kasus digestive cbd

7/26/2019 Kasus Digestive Cbd

1/13

KASUS DIGESTIVE CBD


2/13

Identitas

Nama : I Made Manggeran

RM : 1404540

Um!r : "4 t# $enis Ke%amin : &a'i(%a'i

)e'er*aan : )em+!at )at!ng

MRS : , Ag!st!s -014 R!*!'an : RSU Ganes#a


3/13

Anamnesis

Ke%!#an Utama : m!a% m!nta#

Ri.a/at )en/a'it Se'arang

)asien menge%!# m!a% m!nta# se*a' '!rang %e+i# 5

#ari SMRS M!nta# setia #a+is ma'an Ke%!#andisertai dengan n/eri ada !%! #ati dan seringterasa en!# .a%a! #an/a ma'an sedi'it

Se*a' - mingg! /ang %a%! m!n2!% '!ning ada matadan '!%it Ke%!#an disertai BAK 'e23'%atan seerti

.arna air te# dan BAB /ang +er.arna !2at seertidem!% sedi'it dengan re'!ensi - #ari se'a%i

Demam 6(7


4/13

Ri.a/at )en/a'it Da#!%!

Ri.a/at DM se*a' ta#!n /ang %a%!+er3+at terat!r di d3'ter !m!mde'at r!ma#

Ri.a/at )en/a'it Ke%!arga Disang'a%

Ri.a/at )eng3+atan

Ber3+at 'e RSU Ganes#a'em!dian dir!*!' 'e RS Sang%a#


5/13

)emeri'saan 8si'

Keadaan !m!m : %ema#

Gi9i : 2!'!

GCS : 45,

TD : 100,0 mm;g RR : -0


6/13

T#3ra' :

I : Simetris

)a% : N/eri 6(7 V3'a% @remit!s ??

)er : S3n3r

A! : $ant!ng : S1S- t!ngga% reg!%ar m!rm!r )!%m3 : S!ara naas esi'!%er ?? R3n2#i (( Bising ((

A+d3men:

I : Distensi 6(7

A! : BU 6?7 N3rma%

)a% : S3ee% N/eri te'an 6?7 eigastri!m ;ear dan &ientida' tera+a mem+esar

)er : Timani

E'stremitas : a'ra% #angat edema 6(7


7/13

)emeri'saan en!n*ang

Darah lengkap (05/8)

BC ">5 &

Ne! 451

&/m 4-1

M3 =,

E3 ,>

Ba 04

;+ 10> gd&

;2t ==-

MC; -= &

MC;C =-5 &

MCV 01 &

)%t -=010= &

Kimia darah (31/7)

SGFT 10, U&

SG)T >5 U&

;+S Ag : 6(7 Bi%ir!+in T3ta% : "4 mgd&

Bi%ir!+in dire' : ," mgd&

A%+!min 1

GDS =-= mgd&

BUN 11mgd&

SK 11 mgd&


8/13

Serum elektrolit(31/7)

Na 1=4 mm3%&

K -5 mm3%&

C% 5 mm3%&

Faal hemostasis (5/8)

))T 144 deti' K3ntr3% 144 deti'

A)TT -, deti'

K3ntr3% =-1 deti'

INR 1-=


9/13

Urine &eng'a 65>7

Berat *enis : 1010

; : "

&e! : 500 6???7

Nitrat : 6(7

)r3tein : -5 6?7

G%!'3sa 6!rine7 : N3rma% Ket : 6(7

Ur3+i%in3gen : N3rma%

Bi%ir!+in 6!rine7 : 16?7

Er/ : negatie

arna : 23'%at Sedimen : &e!'3sit 4(,%

Eritr3sit 6(7

Se% Eite% Geeng =(5%

Ba'teri 6?7


10/13

Pemeriksaan S! "#dome n;ear :

%3+!s 'anan tida' mem+esar %3+!s 'iritida' mem+esar

S!d!t ta*am tei rata

E2#3 aren2#/ma masi# n3rma% Vena 3rta tida' me%e+ar

Vena #eati2a n3rma%

Tama' di%atasi I;BD C;BD dan CBDdista% dengan +at! 6?7 !'!ran -45 2mdinding mene+a%

Massa 6(7 'ista 6(7 a+ses 6(7

GB :

s!%it diea%!asi

)an2reas :

!'!ran n3rma% e2#3 aren'im n3rma%n3d!%'ista 6(7

&ien :

tida' mem+esar e2#3 aren2#/man3rma% massa'ista 6(7

Gin*a% Kanan 'iri :

!'!ran n3rma% e2#323rte< #3m3gens/stem e%i232a%/2ea% tida' me%e+ar+at!'istamassa 6(7

VU :

terisi !rine 2!'! tama' ene+a%andinding ta' tama' +at!

Kesan $

%holangiopath& dengan #atu %'Ddistal pnp *5 +m

!' sulit die,aluasi

%&stitis


11/13


12/13


13/13

Diagn3sis: i'ter!s 3+str!'si et 2a!sa+at! CBD

)r3gn3sis: d!+ia ad +3nam

kasus digestive cbd

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