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7/25/2019 MR timus pulmonologi
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Laporan Pagi
24-06-2016
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IDENTITAS #1
Nama : Tn. Tinus
Jenis e!amin : La"i-!a"i
mur : 20 $a%un A!ama$ : Serun&u"' Sin$ang
Pe"er(aan : s)as$a
Tangga! *asu" +S : 24-06-2016'Jam 1,.0
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ELAN TA*A
Sesa" na/as
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+IAAT PENAITSEA+AN
Pasien &a$ang &engan "e!u%an sesa" na/asse(a" (am S*+S &iser$ai 3a$u" 3er&a%a"3er)arna pu$i%' u 5-' 3a$u" &ara% 5-. *ua!
5-' mun$a% 5-' n7eri mene!an 5-&emam 58se(a" 1 %ari 7ang !a!u. sesa" &irasa"an $i&a"&ipengaru%i o!e% a"$i9i$as &an $i&a"mem3era$ saa$ ma!am %ari. +i)a7a$ mero"o"
58' a!"o%o! 58' ri)a7a$ $rauma 58 saa$$er(a$u% "e &a!am sumur &an pingsan 1 %ari7ang !a!u' ri)a7a$ T 5-' ri)a7a$ D* 5-' a!ergio3a$ 5-' asma 5-' a!ergi ma"anan 5-
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+IAAT PENAIT DAL
+i)a7a$ "e!u%an 7ang sama&isang"a!
+i)a7a$ minum o3a$ se!ama 6 3u!an&isang"a!.
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+IAAT PENAITELA+A
Di "e!uarga $i&a" a&a 7angmenga!ami "e!u%an serupa.
+i)a7a$ "e!uarga meminum o3a$ 63u!an 5-
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+IAAT SSIAL EN*I
+i)a7a$ mero"o" ; 2 3ung"us per%ari se(a" , $a%un 7g !a!u' &an saa$ini masi% mero"o"
I< = 4> ? , = 240 pero"o" 3era$
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PE*E+ISAAN @ISI
ea&aan umum: $ampa" sesa"
esa&aran : ompos men$is
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epa!a: normose/a!i
*a$a : "on(un$i9a anemis 5-B-'s"!era i"$eri" 5-
Te!inga : se"re$ 5-
i&ung : se"re$ 5-
*u!u$ : 3i3ir sianosis 5-' !i&a% "o$or5-' $onsi! T1BT1
Le%er : Pem3esaran !im/ono&us 5-
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Jan$ung
Inspe"si : i"$us "or&is $er!i%a$ &i si , !msinis$ra
Pa!pasi : i"$us "or&is $era3a &i si , !m sinis$ra.ua$ ang"a$ . Ti&a" a&a $%ri!!.
Per"usi : 3a$as "anan (an$ung &i !ineaparas$erna!is &e?$ra IFS 4' 3a$as a$as (an$ung &i!inea paras$erna!is sinis$ra IFS 2' &an 3a$as "iri
(an$ung &i !inea mi&!a9iu!aris sinis$ra IFS ,.
Aus"u!$asi: 3un7i (an$ung S1BS2 $ungga!'murmur 5-' ga!!op 5-
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Paru Inspe"si
s$a$is : sime$ris
&inamis: gera"an paru sime$ris' $i&a" a&a"e$ingga!an gera"
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A3&omen Inspe"si : &a$ar' &is$en&e& 5-' s"ar 5-'
apu$ me&usa 5-
Aus"u!$asi: 3ising usus 58
Pa!pasi : n7eri $e"an 5-' %epar $i&a"$era3a' %epar $i&a" $era3a
Per"usi : $impani 58
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E"s$remi$as : e&em
A"ra! &ingin
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PE*E+ISAAN PENNJAN
Laboratorium Darah
Rutin
WBC : 15,24
/uL
+'6 /L
*FF : ,' gB&L
PLT : 46 BuL14
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+a&io!ogi
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+a&io!ogi
T%ora"s PA' ere$
Tra"ea &an me&ias$inum : $a" $ampa" "e!ainan
Jan$ung &an pem3u!u% &ara% 3esar : $a" $ampa""e!ainan
Paru &an pem3u!u% &ara% paru : $ampa""onso!i&asi pa&a !o3us "anan 3agian 3a)a% &iser$aipening"a$an ora"an 3ron"o9as"u!ar pa&a !o3us"anan 3a)a%
Diag/ragma &an a3&omen : $a" $ampa" "e!ainan
P!eura &an su&u$ "os$o/reni"us $a" $ampa" "e!ainan
Tu!ang &an (aringan i"a$ : $a" $ampa" "e!ainan
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E
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Irama : sinus
@re"uensi : C "a!iBmin
A?is : $i&a" a&a &e9iasi
ona $ransisi : pa&a !ea& -4 e!om3ang P $a" $ampa" "e!ainan
omp!e"s Krs $a" $ampa" "e!ainan
e!om3ang T $a" $ampa" "e!ainan
pr in$er9a! $a" $ampa" "e!ainan
K$ in$er9a! $a" $ampa" "e!ainan
Segmen ST $a" $ampa" "e!ainan
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Da/$ar *asa!a% Semen$ara
1. Sesa"
2.
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Da/$ar *asa!a% Te$apAnalisa P Dx P Tx P Mo
Sesa" - 2 2-4 !pm !inisSa$urasi 2AD
Pneumonia"omuni$i 5FAP
Pengea$angram
u!$ur 3a"$eriaero3
Fe/$ria?on 2?1gr
PFT ?,00 mg
!inisDL
+onsen