kasus menintis tb gerey.doc

8/18/2019 kasus menintis TB gerey.doc

1/12

STATUS PEMERIKSAAN PASIEN

DEPARTEMEN NEUROLOGI

FK UKRIDA – RS PANTI WILASA “Dr. Cipto” SEMARANG

Pembimbin ! "r. En"#n K$%tioti' Sp.S (K)' MSi.Me"

STATUS MAHASISWA

N#m# ! GERE*N+

NIM ! ,,-/,,-,0

I. IDENTITAS PASIEN

• N#m# ! Tn. MN

• Um$r ! 1 t#2$n

• 3eni% 4e5#min ! L#4i-5#4i

• St#t$% per4#&in#n ! 6e5$m Meni4#2

• Pen"i"i4#n ! SMA

• Pe4er7##n ! 6e5$m 6e4er7#

A5#m#t ! P#n"#n%#ri Sem#r#n

• No. Re4#m me"i% ! 89:8

PASIEN DATANG KE RS

Sen"iri ; bi%# 7#5#n ; t#4 bi%# 7#5#n ; "en#n #5#t b#nt$

Dib# o5e2 4e5$#r# !


2/12

Pen$r$n#n Ke%#"#r#n

!. R"#a$at Pen$a%"t Se%a&an'

+% "#t#n 4e IGD RS p#nti &i5#%# "en#n 4irim#n "#ri p$%4e%m#%

>#5m#2er# "im#n# p#%ien %$"#2 men#5#mi p#n#% ? 2#ri


3/12

1. Statu+ P&e+en+

Ke%#"#r#n ! =om# (GCS ! E,M@,)

Ke#"##n $m$m ! t#mp#4 %#4it ber#t

T#n"# – t#n"# it#5 !

TD ! :9;9? mm>

N#"i ! 11 B;menit

N##% ! ? B;menit

S$2$ ! 8'0 C

• Kep#5# ! normo=ep2#5i' 4on7$nti# #nemi% (;)' %45er#

i4teri4 (-;-)' Re5e4

• Le2er ! ti"#4 #"# pembe%#r#n KG6' T,-T, ten#n

• D#"# ! 6ent$4 ! %imetri%

6$#2 "#"# ! norm#5

Pemb$5$2 "#r#2 ! ti"#4 t#mp#4 en# 4o55#ter#5.

• 3#nt$n !

In%pe4%i Ti"#4 t#mp#4 p$5%#%i i4t$% =or"i%

P#5p#%i I4t$% =or"i% ter#b# tet#pi ti"#4 4$#t #n4#t

Per4$%i D#5#m b#t#% norm#5

A$%4$5t#%i 6$n


4/12

Ti"#4 #"# &2eein Ti"#4 #"# &2eein

K#n#n S$#r# n##% e%i4$5er

#"# ron=2i

Ti"#4 #"# &2eein

S$#r# n##% e%i4$5er

Ti"#4 "ini5#i

Ti"#4 #"# &2eein

• Ab"omen!

In%pe4%i Simetri%' "#t#r' ti"#4 #"# ben7o5#n

P#5p#%i Din"in per$t

>#ti

Limp#

Gin7#5

S$pe5' n


5/12

. Ne&2u+ &an"al"+

N.I Kanan K"&"

S$b


6/12

Si4#p b$5b$% Ti"#4 "#p#t "ini5#i Ti"#4 "#p#t "ini5#i

Me5i2#t 4emb#r Ti"#4 "#p#t "ini5#i Ti"#4 "#p#t "ini5#i

N.4II Kanan K"&"

Mener$t4#n "#2i Ti"#4 "#p#t "ini5#i Ti"#4 "#p#t "ini5#i

Men$t$p m#t# Ti"#4 "#p#t "ini5#i Ti"#4 "#p#t "ini5#iMemper5i2#t4#n ii Ti"#4 "#p#t "ini5#i Ti"#4 "#p#t "ini5#i

6er%i$5 Ti"#4 "#p#t "ini5#i Ti"#4 "#p#t "ini5#i

Per#%##n 5i"#2 b#. M$4# Ti"#4 "#p#t "ini5#i Ti"#4 "#p#t "ini5#i

N.4III Kanan K"&"

Deti4 #r5o7i Ti"#4 "i5#4$4#n Ti"#4 "i5#4$4#n

S$#r# beri%i4 Ti"#4 "#p#t "ini5#i Ti"#4 "#p#t "ini5#i

Weber Ti"#4 "i5#4$4#n Ti"#4 "i5#4$4#n

Rinne Ti"#4 "i5#4$4#n Ti"#4 "i5#4$4#n

N.I5 Kanan K"&"

Per#%##n 5i"#2 b#.

