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ANAMNESIS, PEMERIKSAAN FISIK DAN

PEMERIKSAAN PENUNJANG PADA PASIEN

DENGAN KELUHAN BATUK

TUBERKULOSIS

e

DENOK KOSASI

NIM 030.10.074

UNIVERSITAS TRISAKTI

FAKULTAS KEDOKTERAN

JAKARTA, 01 DESEMBER 2014



ANAMNESIS

Perken ! n

P "#en $ % n& $en& n 'en&e%(k )#n%( r( n& n $*k%er $ n ' "(k ke $ ! '

r( n& n

P "#en+ Se! ' % ) &# $*k -

D*k%er+ Se! ' % ) &# ) k, "#! k n $($(k. Perken ! n " / $*k%er Den*k

K*" "# / n& "e$ n& er%(& " ) $ r# #n#. B #k ) k, ) $ r# #n# " / k n

'e! k(k n % n/ $en& n ) k (n%(k 'en&e% (# k*n$#"# ke"e % n ) k "ek r n&, N '(n " / k n 'e!en&k )# $ % #$en%#% " ) k %er!e #

$ (!( / ) k.-

I$en%#% "

Dokter PasienB ) k n ' n/ "# ) Tn. P*!!/U'(rn/ er ) ) k 3 % (nA! ' %n/ $#' n S / %#n&& ! $# T*' n& $*k B ) k )eker nn/ ) S()#r % k"#S($ 'en#k e!(' ) k S($M 5 ) k, )en$#$#k n %er k #r S ') # SMAB*!e % ( " ! ) k $ r#' n JA& ' ) k ) I"! '

Ke!( n U% '

Dokter PasienB #k! ) k, $ / n& #" " /

n%(

S / %(k6 %(k "($ ! ' $*k

S($ "e k k ) n ) k S($ " %( (! n !e # $*k

R# / % Pen/ k#% Sek r n&

Dokter PasienB & #' n ke $ n ) k S / k#r (' %(k r#n& n % )# %#$ k



"e e!(' ) k 'er " k n

ke!( n "ek r n&, "e % % (

" k#%

"e' ( "e' ( $*k.

A) k ) k )ern 'en& ! '#

" k#% / n& "e)er%# #n#

Be!(' )ern "# $*k, $(!( k !* " /

%(k & k "e! ' #n# "# $*k.A) k %(kn/ er$ k % (

ker#n&

P $ !n/ %(k # " $*k % )#

"ek r n& $# er$ k.8 rn $ kn/ ) , ) k A !n/ ke # ( n % )# "ek r n& & k

'er 'er $ r $*k.A) k $ $ r n/ I/ $*k, " / % k(%n/ ke'er n #%(

$ r .J#k $# n$#n&k n $en& n ! %

r(' % n&& k#r 6k#r $ k

/ n& ke!( r "e n/ k ) / ) k

M(n&k#n "e%en& &e! " $*k, #%( )(n

/ n& & k ke!( r $ kn/ ' "# $ .

A) k $ k%( $#' n %(k

' k#n ) r , "e)er%# ' ! ' % (

) &#

P $ ' ! ' r# $*k ' k#n ) r , " /

" ') # "(" %#$(r. B#! "($ %#$(r

" / "er#n& ke n&(n ! &# k ren %(k.A) k ) k (& 'en& ! '#

ker#n& % ) $ ' ! ' ) $ !

%#$ k 'e! k(k n k%#9#% "

I/ "# $*k, r " n/ $# k(r n& en k

$ n. S / (& $# &e!#" $*k.

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n 5 "

A$ $*k, "e%# ) %(k k #r : k #r #n#

$# "e" k.A) k "e" k $#"er% # (n/#

n&#k-

T#$ k k*k $*k, n/ "e" k " .

A) k $ n/er# $ $ " % "e" k T#$ k $ $*k.A) k "e! ' " k#% $ $e' '

Pern ek ) k # %er'*'e%er

A$ $*k % )# e!(' )ern ) ke

%er'*'e%er, $e' ' n/ ) n " r#n& n" $*k.

B & #' n $en& n n 5"( ' k n

) k

I/ $# %#$ k n 5"( ' k n $*k.

Ber % $ n ) k & #' n K % %e% n&& " / "# " / $# !e #

k(r(" $*k, e! n " / (& 'e!*r*%

% )# " / e!*' )ern %#' n& ! &#

$*k.B & #' n k%#9#% " $ n J $# %er& n&&( $*k, )e! n&& n " /



)eker n ) k (& $# n&e!# %#n " / %(k % k(%

%er%(! r e&#%(, " / (& k !* ker $#

!e' ".

