07 Juli 2013

No.RM : 14.53.54 Name : Mrs.SM Age : 28 thn Sex : Female Adress : Sawo RT 4 RW 8 Dukun Gresik Work: Employee Date : July 07th 2013

ANAMNESA: CHIEF COMPLAINT :

Mass in neck PRESENT ILLNESS HISTORY :

patients come with a mass in the right neck that became known only since 2 weeks ago. patients also complained of frequent sweating and palpitations. Pain -, headache +, complaint of a mass elsewhere denied. Shortness of breath, a hoarse voice and difficulty swallowing denied.

BB, nafsu makan, cuaca, PAST ILLNESS HISTORY :- FAMILY ILLNESS HISTORY : -

GCS : 456 Vital sign

• BP : 112/70mmHg• RR : 18x/menit• PR : 85x/menit• Temp : 37C

• Head and Neck:a/i/c/d: -/-/-/-mass in the thyroid gland, moves while swallowing

• Thorax:Simetris, retraksi -, ves/ves, rh-/-, wh -/-, S1S2 single, Murmur -, Gallop -

• ABDOMENFlat, Soepel (+), Met (-), BU + N, Hepar lien difficult to evaluate.

.Ekstrimitas: warm, dry,red, edema -

• Status Lokalis:• Inspeksion : mass in the right thyroid gland, moves while swallowing

• Palpasion : dextra lobe, there ф mass measuring 3x3cm, chewy consistency,, mobile, tenderness - and the part moves while swallowing (+)

JENIS PERIKSA HASIL PEMERIKSAAN

NORMAL

HAEMATOLOGI

Diffcount 2/1/58/30/9 1-2/0-1/49-67/25-33/3-7

Hematokrit 40,3 L 40-54% P 35-47%

Haemoglobin 13,8 P 13,0-18,0 mg/dl L 14,0-18,0 mg/dl

ESR 17/33 L 0-5/jam P 0-7/jam

Lekocyte 9.000 4000-11000

Trombosyte 201.000 150.000 – 450.000

JENIS PERIKSA HASIL PEMERIKSAAN

NORMAL

FAAL HATI

SGOT 21 L 37 U/L P 31 U/L

SGPT 15 L 41 U/L P 31 U/L

JENIS PERIKSA HASIL PEMERIKSAAN

NORMAL

FAAL GINJAL

Creatinin Serum 0,6 P 0,7-1,2 mg/dl L 0,8-1,5 mg/dl

Urea 21 10-50 mg/dlFAAL HEMOSTASIIS

APTT 42,4 24,2 – 38,2 detik

PT 14,7 10,3 – 16,3 detik

Hormon Tiroid

T4 1,35 0,95 nmol/l – 2,5 nmol

T3 56,80 60 nmol/l – 120nmol/l

TsHs 1,32 0,25 – 5,0

Female, 28 Mass in right neck Sweating (+) Palpitation (+) Head and neck : mass in the thyroid gland,

moves while swallowing dextra lobe, there ф mass measuring 3x3cm,

chewy consistency, flat surface, mobile, tenderness -, and the part moves while swallowing (+)

T4 : 1,35 ; T3 : 56,80, TsHs 1,32

Struma Nodusa non Toxica Lobus Dextra

Hashimoto’s Disease

FNAB Follicular Neoplasm

IVFD Assering 1500 cc/24 jam Antrain 1 amp, prn

Konsul: SpBKL Pro Fokal Lobectomy

TTV Keluhan Subjektif pasien

Menjelaskan kepada pasien dan keluarga pasien tengan diagnosis penyakit pasien, pemeriksaan penunjang yg akan dilakukan, terapi yg diberikan, komplikasi dan prognosis penyakit pasien.