6e5#4#n

Ti"#4 "#p#t "ini5#i Ti"#4 "#p#t "ini5#i

Sen%ibi5it#% Ti"#4 "#p#t "ini5#i Ti"#4 "#p#t "ini5#i

P2#r


7/12

M,t,&"%

Re%pir#%i Simetri% %##t %t#ti% "#n "in#mi%

D$"$4 Ti"#4 "#p#t "ini5#i

6ent$4 =o5$mn# ertebr#5i% D#5#m b#t#% Norm#5

Perer#4#n =o5$mn# ertebr#5i% Ti"#4 "#p#t "ini5#i

Sen+"/"l"ta+ Kanan K"&"

T#4ti5 Ti"#4 "#p#t "ini5#i Ti"#4 "#p#t "ini5#i

N


8/12

Re5e4% 4$5it per$t b# Ti"#4 "i5#4$4#n

Re5e4% 4$5it per$t ten#2 Ti"#4 "i5#4$4#n

An'',ta Ge&a% Ata+

M,t,&"% Kanan K"&"

Perer#4#n Ti"#4 "#p#t "ini5#i Ti"#4 "#p#t "ini5#i

Ke4$#t#n Ti"#4 "#p#t "ini5#i Ti"#4 "#p#t "ini5#i

Ton$% Normoton$% Normoton$%

Atroi Ne#ti Ne#ti

Sen+"/"l"ta+ Kanan K"&"T#4ti5 Ti"#4 "#p#t "ini5#i Ti"#4 "#p#t "ini5#i

N


9/12

P#te55#

A=2i55e%

6#bin%4< Ne#ti Ne#ti

C2#""o=4 Ne#ti Ne#ti

S=2#eer Ne#ti Ne#ti

+ppen2eim Ne#ti Ne#ti

Te% L#%e$e Ne#ti Ne#ti

Te% Kerni Ne#ti Ne#ti

). Peme&"%+aan Penun7an'

• D#r#2 R$tin ! (,/-,/-/,)

o >emo5obin 18-9 '&:0L ;L


10/12

o K#5%i$m ' m;"5 (0'0-,/ m;"5)

o M#ne%i$m '/ m;"5 (,'-8'/ m;"5)

CT %=#n 4ep#5# (,/;,/;/,)

• S$5=i "#n ;S+L

T#4 #"# t#n"# penini#n intr#=r#ni#5

I4. RINGKASAN

Su/7e%t"3

p#%ien "#t#n 4e IGD p#nti &i5#%# "en#n r$7$4#n "#ri p$%4e%m#% 2#5m#2er#

%em#r#n "en#n p#n#% ? 2#ri

N#"i ! 11B;menit

Pern#p#%#n ! ?B;menit

S$2$ ! 8'0 C

PRESENTASI KASUS NEUROLOGI Page 10


11/12

M#t# ! p$pi5 i%o4or' Re5e4% =#2#


12/12

• P#r#=et#mo5 $nt$4 "em#m

Ter#pi 42$%$%

• IN> ,H8// m P+

•

Ri#mpi%in ,H?0/ m P+

• Pir#in#mi" ,H,/// m P+

• Et#mb$to5 ,H,/// m P+

• DeH#met#%on ?H0 m I@

4I I . PROGNOSIS

A" it#m ! D$bi# #" m#5#m

A" $n=tion#m ! D$bi# #" m#5#m

A" %#n#tion#m ! D$bi# #" m#5#m

PRESENTASI KASUS NEUROLOGI Page 12

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