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PRESENTASI CASE ASCITES & ANEMIA

Nafesa F. Siregar (110.2006.175)

Pembimbig! "r. A"i S#.P$



I$ENTITAS

• Nama ! N%. I

• m'r ! 0 a*'

• +eis ,e-ami ! Perem#'a

• S',' bagsa! I"esia

• Pe,er/aa ! IRT

• A-ama ! +. Cem#a,a ar'

• Tagga- mas', ! 01 $esember 2015 /am 20.5

• Tagga- ,e-'ar ! 06 $esember 2015

• N CM ! RS.02



Anamnesis• $i-a,',a se3ara ! A'aamesis

• Tagga- ! 2 $esember 2015

•P','- ! 16.0 4I "i r'ag $a*-ia

Keluhan Utama ! Per' memb'3i

Keluhan Tambahan ! A *iam



Ria%a Pe%a,i Se,arag

Pasie "aag ,e I$ RS M* Ri"a Me'ra,sa #a"a *ari se-asaagga- 01 $esember 2015 #','- 20.5 "ega ,e-'*a #er'memb'3i se/a, 8 2 migg' SMRS. Aa-%a9 #asie mega,'me"eria sa,i "emam i:'s 8 2 migg' %ag -a-'9 berba ,e#'s,esmas "a "iberi aibii, "a #araseam-9 #asieme-a, "iraa. Se/a, saa i' #er' #asie "irasa membesar

se"i,i "emi se"i,i9 "iserai "ega ,e-'*a %eri #a"a "aera*#er' aa' %eri #a"a '-' *ai. $emam "ia,'i *i-ag imb'-9 "a'r' "ega #araseam-. Na:s' ma,a biasa. M'a- "am'a* "isag,a-9 me3re "isag,a- "a #asie mega,' A%a *iam se/a, ; *ari %ag -a-'9 ,e-'ar se"i,i<se"i,i "a i"a,-a3ar. A= i"a, a"a ,e-'*a9 #i#is mera* "isag,a-. Se-ai i'

#asie /'ga merasa,a sa,i ,e#a-a ber"e%' "a ba', ,erig9sesa, "isag,a-. Pasie mega,' ria%a sa,i maag se/a,-ama9 "ibai "ega m%-aa aa' #rmag. Pasie i"a, #era*mega-ami ge/a-a se#eri ii sebe-'m%a. Pasie i"a, memi-i,i,ebiasaa mer,, "a i"a, mi'm a-,*- "a ,e-'arga /'gai"a, mer,,. =e-'*a ria%a #e%a,i asma9"a ria%a

#e%a,i TC "isag,a-.



Riwayat Penyakit Dahulu• Ria%a $emam T%#*i" "ia,'i

2 migg' -a-'9 berba ,e#'s,esmas "a "iberi ba

• Ria%a =e-'*a %ag sama"isag,a-

• Ria%a $M "isag,a-

• Ria%a >i#eresi "isag,a-

• Ria%a $is-i#i"emia "isag,a-

• Ria%a Asma "isag,a-

• Ria%a Pe%a,i /a'g

"isag,a-• Ria%a Pe%a,i #ar' "isag,a-

• Ria%a Pe%a,i gi/a-"isag,a-

•

Riwayat Penyakit keluarga• Ti"a, a"a #e%a,i %ag sama

"irasa,a -e* ,e-'arga #asie

• Ria%a ,e-'arga #e%a,i*i#eresi "isag,a-

• Ria%a ,e-'arga #e%a,i"iabees "isag,a-

• Ria%a ,e-'arga #e%a,i /a'g "isag,a-

• Ria%a ,e-'arga #e%a,iasma "isag,a-

• Ria%a ,e-'arga #e%a,i#ar' "isag,a-

• Ria%a ,e-'arga a-ergi ba"isag,a-



PEMERI=SAAN FISI=

•

Keadaan Umum : Tam#a, sa,i se"ag? gi@i 3','#• Kesadaran : Cm#s Meis

• Status nutrisi ! Nrma-

! 5 =g

T ! 150 3m

MI ! 19; ,g?m2

• Tanda vital

Te,aa "ara* ! 110?;0 mm>g

Na"i ! ;B?mei

Pera#asa ! 22B?mei

S'*' ! ;920 C

S#2 ! 7D



=e#a-a

• e', ! Nrm3e#*a-

• Simeris ! Simeris

• Pe/-a ! Ti"a, a"a

Maa• Aemis ! (?)

