Dr.dhani Pneumonia
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LAPORAN PAGI22 Mei 2014
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IDENTITAS PASIEN
Nama : Tn.T
Umur : 62 tahun
Suku : Jawa
Alamat : Gilingan Banjarsari
Pekerjaan : -
Masuk RS : 22 Mei 2014
Nomor CM : 01095705
Ruang : Mlt1/3G
Bangsal jam : 17.00 WIB
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3ANAMNESIS
Sejak 2 hari SMRS: Panas timbul terutama sore dan
malam hari, tinggi tanpa diikuti menggigil. Turun dengan penurun panas lalu kembali tinggi saat efek obat habis
Batuk (+) berdahak warna putih kental.
Sesak nafas (+) hilang timbul, tidak dicetuskan oleh aktifitas ataupun perubahan suhu dan cuaca
Nyeri ulu hati disertai mual dan muntah tiap makan dan minum
Mimisan (-), muntah hitam (-), perdarahan kulit (-)
Pasien mengeluhkan lemas, diseluruh badan, terus menerus, mudah lelah, berkunang-kunang (-), telinga berdenging (-), berdebar-debar (-), nyeri telan (-).
Buang air kecil sehari 4-5x/hari, warna kuning jernih. Nyeri (-), anyang2an (-). BAB 1x/hari, diare disangkal, BAB hitam disangkal
Keluhan Utama: Badan Panas
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RIWAYAT PENYAKIT DAHULU
Riwayat sakit gula : disangkal
Riwayat tensi tinggi : disangkal
Riwayat sakit jantung : disangkal
Riwayat flek paru : disangkal
Riwayat sakit liver : disangkal
Riwayat mondok (+) 2 thn yg lalu di ICU RSDM dgn diagnosa infeksi paru
dan maag kronis
RIWAYAT PENYAKIT KELUARGA
Riwayat sakit gula : disangkal
Riwayat tensi tinggi : disangkal
Riwayat sakit jantung : disangkal
Riwayat flek paru : disangkal
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Pemeriksaan Fisik
Compos mentis, tampak lemas, gizi kesan cukup
Keadaan Umum :
Tanda Vital :
T : 120/70 mmHg
N : 120 x/menit, isi dan tegangan cukup
R : 24 x/menit
S : 38,6 oC (aksiler)
BB : 50 kg
TB : 158 cm
BMI : 18,7 kg/m2
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Kepala : mesocephalMata: CP (-/-), SI (+/+)Mulut: papil lidah atrofi (-)Leher: JVP R+3cm
AbdomenI : DP//DDA:peristaltik(+) 20x/1’P: timpani, area troube timpaniP: supel, Hepar/lien tidak teraba, NT (-),
Ekstremitas:Oedem (-/-), ad (-/-), flat nail (-/-)
Cor: I.IC tidak tampak P. IC tidak kuat angkat teraba1cm LMCS SIC VP. Bts jantung tidak melebarA.BJ I-II Reguler, bising(-),gallop (-)Pulmo: I. PD kanan=kiriP. FR kanan=kiriP. Sonor/SonorA.SDV (+/+) RBK (+/+) basal paru
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PEMERIKSAAN LABORATORIUM DARAH
Hb 13,8Hct 38AE 4,58AL 16,2AT 175SGOT 402SGPT 391
Cr 0,7Ur 24
GDS 183Na 136K 3,0Cl 102
HbSag Non react
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Ro Thorax PA
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EKG :
Sinus ritme, HR 100 x/’
Zone transisi V4
LAD, LVH, T Tall
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Diagnosa
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Planning Diagnosis
1. GDP GD2PP, HbA1c
2. Bilirubin total/direct/indirect
3. Anti Hbc, anti HCV, LFT
4. Sputum BTA, Kultur Sputum
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Terapi
1. Bed rest tidak total 2. O2 2 lpm nk sesuai FiO23. Diet sepsis TKTP 2100kkal 4. Inf NaCL 0,9 % 24 tpm makro 5. Inj Ceftriaxone 2 gr/24jam6. Inf. Metronidazole 500 mg/8 jam7. Inj. Dexamethasone 5 mg/8 jam8. Inj. Omeprazole 40 mg/12 jam9. Sucralfat syr 3xC110. PCT 500 mg 3x1 (k/p)11. Curcuma 3x112. NAC 200 mg 3x1
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Planning Monitoring :
Edukasi pasien dan keluarga tentang penyakit, tatalaksana, komplikasi,
Planning Edukasi :
KUVS/8 jam
BC pagi/12 jam
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Peningkatan enz.
transaminaseHiperglikemia
Klinis pneumonia
dengan sepsis
Dispepsia ulcer like type
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TERIMA KASIH