kasus kecil_1st

8/9/2019 Kasus Kecil_1st

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Laporan Kasus Kecil

SEORANG WANITA USIA 47 TAHUN DENGAN SINDROM NEFROTIK

HI!ERTENSI STAGE II DAN HEMATURIA LEUKOSITURIA !OSITIF

Ole"#

Res$u Ma"aran% Aru&nin'$%as

G(((7)*+

!e&,i&,in'#

-r. Sa$ri%o -r. D"ani Re-"ono H. Sp.!D

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KEPANITERAAN KLINIK ILMU PENYAKIT DALAM

FAKULTAS KEDOKTERAN

UNIVERSITAS SEBELAS MARET/ RSUD DR. MOEWARDI

SURAKARTA

2011

DAFTAR MASALAH

No

.

Masalah Ak!" Ta#$$al Masalah I#ak!" Ta#$$al

1. S!#%&o' N("&o!k 2) A*&!l 2011

2. +!*(&(#s! Sa$( II 2, A*&!l 2011

2. +('a-&!a L(-kos!o&!a Pos!!" 2 A*&!l 2011

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LA!ORAN KASUS

I. ANAMNESA

A. I-en$i$as !en-eri$a

Na'a N. S

U'-& ), ah-#

(#!s K(la'!# Wa#!a

Ala'a Pla'*(la# 3/, S(#%a#$ Wo#o$!&!

S-k- a4a

A$a'a Isla'

Sa-s P(&ka4!#a# M(#!kah

P(k(&5aa# P(a#!

No. RM 01 06 27 ,7

Mas-k RS 2) A*&!l 2011

P('(&!ksaa# 2, A*&!l 2011

/. Kelu"an U$a&a

/en'0a0 -i seluru" ,a-an

1. Ri2a%a$ !en%a0i$ Se0aran'

S(5ak 81 '!#$$- s(9(l-' 'as-k &-'ah sak! *as!(# '(#$(l-hka#

9(#$kak %! s(l-&-h 9a%a#. B(#$kak (&-s:'(#(&-s !%ak h!la#$ saa *a$!

ha&! 9(#$kak !%ak 9(&k-&a#$ %(#$a# '!#-' o9a a#$ %!9(l! %! 4a&-#$

%a# 9(#$kak s('ak!# la'a s('ak!# '('9(sa&. Pas!(# 5-$a '(#$(l-hka#

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4/14

'-al:'-al. M-al %!&asaka# h!la#$ !'9-l !%ak %!s(&a! '-#ah. M-al

!%ak 9(&k-&a#$ %(#$a# *('9(&!a# 'aka# 5-$a !%ak 9(&a'9ah s((lah

'aka# *-s!#$ ;:ha&! C @ $(las<

R!4aa '!#-' ko*! ;:<

R!4aa '!#-' s-*l('(# %!sa#$kal

R!4aa 'aka# 'aka#a# 9(&l('ak/sa#a# %!sa#$kal

F. Ri2a%a$ !en%a0i$ pa-a Keluar'a

R!4aa *(#ak! $-la %!sa#$kal

R!4aa (ka#a# %a&ah !#$$! %!sa#$kal

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R!4aa s&ok( %!sa#$kal

R!4aa *(#ak! 5a#-#$ %!sa#$kal

R!4aa *(#ak! $!#5al %!sa#$kal

G. Ri2a%a$ Gi3i

Pas!(# 'aka# 2:3 kal!/ha&! #as! 1 (#o#$ %(#$a# sa-& %a# la-k

*a-k ah- ('*(. T(&ka%a#$ 'aka# (l-& !ka# 'a-*-# %a$!#$.

H. Ri2a%a$ Sosial E0ono&i

Pas!(# a%alah s(o&a#$ *(a#! %(#$a# sa-s sa4ah 9-ka# '!l!k

*&!9a%! ;sa4ah $a&a*a#


6/14

'aka# '(#-&-# ;: ? : @ $(las

9(l!'9!#$. Waa a!& k(#!#$ k-#!#$ 5(!h

BAK %a&ah ;:


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II. !EMERIKSAAN FISIK

A K(a%aa# U'-' Sak! s(%a#$ o'*os '(#!s $!G! k(sa# 9(&l(9!h

B Sa-s $!G! BBH , k$

TBH 10 '

L!#$ka& *(&- H 103 '

L!#$ka& *!#$$a#$ H 110 '

L!#$ka& *!#$$-l H 10 '

BMIH 333 k$/'2 ;+R H 1:22 k$/'2<

K(sa# overweight

Ta#%a V!al Te0anan -ara"# )7(8)(( &&H'

Na%! ) =/'(#! k-a !&a'a &($-l(& !s! %a#

($a#$a# -k-*

Fre0uensi Respirasi# 9: ;8&eni$

S-h- 36 0 *(& a=!lla&

K-l! Waa sa4o 'aa#$ -&$o& '(#-&-# ;:


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*('9(sa&a# k(l(#5a& !&o!% ;:i'urasi


9/14

a9sol- *a&-:h(*a& %! SI VI l!#(a '(%!o

la!-la&!s %(=&a.