R# / % Pen/ k#% D (!(

Dokter PasienA) k ) k 'e')(n/ # !er&#

"e)er%# %er $ ) * %, ' k n n,

($ r $#n&#n % ( $e (

T#$ k $ $*k.

A) k ) k 'e'#!#k# r# / % )en/ k#% ken #n& ' n#"

I/ $ $*k, " / )(n/ )en/ k#%ken #n& ' n#".

A) k ) k 'e'#!#k# r# / %

)en/ k#% $ r %#n&&#

T#$ k $ $*k.

A) k ) k )ern %erken

)en/ k#% r $ n& ) r( "e)er%# TB;,

Br*nk#%#", Pne('*n#

T#$ k )ern $*k.

M 5 / ) k, ) k '(n&k#n

) k )ern %er n&k#% <IV

T#$ k $*k.

R# / % Ke # " n $ n L#n&k(n& n

Dokter PasienA) k ) k 'er*k*k Ber )

% n& "e r# Se k k ) n

I/ " / "e k ('(r 17 % (n #n&&

"ek r n& "e! !( 'er*k*k $*k, /

) !#n& 1 (n&k(" $ # " ' "*e "e r#. =1>

% n&?A) k ) k '#n(' !k* *! T#$ k $*k.M 5 ) k, ) k ) k )ern

'e' k # n rk* A% ( '(n&k#n

% %**

T#$ k )ern $*k.

M 5 ) k, ) k ) k "er#n&

'e! k(k n "ek" e "

T#$ k )ern $*k.

A) k ) k "er#n& er& $ n& I/ $*k, " / k $ n& "er#n& n*n%*n



*! ren& $en& n %e% n&& " / .B & #' n ke # " n ' k n

) k, er ) k !# ' k n $ ! '

" %( r# A) k 4 "e % @

"e')(rn %er)en( #

I/ # " n/ 3 k !# "e r# $*k ' k n

"e $ n/ " , % )# k ren e! k n& n

#n# %#$ k n 5"( ' k n / ) !#n& 1 k !#

"e r# k ! ( en r : en r ! ) r "

$*k.A) k ) k "er#n& *! r & J r n& $*k B ) k %#n&& ! $#r(' $en& n

"# )

S / %#n&& ! $en& n #"%r# $ n n k " /

$*k.B & #' n ke $ n r(' ) k,

) $ % )en$($(kn/

I/ $*k, ) $ % / " / " ' %e% n&&

r(' n/ " ne')e!, n ' n/ (&

r(' )e% k $*k.B & #' n $en& n 9en%#! "# % (

en$e! Pen / n $ r#

' % r# ) k #" ' "(k ke

r('

K ! ( 9en%#! "# "# %#$ k $ $*k, ) !#n&

n/ en$e! " %(. J r n& $# (k $*k

% k(% $e ( ' "(k n n%# ken ( ( " / ,

/ $# / ' % r# %#$ k ' "(k

$*k.A) k $#"ek#% r r(' ) k

$ / n& 'en& ! '# ! "e)er%#

) k

I/ $ $*k, #%( %e' n n*n&kr*n& $ n

n*n%*n *! " / #%( (& %(k %(k

% )# $# "($ $ ) % * % $ r# r('

" k#%.A) k ) k "er#n&

'e'er#k" k n ke"e % n ) k ke

$*k%er % ( r(' " k#%

T#$ k $*k, k !* " / " k#% n/

'#n(' * % r(n& " $*k.

R# / % Ke!( r&Dokter Pasien

A) k $#ke!( r& $ / n&

'en& ! '# ! "e)er%# #n#

T#$ k $ $*k.

A) k $ ke!( r& ) k / n&

'e'#!#k# )en/ k#% ken #n& ' n#"

% ( $ r %#n&&#

I/ # ( " / (& $(!( ken #n& ' n#"

$*k $ n ) " / 'en$er#% $ r

%#n&&#.A) k $ / n& 'e'#!#k#

)en/ k#% ) r( "e)er%# %

K(r n& % ( " / $*k.



A) k $ ke!( r& / n&

'en#n&& ! k ren )en/ k#% ) r(

K ! ( k kek " / $(!(.