• S3-era i,eri, ! (<?<)

• EB#*a-m's ! (<?<)

• E#*a-m's ! (<?<)

• E"ema ,e-#a, ! (<?<)

='-i

4ara ! P'3a

+ariga #ar' ! Ti"a,a"a

Per'mb'*a ramb'!Nrma-

S'*' raba ! >aga

=eriga ! m'm

=e-emba#a ! embab

T'rgr ! C','#

I,er's ! Ti"a,a"a

E"ema ! Ti"a,a"a



• $a"a

• Is#e,si ! Nrm3*es Simeris

,iri ,aa9• Pa-#asi! N%eri e,a (<)9 massa (<)9

G3a- :remi's ,iri ,aa

• Per,'si ! Sr "i ,e"'a -a#ag#ar'

•

A's,'-asi ! P'-m ! HS?9r*,i <?<9 *ee@ig <?<

+a'g

• Is#e,si ! I3's 3r"is i"a,am#a,

• Pa-#asi ! I3's 3r"is eraba #a"a

ICS H garis mi"3-aGi3'-a siisra

• Per,'si ! aas aas ! se-a iga IIIgaris #arasera- siisra

• aas ,aa ! se-a iga H garissera- "eBra

• aas ,iri ! se-a iga H garismi"3-aGi3'-a siisra

Telinga

Pendengaran : Baik

Membran timpani : Tidakdilakukan

Darah : Tidak ada

airan : Tidak ada

BibirSian"sis : #$%& Kering

'eher

Trakea : Tidak deviasi

Kelen(ar tir"id : Tidak

membesarKelen(ar 'im)e : Tidakmembesar

*+P : ,"rmal& tidakterlihat



Ab"me

• Is#e,si ! Per' memb'3i9 3a#' me"'sa(<)9 s#i"er eGi (<)

• A's,'-asi ! isig 's's () rma-

• Pa-#asi ! Teraba egag9 $isesi ()9 N%erie,a (<)9 *e#ar "a -ie i"a, "a#a "ii-ai9'"'-asi ()

• Per,'si ! S*i:ig "'-ess ()

E,sremias

• Perabaa ! A,ra- *aga

• E"ema 'g,ai! <?<



Pemeriksaan -lektr"kardi"gra.

/010212/03



Pemeriksaan 'ab"rat"rium #/010212/03%



Pasie "aag ,e I$ RS M* Ri"a Me'ra,sa #a"a *ari se-asa agga-01 $esember 2015 #','- 20.5 "ega ,e-'*a #er' memb'3i se/a,

8 2 migg' SMRS. Pasie mega,' me"eria sa,i "emam i:'s 8 2migg' %ag -a-'9 berba ,e #'s,esmas "a "iberi aibii, "a#araseam-9 #asie me-a, "iraa. Se/a, saa i' #er' #asie "irasamembesar se"i,i "emi se"i,i9 "iserai "ega ,e-'*a %eri #a"a"aera* #er' aa' %eri #a"a '-' *ai. $emam "ia,'i *i-ag imb'-9 "a'r' "ega #araseam-. Pasie mega,' A %a *iam se/a, ; *ari

%ag -a-'9 ,e-'ar se"i,i<se"i,i "a i"a, -a3ar. Se-ai i' #asie /'gamerasa,a sa,i ,e#a-a ber"e%' "a ba', ,erig. Pasie mega,'ria%a sa,i maag se/a, -ama9 "ibai "ega m%-aa aa' #rmag.Pasie i"a, #era* mega-ami ge/a-a se#eri ii sebe-'m%a. Pasiei"a, memi-i,i ,ebiasaa mer,, "a i"a, mi'm a-,*-.

•

>asi- #emeri,saa fsi, sebagia besar "a-am baas rma-.Pa"a #emeri,saa ab"me "i"a#a,a !

• Is#e,si ! Per' memb'3i9 3a#' me"'sa (<)9 s#i"er eGi (<)

• A's,'-asi ! isig 's's () rma-

• Pa-#asi ! Teraba egag9 $isesi ()9 N%eri e,a (<)9 *e#ar "a -ie i"a,"a#a "ii-ai9 '"'-asi ()

•Per,'si ! S*i:ig "'-ess ()



$iagsa ,er/a

• As3ies

• Aemia e3. #er"ara*a



Taa a,saa

• IHF$ R 1 ,-:?2 /am

• F'rsemi"e 2 B 1 am#

•

A-"a3 1 B 25 mg• Tras:'si PRC 600 33

• Para3eam- B 1 ab

•

AmbrB- B 1 ab



Prgsis

• A" Giam ! "'bia a" bam

• A" :'3iam ! "'bia a" bam

•

A" saaiam ! "'bia a" bam

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