K!&! So#o& 9aas *a&-:la'9-#$ s(!#$$! SI VIII l!#(a

'(%!o la!-la&!s s!#!s&a.

A-sk-las! Ka#a# S-a&a %asa& (s!k-l(& !#(#s!as #o&'al s-a&a

a'9aha# ;:<

K!&! S-a&a %asa& (s!k-l(& !#(#s!as #o&'al s-a&a

a'9aha# ;:<

Belakang

I#s*(ks! Sa!s No&'oh(s s!'(&!s s(la !$a !%ak '(l(9a&.

D!#a'!s P(#$('9a#$a# %a%a s!'(&!s ka#a# H k!&! s(la !$a

!%ak '(l(9a&

Pal*as! Sa!s S!'(&!s

D!#a'!s P(&$(&aka# ka#a# H k!&! s!'(&!s "&('!-s &a9a

ka#a# H k!&!.

P(&k-s! Ka / K! So#o& / so#o&.

A-sk-las! Ka#a# S-a&a %asa& (s!k-l(& #o&'al s-a&a a'9aha# ;:<

K!&! S-a&a %asa& (s!k-l(& #o&'al s-a&a a'9aha# ;:<

P-#$$-#$ K!"os!s ;:


10/14

$(&ak ;:


11/14

I@. R

E

S

U

M

E

11

98(4 9:8(4Sa$uan Nilai nor&al

He&a$olo'i

+9 +) 7( $/%l 12.3:1.3

+ 9+ 99 % 3:),

RB *+) 9.:( 106/µl ).10:.10

MV 7* /-' 0:76

M+ 9** P$ 2:33

M+ *)( $/%l 33:36

RDW )7+ J 11.6 1).6+DW 3.1 $/%l 2.2 3.2

MPV ) Fl ,.2 11.1

PDW 36 J 2 6

WB ., .2 103/µl ).:1).

:#(&o"!l

:l!'"os!

:'o#os!

:(os!#o"!l

:9aso"!l

,060

):(

),0

B((

020

J

J

J

J

J

:0

22:))

0:,

0:)

0:2

AT 2) 201 103/µl 10:)0

R(!k-los! J 0.:1.

LU J :

LED 1 5a' ''/5a' 0 1

LED 2 5a' ''/5a' :

PT D(!k 10:1

APTT D(!k 20:)0

INR D(!k :

Ki&ia 0lini0

+9A1 J ). .7

DS '$/%l 60:1)0

DP '$/%l ,0:110

D2PP '$/%l 0:1)0

ol. Da&ah O

SOT 27 -/l 0:3

SPT 10 -/l 0:)

ALP -/l 6:117

a''a T -/l C

B!l. To '$/%l 0.00:1.00

B!l. D!&(k '$/%l 0.00:0.30B!l. I#%!&(k '$/%l 0.00:0.,0

P&o. Toal 4)( $/%l 6.)0:.30

Al9-'!# 9)( $/%l 3.0:.20

lo9-l!# 200 $/%l :

K&(a!#!# ** *.+ '$/%l 0.6:1.1

U&(-' )(9 +: '$/%l C 0

Asa' -&a B4 '$/%l 2.):6.1

Kol. Toal 176 '$/%l 0:200

+DL Kol. 37 '$/%l 31:,

LDL Kol. 71 '$/%l :16T&!$l!s(&!%a 9): '$/%l C10

LD+ -/l 1)0:300

B(s! ;SI< -$/%l 2,:13

TIB -$/%l 22:)2

Sa.&a#s"(&!# J 1:)

Ki&ia Urin


12/14

S(5ak 81 '!#$$- s(9(l-' 'as-k &-'ah sak! *as!(# '(#$(l-hka#

9(#$kak %! s(l-&-h 9a%a#. B(#$kak (&-s:'(#(&-s !%ak h!la#$ saa *a$! ha&!

9(#$kak !%ak 9(&k-&a#$ %(#$a# '!#-' o9a a#$ %!9(l! %! 4a&-#$ %a#

9(#$kak s('ak!# la'a s('ak!# '('9(sa&. Pas!(# 5-$a '(#$(l-hka# '-al:

'-al. M-al %!&asaka# h!la#$ !'9-l !%ak %!s(&a! '-#ah. M-al !%ak

9(&k-&a#$ %(#$a# *('9(&!a# 'aka# 5-$a !%ak 9(&a'9ah s((lah 'aka#.

Pas!(# !%ak '(#$(l-hka# *-s!#$ %a# *as!(# !%ak %('a'.

K(%-a k(lo*ak 'aa 9(#$kak (ks&('!as aas %a# 9a4ah 9(#$kak.

BAK 8 3:) =/ha&! > ? : @ $(las 9(l!'9!#$ 4aa a!& k(#!#$ k-#!#$ 5(!h

BAK !%ak a%a %a&ah 9a- *as!& 5-$a !%ak a%a #(&! saa BAK *a#as

aa-*-# a#a#$:a#a#$a#. BAB 1=/ha&! > 1:1 @ $(las 9(l!'9!#$ l-#ak

4aa k-#!#$ k(oklaa# !%ak a%a l(#%(& %a&ah 'a-*-# BAB h!a'.

