CBD Dr Lusito Ardya New2

8/19/2019 CBD Dr Lusito Ardya New2

1/20


2/20

CASE BASED DISCUSSION

ADVISOR : DR. LUSITO, SP.PD

PRESENTED BY :ARDYA GARRY SUSENO01.211.6334COASS INTERNA

SULTAN AGUNG ISLAMIC HOSPITAL


3/20

PATIENT`S IDENTITY

Name : Ny. S

Age : 59 y.o

Sex : ema!e

Re!"g"o# : $oe%!em

&o' : Pe(aga#g %em'a)o

No. $e("*a! Re*o+( : 01152391

A((+e%% : Tega! Re,o +- 0/09 Sem T"m+.

Room a+e : Ba"-! a 1

Da-e "# : 2-4 o o*-o'e+ 2015

Da-e o- : 01

-4

o #oem'e+ 2015 S-a-% a+e : &7N #o# PB


4/20

A#am#e%"%

7e!a# U-ama : BAB )o#%"%-e#%" *a"+ 10 x (a!am %a- a+"

R"8aya- Pe#ya)"- Se)a+a#g :

O#%e- : 4+

7+o#o!og" : Pa%"e# me#ga!am" 'e+)a!")a!" BAB (e#ga#)o#%"%-e#%" *a"+ %ea+" '"%a "#gga 10 x (a# ma!m#-a.

7a!"-a% : BAB *a"+ me#yem;+o-


5/20

History of Illnss

History of !r"io#s illnssH$rt %is$s &istory

'() Hy!rtnsion &istory

'() Ast&*$ &istory

'() D+ &istory '()

+$$ '() Allry '()

-$*ilys &istory of %is$s• Hy!rtnsion &istory '()

• Ast&*$ &istory '()

• D+ &istory

'()


6/20

So%"oE*o#om"* @"%-o+y

• B/r0$ s1$$i !%$$n s*1$/o• P$sin ti%$/ *ro/o/• P$sin ti%$/ *in#* *in#*$n 1r$l/o&ol• P$sin tin$l 1rs$*$ An$/


7/20

2nr$l : 3$/ '4), $1%o*in$l !$in '4)

S/in : it6&in '(), 0$#n%i6 '(), !$l '4), /rinH$% : &$%$6& '()Eys : 1l#rr% "ision '(), r%ys '(), i6tri6 s6lr$ '(7()E$rs : &$rin loss '(), %is6&$r '()Nos : nos1l% '(), %is6&$r '()

+o#t& : 6y$nosis '(), t&r#s& '(), 1l%in #*s '() T&ro$t : !$in s3$llo3'(), &o$rsnss '(), %i86#lt ins3$llo3in '()

N6/ : nl$r*nt of t& l$n% '(), n$! !$in '()C&st : 6o#& '(), s!#t#* '(), 1loo% '()C$r%i$6 : 6&st !$in '()

Disti" : $1%o*in$l !$in '4), %6r$s% $!!tit '(), n$#s$ '4), "o*itin '4), %f6$t7*i6si

'474)+#s6#los6lt$l : 3$/ '4), rii% '(), 1$6/ !$in '()E9tr*ity : o%* infrior 9tr*ity '(), 6$!il$ry

r8l s6on%

Syst*i6 An$*nsis


8/20

Ge#e+a! S-a-%

◦ 2nr$l : ;$/ '4)

◦ A3$rnss : 6o*!os*ntis

◦ N#trint St$t#s

Hi&t < =>? 6* $n% 3i&t < >> /

B+I < BB'/)7TB@'*@) < >> /< >> /7'=,>? *)@@

< >>7,>< >>7,>

< , 'nor*o3i&t)< , 'nor*o3i&t)

PHYSICAL EA+INATIONS


9/20

Vit$l Sin

o Bloo% Prss#r : =?7 ?**H

o H$rt r$t : fr. 97*in#ts

o Br$t& -r#n6y: 97*in#ts

o T*! : F,o C

H$% : +so6!&$l, $lo!si$ '()

Eys : An*i6 Con0#nti"$'(7(), I6tri6

s6lr$'(7(), *$t$ 6/#n '4) Nos : sy**tri6, s6rt '(), Nostril Br$t& '()

E$rs : Nor*$l S&$!, %is6&$r '(7()

Eso!&$#s : Hy!r*i6 '(), !$in %"o#r '()

+o#t& : Cy$nosis '(), %ry li!s '4),

N6/ : Tr$/&$ %"i$tion '(), Ly*!& Hy!rtro!y '()

E9tr*ity : O%* of lo3r $n% #!!r 9tr*ity '()

6$!il$ry r8l s6on%


10/20

THORA ( LUN2

NSPE7S ANTEROR POSTEROR

St$ti6 RR : 97*in, Hy!r!i*nt$tion'(), t#*or '(), inG$**$tion '(), s!i%rn"i '(), H*it&or$9 D


11/20

CARDIAC• Ins!6tion : I6t#s 6or%is isnt sn.

