"! di "pe#$ #"n"n, l"p"ng"n "!"$ p"r*
#iri $er!" l"p"ng"n !eng"h #"n"n
Sin*$ c$!r?reni#*$ d"n di"?r"gm" #iri nrm"l
(*l"ng d"n "ring"n l*n"# dinding #e$"n b"i#
Kesan( T) !aru du!leks dengan e*usi !leurakanan
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Pemeriksaan Darah "1#
D"r"h r*!in
>e*#$i! 3.500µ>
(rmb$i! 238.000µ>
>ED 82 mm"mG
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Pemeriksaan Darah "$#
Ele#!rli!
N" 128 mml>G
+ '.' mml>
C" 1.03 mml>
Cl 10' mml>
F*ng$i Ain"l
)re*m 17 mgd>
+re"!inin 0.7 mgd>
Al*#$" $e"#!*: 113
mgd>
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Resume Pri" '1 !"h*n #el*h"n *!"m" $e$"# $e"# 1 mingg*, dem"m d"n b"!*# $e"# ' mingg*.
Se$"# dir"$"#"n !er*$ mener*$, !er*!"m" p"d" p$i$i !id*r"n, ber#*r"ng #e!i#" p$i$i d*d*#. D"d" $ebel"h
#"n"n dir"$"#"n ber"! p"d" $""! bern"p"$ Dem"m dir"$"#"n !er*!"m" p"d" m"l"m h"ri di$er!"i deng"n
#ering"! dingin. "!*# !"np" di$er!"i d"h"#, b"!*# d"r"h di$"ng#"l. /i"&"! mer## 9
PF
+e$"d"r"n : Cmp$ en!i$
(e#"n"n d"r"h : 12080 mmED 82 mm"mG, N" 128 mml>G
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Assessment
Pri" '1 !"h*n deng"n:
E?*$i e.c. ( p"r* n
( 1 mingg*
CPH
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Tatalaksana
/""! n"p d"l"m b"ng$"l Die! beb"$ 1800 ##"l
#$igen 2 lpm deng"n n"$"l c"n*l
FD N"Cl 0.3 1500 cc24 "m
b"!
Ce?!ri"=ne 2=1 gr"m Aen!"mi$in 2=80 mg
(
/: 1=400 mg P
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Tin'auan Pustaka
2lini0al *eatures Pneumonia Tuber0ulosis
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2lini0al *eatures Pneumonia Tuber0ulosis
i#rrg"ni$me "#!eri, ir*$, ?*ngi .(b
rg"n $&$!em >*ng$ >*ng$, !her rg"n$.
/"dilgi$ Depend$Cn$lid"!in, re!ic*lnd*l"r
p"!!ern, e!c
Fibr$i$ necr$i$ in *pper ;ler, /e!ic*lnd*l"r p"!!ern,
c"i!&, e!c.
P.E. Feer, he"d"che, $e"!ing,m&"llgi"
Chrnic c*gh, e"#ne$$,h"emp!&$i$
Sp*!*m *l# $p*!*m 9 prd*c!iec*gh
Sp*!*m mild r "b$en! 9 nnprd*c!ie c*gh
Di"gn$i$ Che$! r"digr"ph$, clinic"l "n!*=, r"digr"?i, clinic"l
(re"!men! n?ec!in !re"!men! i!hPenicillinCeph"l$prin
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Dys!nea
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+ur A!!roa0h
n"mne$": r!pne": C
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Pneumonia
n?e#$i p"d" p"ren#im !aru
d&$pne", ?eer, prd*c!iec*gh,
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3ani*estasi Klinis
Der""! #ep"r"h"n pen&"#i! !erg"n!*ng d"ri $!r*#!*r p"r* &"ng
!er#en".
Dem"m d"n !"#i#"rdi" .
"!*# nn prd*#!i? "!"* prd*#!i? m*#id, p*r*len!, d"r"h
+e!erlib"!"hn ple*r": ple*ri!ic che$! p"in
PF: pengg*n""n !! K !! !"mb"h"n *n!*# bern"p"$
p"lp"$i: ?remi!*$ !"#!il &"ng mening#"! "!"* men*r*n
per#*$i: d*ll: #n$lid"$i
?l"!: e?*$i ple*r"
*$#*l!"$i: cr"c#le$ , $*"r" n"p"$ brn#i"l d"n ple*r"l
?ric!in r*b
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De?ini$i: n?e#$i &"ng di$eb"b#"n leh &cb"c!eri*m
!*berc*l$i$
Tuber0ulosis
Ae"l" *m*m ( p"r*:
"!*# prd*#!i? ; 2 mingg* &"ng di$er!"i ge"l"
pern"p"$"n $eper!i $e$"# n"p"$, n&eri d"d", b"!*#
d"r"h d"n "!"* ge"l" !"mb"h"n $eper!i men*r*nn&"
n"?$* m"#"n, men*r*n ber"! b"d"n, #ering"! m"l"m
d"n m*d"h lel"h
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Di"gn$i$ (
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( (re"!men! +"!egri 1: 2
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Ple*r"l E?*$$in
Pengel*"r"n ; Pen&er"p"n c"ir"n rngg" ple*r"
Pleural 4**ussion
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Pola !ikir
(r"n$*d"!
Cnge$!ie c"rdi"c ?"il*re
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45!e0ted results(ADA 6 7 IU8 atau In* 17 !gm8
Protein 6 97: ;s< Serum== -lu0ose 0on0entration
!> =?
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Di$#*$i d"n per!"n&""nH
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(