S(5ak 8 3 9-la# s(9(l-' 'as-k &-'ah sak! *as!(# '-la! '(&asaka#

-9-h 9(#$kak %! 4a5ah k('-%!a# s('ak!# la'a '(#5ala& k( s(l-&-h -9-h

'-al h!la#$ !'9-l BAK #o&'al BAB #o&'al.

S(5ak 6 9-la# s(9(l-' 'as-k &-'ah sak! *as!(# '(#$(l-hka# '-al:

'-al !%ak '-#ah *as!(# *(ah %!&a4a %! RS So(%!&a# Ma#$-# S-'ao

Wo#o$!&! %a# %a&! *!hak &-'ah sak! %!#aaka# sak! $!#5al.

Pa%a *('(&!ksaa# "!s!k %!%a*aka# k(a%aa# -'-' a'*ak sak! s(%a#$

sa-s $!G! -k-*. Pas!(# h!*(&(#s! o#5-#$!a *-a %a# (%('a *al*(9&a.

a#-#$ '(l(9a& k( a&ah a-%ola(&al (&%a*a *(kak s!s! %a# *(kak al!h *a%a

a9%o'(# s(&a * !!#$ o(%(' *a%a (ks&('!as s-*(&!o& %a# !#"(&!o&.

Pa%a *('(&!ksaa# la9o&ao&!-' %a&ah a#$$al 2 A*&!l 2011 %!%a*aka#

has!l *as!(# '(#$ala'! a#('!a h!*(&-&!s('!a h!*(&k&(a!#('!a

h!*(&&!$l!s(&!%a h!*okals('! *&o(!#-&!a h('a-&!a %a# l(-kos!-&!a.

@. DAFTAR A/NORMALITAS

1. K(%-a k(lo*ak 'aa 9(#$kak

2. Eks&('!as aas %a# 9a4ah 9(#$kak

3. M-al a#$ 9(&-la#$ '(#5ala& k( s(l-&-h -9-h %a# h!la#$ !'9-l

). +!*(&(#s!

. Tak!*#(-

6. Ko#5-#$!a *-a ;/<

,. E%('a *al*(9&a ;/<

. Ko#"!$-&as! 5a#-#$ '(l(9a& k( a&ah a-%ola(&al

7. E%('a *!!#$ ;< %! (ks&('!as s-*(&!o& %a# !#"(&!o&

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10. A#('!a s(%a#$

11. +!*(&k&(a!#('!a

12. +!*(&-&!s('!a13. +!*(&&!$l!s(&!%a

1). +!*okals('!a

1. P&o(!#-&!a

16. +('a-&!a

1,. L(-kos!-&!a

A9#o&'al!as 1 2 3 6 , 10 11 12 13 1) 1 S!#%&o' N("&o!k

A9#o&'al!as )

+!*(&(#s! Sa$( IIA9#o&'al!as 16 1, +('a-&!a L(-kos!-&!a

*os!!"

@I. !RO/LEM

!ro,le& ). Sin-ro& Ne>ro$i0

Ass(ss'(# D!a$#osa P(#aalaksa#aa# %a# Ko'*l!kas!

I* D= US A9%o'(#

I* T= B(% R(s !%ak oal *os!s! @ %-%-k

D!( !#5al 1,00 kkal $a&a' C $&/ha&! D!( (ks&a *-!h (l-&

I#"-s DJ 12 *' '!k&o

F-&os('!% )0 '$ 0:0:1

M(!l *&(%#!solo# 16 '$ 3:0:1

S!'asa!# 20 '$ 0:0:1

V!a'!# B*l(= 3=1

I* M= Ka%a& al9-'!# Es9ah

I* E= M('9(&! *(#5(lasa# k(*a%a *as!(# %a# k(l-a&$a '(#$(#a!

*(#ak! ko'*l!kas! (&a*!

!ro,le& 9. Hiper$ensi S$a'e II

Ass(s'(# Ko'*l!kas!

: P(#ak! a#-#$

: R(!#o*a!

: N("&o*a!

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: VA

I* D= :

I* T= a*o*&!l 3=2 '$

I* M= KUVS

I* E= P(#5(lasa# k(*a%a *as!(# (#a#$ *(#ak!#a

!ro,le& *. He&a$uria Leu0osi$uria !osi$i>

Ass(s'(# E!olo$! DD

: ISK

I* D= K-l-& -&!# T(s s(#s!!!as k-'a#

I* T= Asa' *!*('!%a 2=1

I* M= U&!# -la#$ s((lah , ha&!

I* E= P(#5(lasa# k(*a%a *as!(# (#a#$ *(#ak!#a

I* P=

A% !a' D-9!a a% 'ala'

A% sa#a' D-9!a a% 'ala'

A% "-#$s!o#a' D-9!a a% 'ala'

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