R# / % Pen&* % n

Dokter PasienSe! ' " k#% #n# ) k )ern

er* %

Be!(' $*k, % )# k ! ( '#n(' * % #/

$*k.B ) k '#n(' * % )

B & #' n "#!n/ "e%e!

'#n(' * %

O % r(n& " $*k, #/ #%( %#$ k

"e' ( $*k, ) $ ! $(!( k !* " /

%(k '#n(' #%( "e' ( $*k.

PEMERIKSAAN FISIK

Per"# ) n Pe'er#k" n

D*k%er 'en e! "k n $ n/ ke'(n&k#n n )en/ k#% ) r(. Un%(k $# &n*"#"

$*k%er 'e' (%( k n )e'er#k" n 5#"#k $ n )en(n n&. D# r )k n ) "#en

%#$ k ke er % n.

D*k%er #k ) k " / k n 'e! n (%k n $en& n )e'er#k" n 5#"#k & r

$ ) % $#%e'(k n )en/ k#% ) k, ) k er"e$# -.

P "#en I/ er"e$# $*k-.

D*k%er B #k ) k %*!*n& (k (n/ / , " / k n 'en ( # % n& n

%er!e # $ (!( -

P "#en #/ #k $*k - .

D*k%er ) #! n n%# " % )e'er#k" n ) k 'er " n/er# % ( $ / n&

%#$ k n/ ' n %*!*n& er#% ( " / / ) k-.

P "#en #k $*k-.

P "#en $# )er"#! k n $($(k $# % " r n n& )e'er#k" $ n $*k%er er$#r#

$#"e e! k n n ) "#en.

Ke $ n U'(' $ n T n$ V#% !



Keadaan Um m PasienKe" $ r n ;*')*" 'en%#"Ke" n " k#% S k#% "e$ n&Ke" n &# # # # k(r n&< #%(" A"%en#k("T k"#r n ("# T ') k "e"( # $en& n ("# n/

Tanda !ita" PasienS( ( 37, @ * ;Tek n n D r 130C 0

N $# 7> C'en#%Pern 5 " n 1 C'en#%

Antro#ometri PasienBer % B $ n > k&T#n&&# B $ n 1 0 '

Pe'er#k" n S% %(" ener !#"

Stat s Genera"is PasienKe) ! N*r'* e) !#R ' (% 8 rn #% ', %#%)#", $#"%r# ("# 'er %M % P()#! #"*k*r, k*n (n&%#9 ne'#" = 6 ?,

"k!er #k%er#k = 6 ?, R;LCR;TL = C ?Te!#n& D ! ' % " n*r' !<#$(n& D ! ' % " n*r' !B# #r S# n*"#" = 6 ?, S%*' %#%#" = 6 ?M(!(% D ! ' % " n*r' !Ten&&*r*k n U9(! $#%en& , '(k*" 5 r#n&

#)ere'#", %*n"#! T1CT1

Le$erKe!en r &e% en#n& $ n %#r*#$ D ! ' % " n*r' !JVP @ : 2

T$oraksPe'er#k" n P r(

In")ek"# − Ben%(k "e$#k#% &e)en&, "#'e%r#"

%#$ k % ') k !*r$*"#","k*!#*"#",



$ n &# (". Se$#k#% k#5*"#".

−K(!#% " * ' % n&, %#$ k #k%er#k,%#$ k "# n*"#", %#$ k $

ke'er n "e)er%# ")#$er n 9/

% ( r*"e*! ")*%. T#$ k % ') k

e5!*re"en"# / n& er' kn $ n

%#$ k % ') k )e!e r n )e' (!(

$ r .

− er k n n 5 " "#'e%r#", %#$ k $

n 5 " / n& %er%#n&& !, %#)e

)ern 5 " n $*'#n*% *r k !.

− I %(" *r$#" %#$ k % ') k.

− Ben%(k #& "e$#k#% 9er%#k !, $ n

"e! n% r #& 'en/e')#%.P !) "# − Per&er k n n 5 " "#'e%r#" k n n

$ n k#r#.

− V*k ! 5re'#%(" "#'e%r#", " '

k( % k n n k#r# ) $ $ $ $ n

)(n&&(n&.

− S($(% n&(!(" "( *"% G 70*

Perk("# − P $ &# n )ek" ) r( k n n

$#$ ) %k n "( r re$().