• P$l!$tion : I6t#s 6or%is is !$l!$1l $t ICS VI 6* lin$ *i%6l$"i6#l$ sinistr$, t&rill '(), !#ls#s !i$stri#* '(),

!#ls#s !$r$(strn$l '(), strn$l lift '().

• Pr6#ssion : %#ll so#n%

U!!r 1or%rlin of &$rt : SIC II lin$ strn$lissinistr$

;$ist of &$rt : SIC III lin$ !$r$strn$lissinistr$

Lo3r ri&t 1or%rlin of &$rt : SIC V lin$ strn$lis

%9tr$ Lo3r lft 1or%rlin of &$rt : SIC VI lin$ *i% 6l$"i6#l$

sinistr$• A#s6#lt$tion

Aort$ "$l" : S= J S st$n%$rt, $%%ition$l so#n% '(), AI

A P#l*on$l "$l" : S= J S st$n%$rt, $%%ition$l so#n%#-e+;+e-a-"o# : No+ma!


12/20

A1%o*n Ins!6tion : 6on"9 of s#rf$6'4), sy6$tri6'(), stri$'(),

nl$r*nt of "n$ '(), 6$!#t *%#s$ '()

A#s6#lt$tion : !rist$lti6 in6r$s 97*nit '4)

P$l!$tion S#!rsi$l : s#!l, *$ss '() D!r : $1%o*in$l !$in '4), &!$r J

lin $rnt !$l!$1l, +#r!&ys sin '() 't#ror

1#r#/)

Pr6#ssion : ty*!$ny, si% of %$f '(), s&iftin%#llnss '() H!$r : %$f '4), li"r s!$n %9tr$ == 6*, li"r

s!$n sinistr$ M 6*

#-e+;+e-a-"o# : a'(om"#a!

;a"#


13/20

E9tr*itis

E/str*it$s s#!rior infrior

( O%* (7( (7(( 6ol% 9tr*itis (7((7(( P&ysioloi6$l rG9 474

474( I6tri6 (7((7(


14/20

L$1or$tory`s E9$*in$tionexamination +e%!-

H1 =, 7%l 'L)

Ht >,

L#6o6yt =M, ri1#7#L

T&ro*1o6yt ? ri1#7#L

*em"*a!'!oo(

+e%!-

Natrium =,= **ol7L

Kalium ,= **ol7L

chloride =?F,M **ol7L

calsium . *7%l

#-e+;+e-a%":>e)o%"-o%"%@";o)a!em"a

@";e+*!o+em"a@";o*a!%em"a


15/20


16/20

EG #-e;+e-a-"o#EG #-e;+e-a-"o#


17/20

Data of Abnormality

An$*nsis :

=.BAB 6$ir =? 97&$ri

.L*$s

.P#6$t

.2$*!$n &$#s

>.Bi1ir /rin

M.Nyri !r#t

P&ysi6$lE9$*in$tion:•Ge#e+a! S-a-%F. $%$$n #*#*l*$s. T#ror /#lit

*n#r#n

A1%o*nt. Nyri $1%o*n

A%"$n6

E9$*in$tion:

•H*$toloi=?. L#/osit : =M,ri1#7#L

•

/i*i$

==. $li#* : .=**ol7L

=. C&lori% : =?F.M**ol7L

=.C$lsi#* : ,*7%l

•EC2

=. SVT


18/20

PROBLEM LIST

=. 2$strontritis $/#t '=,,=?)

. D&i%r$si',,,>,F,,==,=,=)


19/20

2ASTROENTERITIS AUT

A%% :

◦ 2$strontritis 1$/tri$l, 2$strontritis "ir#s, 2$strontritis !$r$sit, 2$strontritis non inf/si.

;. Dx : Da+a +-"# BGA 7!-+ e%e%

;. Tx : Re"(+a%" *a"+a# o+a! ORA>T Re"(+a%" *a"+a# ;a+e#-e+a!


20/20

DEHIDRASI

A%% : De"(+a%" +"#ga# De"(+a%" Se(a#g De"(+a%" Be+a-.P.Dx : BGA)"m"a (a+a.

P.Tx : Re"(+a%" *a"+a# o+a! ORA>T Re"(+a%" *a"+a#;a+e#-e+a!

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CBD Dr Lusito Ardya New2