Status Pulmo William Tarakan

Jl.Terusan Arjuna No 6 Keon Jeru! "Ja!ar#a $ara#
KE%ANITERAAN KLINIK
FAKULTAS KEDOKTERAN UKRIDA
S&F %UL&ONOLO-I
RSUD TARAKAN
Naa , Wlla Ale/an0er Se#a1an Tan0a Tan+an
NI& , 22342537
88888888..
IDENTITAS %ASIEN
Naa len+!a; , Tn. 'J Jens !elan , La!"la!
Te;a# * #an++al la<r, 3 &are# 2=>6 Su!u $an+sa , Ja1a
S#a#us ;er!a1nan, &en!a< A+aa , Isla
%e!erjaan , Lan"lan %en00!an , S&U
Alaa#, -ar
ANAMNESIS
Dal 0ar au#onaness #an++al 5 Jun 342?
Keluhan utama
Riwayat Penyakit Sekarang
2 ulan S&RS os en+a#a!an a0a !elu<an a#u!"a#u!. Selan a#u!: os ju+a sern+
en+ala 0ea. Dea 0rasa na! #urun 0an sern+ #erja0 0e!an #eru#aa j!a os
era!#@#as @s! 9an+ a+a! era#. Seja! seulan ju+a os erasa na@su a!an enurun
se<n++a era# a0an os enurun.
5 n++u S&RS os eroa# !e ;us!esas 0 0e!a# rua<n9a !arena ula erasa
#0a! n9aan 0en+an !elu<an a#u! 9an+ 0ala ;asen 9an+ su0a< 3 n++u n #a!
!unjun+ ea!. Os eroa# 0 ;us!esas 0an !elu<an a#u! er!uran+ 1alau #0a!
seu< seu#u<n9a.
2 n++u S&RS os !eal eroa# !e ;us!esas !arena !elu<an a#u! ;asen
unul !eal. Os se;a# enjalan ;eer!saan ron#+en ;a0a !unjun+an !e0ua eroa# 0
1

;us!esas !al n. Dar <asl ron#+en 0!a#a!an a<1a ;a0a ;aru os #er0a;a# e@us ;leura 0an
os 0saran!an un#u! 0ruju! !e RS: naun os #0a! en+<rau!an 0an <an9a en+!onsus
oa#"oa#an 9an+ 00a;a# os 0 ;us!esas.
3 <ar S&RS os erasa a+a! sesa! 0 0a0a: !elu<an sesa! #a"#a saja 0rasa!an os
#an;a os #a<u a;a sean9a. Kelu<an a#u! ju+a 0rasa eera#. Naun os elu ju+a
<en0a! eer!sa!an 0rn9a !eal.
? ja S&RS os erasa sesa! a!n eera# se<n++a os 0a#an+ !e I-D RSUD
Tara!an. Sesa;an9a 0 I-D: os lan+sun+ en0a;a# ;enan+anan un#u! !elu<an sesa!n9a.
D0a;a#!an !e#eran+an r1a9a# ero!o! ;a0a os seja! > #a<un lalu: r1a9a# nu nuan
al!<o<ol seja! ? #a<un lalu. Os en+a#a!an #0a! el! r1a9a# 0ae#es: r1a9a# 0ara<
#n++: r1a9a# ;en9a!# jan#un+: r1a9a# asa. Os ju+a en9a#a!an elu ;erna< enjalan
#era; 0en+an OAT.
( " ) Caar ar ( " ) e;a##s ( " ) $%
( " ) D@#er ( " ) T@us A0onals ( " ) Wasr
( " ) $a#u rejan ( " ) S!ro@ula ( " ) Dae#es
( + ) Campak ( " ) S@ls ( " ) Aler+
( + ) Influena ( " ) -onore ( " ) Tuor
( " ) Tonsl#s ( " ) ;er#ens ( " ) $a#u +njal
( " ) Korea ( " ) Ul!us Ven#r!ul ( " ) -as#r#s
( " ) Dea Rea#! A!u# ( " ) Ul!us Duo0en ( " ) %s!oss
( " ) %neuona ( " ) %en9a!# %eulu< ( " ) Neuross
( " ) %leur#s ( " ) $a#u E;e0u ( " ) Keela!aan
( " ) Tuer!oloss ( " ) %er0ara<an o#a! ( " ) &alara
Riwayat Keluarga
(Ta<un)
Jens Kelan Kea0aan Kese<a#an %en9ea
&enn++al
Sau0ara 5? La!"la! Se<a#
A!akah kera"at yang men!erita
Aler+ "
ANAMNESIS SIS#EM
Ca#a# !elu<an #aa<an ;os#@ 0sa;n+ ju0ul " ju0ul 9an+ ersan+!u#an.
ara; 0s, $la 9a ( B ): la #0a! ( " ).
Kulit
( " ) $sul
( " ) Ku!u
( " ) Ke#ajaan ;en+l<a#an
#elinga
( " ) N9er
( " ) Se!re#
$i!ung
( " ) %le!