− B % " ) r( $ n e) r $# I;S V

) $ & r#" '#$ ! 9# (! r#" k n n

$en& n "( r re$() $ n

$#%e'(k n )er n k n 2 r#

)e'er#k" .

− B % " ) r( $ n n%(n& k n n

) $ I;S III #n&& I;S V ) $

& r#" "%ern !#" k n n $en& n

"( r re$().



− B % " ) r( $ n n%(n& k#r# $#

I;S V $ r# & r#" '#$ ! 9# (! r#"k#r# $en& n "( r re$().

− B % " % " n%(n& $# I;S III $ r#

& r#" ) r "%ern !#" k#r# $en& n

"(r re$().

− B % " ) r( $ n ! ' (n& $# I;S

VIII ) $ & r#" k"#! r#" n%er#*r

k#r# $en& n "( r %#') n#.− M r&#n *5 I"% '(" Kr*n#&

%er$ ) % re$() 3 r# )e'er#k"A("k(!% "# − P $ "( r n 5 " r*nk*9e"#k(! r

%er$ ) % r*nk# " k " r ) $

)ek" ) r(.

− S( r n 5 " 'e!e' ) $ ) r(

k n n.

− D#%e'(k n "( r n*r' !

er() '5*r#k.Pe'er#k" n J n%(n&

In")ek"# − T#$ k % ') k )(!" "# n*r' !.

− T#$ k % ') k )(!" "# # %(" *r$#".P !) "# − I %(" *r$#" "e%#n&&# I;S V

k(r n& !e # 1 ' 'e$# ! $ r#

& r#" '#$ ! 9# (! r#" k#r#.− T#$ k %er % r#!! ) $ ke 4 re

k %() n%(n&.Perk("# − B % " ) r( $ n n%(n& k n n

) $ I;S III #n&& I;S V ) $

& r#" "%ern !#" k n n $en& n

"( r re$().

− B % " ) r( $ n n%(n& k#r# $#



I;S V $ r# & r#" '#$ ! 9# (! r#"

k#r# $en& n "( r re$().

− B % " % " n%(n& $# I;S III $ r#

& r#" ) r "%ern !#" k#r# $en& n

"(r re$().A("k(!% "# − Ir ' n%(n& re&(!er $en& n

5rek(en"# 7> C'en#%.

− BJ I $ n BJ II n*r' !, $en& n

#n%en"#% " BJ I !e # k( % $# '#%r !

$ n %r#k(")#$, "e$ n&k n BJ II

*r% $ n )(!'*n !.

− T#$ k %er$en& r $ n/ ")!#%,

(n/# n%(n& % ' n "e)er%#H

BJ III, BJ IV, e e %#*n "*(n$,

"#"%*!# !# k, *)en#n& "n ), "er%

%#$ k %er$en& r #"#n& n%(n&.A%domen

In")ek"#, A("k(!% "#, P !) "#,

Perk("#

D ! ' % " n*r' !

EkstremitasEk"%re'#% " % " $ n ek"%re'#% "

D ! '" % " n*r' !

PEMERIKSAAN PENUNJANG

Pemeriksaan Pasien



L *r %*r#(' $ r < + 10&C$L =N +13 : 1> &C$L?

Er#%r*"#% + 4,0 (% =N + 4,@ : @,@ (% ?

Ne(%r*5#! + 7@ =N + @0 : 7@ ?

LED + 20 ''C ' =N + G 10 ''C ?S)(%(' ="e k%(, ) &#, "e k%(? BTA = ? $#%e'(k n

M/ * %er#(' T( erk(!*"#".K(!%(r K(' n B "#! = ?Te" M n%*( = ? #n$(r "# 1@ 'U # re"#"%en"# U # * % TB; / n& ')(R*n%&en T *r k" Ter$ ) % & ' r n 5# r*#n5#!%r % $#"er% #

k 9#% " $en& n rn !( en% / n&$#ke!#!#n&# er k er n $en&n rn

*) (e ) $ &# n )ek" ) r( k n n.

DIAGN&SIS

Ber$ " rk n n 'ne"#", )e'er#k" n 5#"#k, $ n )e'er#k" n )en(n n& / n& %e!

$#! k(k n k #rn/ $#%e'(k n "#! / n& 'en( ( $# &n*"#" (n%(k ) "#en $en& n

n ' Tn.P*!!/. D# &n*"#" ker Tn. P*!!/ $ ! T %erk "osis $en& n $# &n*"#"

n$#n& # ! Pne monia .

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