Lapsus Rheuma SLE 24 Feb 16
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Transcript of Lapsus Rheuma SLE 24 Feb 16
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LAPORAN KASUS
SUSP. SISTEMIK LUPUS
ERITEMATOUS
NAMA : HUMAIRA A. HI BAYAN
NIM : C111 10 181BAGIAN : INTERNA
SUBDIVISI: RHEUMATOLOGI
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ANA)NESIS
KELUHAN UTAMA : %era# mera! *i #e*ua pipi
RIWAYAT PENYAKIT SEKARANG
Dialami se$a# #eluar *ari ruma! sa#i se#iar 3 ulan an" lalu. %era# *i #e*ua
pipi enu# seperi #upu-#upu #emera!an $u"a er*apa pa*a #e*ua per"elan"anan"an *an pun""un" ela#an" *iserai rasa "aal *an rasa "aalna memera
pa*a malam !ari. &iaa er'a #e P'li Tr'pis 1 ulan an" lalu *i *ia"n'sa
*en"an i'i* *an *ieri 'a 'ral nama 'a *i lupa 'le! pasien. Kemera!anna
er#uran" se*i#i-se*i#i seiap !ari *en"an 'a erama! para! $i#a 'ana
er!eni *i minum.
Demam i*a# a*a. &iaa *emam 4 3 !ari an" lalu i*a# minum 'a. &iaa
*emam seelumna , ulan an" lalu *emam nai# urun perna! #'nsumsi 'a
penurun *emam *an semu!. &iaa 'ser5asi masu# U6D ulan 11 *en"an
*emam namun i*a# *ila#u#an e5aluasi lei! lan$u.
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7asil 8a :
- 7 : 9 "/*l 120 1;0 "/*l<
- (%= : 29.>2 10?3/u8 ,.00 10.0 10?3/u8<
- Alumin : 29 "/*l 3> >0 "/*l<8emas i*a# a*a neri sen*i i*a# a*a penurunan era
a*an a*a riaa #eluar"a *en"an #elu!an an" sama
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PE)E&IKSAAN ISIK
KU : Sa#i &in"an/6iBi Kuran"/='mp'smenis
%% : ,+ #" I)T : 2+2 #"/m?2 "iBi #uran"<
T% : 1;> m
VITAL SIGN
TD : 110/0 mm7"
7& : ; C/meni re"uler #ua an"#a
&& : 1 C/meni Tipe : T!'ra'-A*'minal
Su!u : 3;, oC (axilla)
VAS Score : 0/10
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Kepala
Ekspresi : Biasa
Simetris muka : simetris kiri = kanan
Deformitas : (-)
Rambut : Rontok (+) riwayat
a!a" : kemera"an #i ke#ua pipi$ bentuk
seperti kupu-kupu
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MataE#s'palmus/En'palmus : -<
6era#an : #e se"ala ara!
Te#anan 'la maa : *alam aas n'rmal
Kel'pa# )aa : e*ema palpera -mm/2>mm
&eleC a!aa @/@Telinga
Pen*en"aran : *alam aas n'rmal
T'p!i : -<
Neri e#an *i pr'sesus mas'i*eus : -<
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HidungPer*ara!an : -<
Se#re : -<
Mulut%iir : pua -
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Leer
Kelen$ar "ea! enin" : i*a# a*a pemesaran
Kelen$ar "'n*'# : i*a# a*a pemesaran
DS : & 4 2 m72
Ka#u #u*u# : -<Tum'r : -<
!ada
In"#e$"i%enu# : n'rm'!es simeris #iri F #anan
Pemulu! *ara! : i*a# a*a #elainan
%ua! *a*a : simeris #iri F #anan
Sela i"a : *alam aas n'rmal
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Paru
Pal#a"i
Neri e#an : -/-<
)assa um'r: -/-<
remius raa : simeris #iri F #anan
Per$u"i
Paru #iri : uni s'n'r Paru #anan : uni s'n'r
%aas paru-!epar : I=S -I
%aas aa! paru ela#an" #anan: sein""i = T! III
%aas aa! paru ela#an" #iri : sein""i = T! IGAu"$ulta"i
%uni pernapasan : esi#uler
%uni ama!an: &!'n#i -/-
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%antungIn"#e$"i : ius 'r*is i*a# ampa#
Pal#a"i : ius 'r*is i*a# eraa
Per$u"i : uni pe#a#
aas aas $anun" : I=S II sinisra
aas #anan $anun" : I=S III-I linea parasernalis *eCra
aas #iri $anun" : I=S linea mi*la5iularis sinisra
Au"$ulta"i : uni $anun" I/II murni re"ular isin" -<
A&do'enIn"#e$"i : emun" i#u "era# napas
Au"$ulta"i : Perisali# @
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S%&%'S RE'&%*,
(alt) : normal
& (&rms) : normal
* (*es) : normal
S (Spine) : normal
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!iagno"i" Se'entara :
Su"#( SLE )"i"te'i$ lu#u" erite'atou"*
Krieria A=& :1. K'n$un"i5a anemis
2. )alar &as!
Planning Pe'eri$"aan :8a'ra'rium :
Dara! ruin : 7em'"l'in 8ED
Ureum #reainin S6T S6PT Alumin
='m es ANA es
&a*i'l'"i :'' T!'raC
EK6
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TERIMA KASIH