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morep 7 juli 2013
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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.