Mulut
( " ) $r
( " ) -us
( " ) Sela;u#
#engg%r%kan
3
Da!a ('antung Paru paru)
( " ) Tnja er1arna <#a
( " ) Kenn+ nana<
Ektremita
( " ) $en+!a!
$era# a0an se!aran+ (K+) , ?4 !+
($la ;asen #0a! #a<u 0en+an ;as#)
4
R1a9a# Kela<ran
Te;a# la<r , ( " ) D rua< ( B ) Rua< $ersaln ( " ) R.S. $ersaln
D#olon+ ole< , ( " ) Do!#er ( B ) $0an ( " ) Du!un ( " ) lan " lan
Riwayat Imuniai (ti!ak !iketahui)
( " ) e;a##s ( " ) $C- ( " ) Ca;a! ( " ) D%T ( " ) %olo ( " ) Te#anus
Riwayat Makanan
Na@su a!an , $a!
Keulitan
%e!erjaan , T0a! a0a asala<
Keluar+a , T0a! a0a asala<
Lan"lan , T0a! a0a asala<
PEMERIKSAAN /ISIK
Sanoss , T0a! a0a
U0ea uu , T0a! a0a
a#us , %!n!us
Cara erjalan , Noral
Uur enuru# ;er!raan ;eer!sa , Sesua
5
Tn+!a< la!u , wa0ar * +elsa< * #enan+ * <;oa!#@ * <;era!#@
Ala ;erasaan , "iaa * se0< * +era * eas * #a!u# * ara<
%roses ;!r , wa0ar * e;a# * +an++uan 1a<a * @oa * oses
Kulit
%er#uu<an rau# , &era#a
Su<u raa , Noro#er
Kern+a# , Uu
Lan"lan ( " ) E@@loresens ( " ) %+en#as
( " ) %eulu< 0ara< ( " ) Lea * !ern+
( " ) I!#erus ( " ) E0ea
%eulu< 0ara< #e;oral , Noral
Mata
Dea#o !onju+ae ( " )
Eno;#<alus ( " )
Te!anan ola a#a Noral
N9s#a+us ( " )
L0a< , Noral
Sela;u# len0r , Noral
&eher
Da!a
%eulu< 0ara< , T0a! #a;a! !elanan
Paruparu
De;an $ela!an+
In;e!s Kr Se#rs: enjolan ( " ) Se#rs: enjolan ( " )
Kanan Se#rs: enjolan ( " ) Se#rs: enjolan ( " )
%al;as Kr $enjolan ( " ) $enjolan ( " )
Re#ra!s sela +a ( " ) Re#ra!s sela +a ( " )
N9er #e!an ( " ) N9er #e!an ( " )
Fre#us #a!#l se#rs Fre#us #a!#l se#rs
Kanan $enjolan ( " ) $enjolan ( " )
N9er #e!an ( " ) N9er #e!an ( " )
Fre#us #a!#l se#rs Fre#us #a!#l se#rs
%er!us Kr Seluru< la;an+ ;aru sonor Seluru< la;an+ ;aru sonor
Kanan Seluru< la;an+ ;aru sonor Seluru< la;an+ ;aru sonor
Aus!ul#as Kr Suara es!uler: wheezing ( " ): rh%nki ( + )
Kanan Suara es!uler: wheezing ( " ): rh%nki ( + )
'antung
In;e!s Kr , Terl<a# !#us !or0s 0 lnea 0laulars sns#ra: ICS V
%al;as Kr , I!#us !or0s #eraa 0 lnea 0laulars sns#ra: ICS V
0en+an 0ae#er 3 jar: !ua# an+!a#: re+uler
%er!us $a#as !anan , Lnea s#ernals 0e/#ra: sela +a IV
$a#as !r , 3 jar e0al 0ar lne a/lars an#eror: sela +a IV
$a#as a#as , Lnea ;aras#ernals sns#ra: sela +a II
Aus!ul#as Kr,
Ka#u; %ulonal , $J I II: re+ular: urur ( " ): gallop ( " )
Ka#u &#ral , $J I II: re+ular: urur ( " ): gallop ( " )
7
Kanan,
Ka#u; Aor#a , $J I II: re+ular: urur ( " ): gallop ( " )
Ka#u; Tr!us;0 , $J I II: re+ular: urur ( " ): gallop ( " )
Pem"uluh !arah
Ar#er Karo#s , Teraa ;ulsas
Ar#er $ra!als , Teraa ;ulsas
Ar#er Ra0als , Teraa ;ulsas
Ar#er Feorals , Teraa ;ulsas
Ar#er %o;l#ea , Teraa ;ulsas
Ar#er Tals %os#eror , Teraa ;ulsas
Ar#er Dorsals %e0s , Teraa ;ulsas
Perut
Ins;e!s , &eun#: enjolan ( " ): ;eulu< 0ara< !ola#eral ( " ): <erna ( " )
%al;as , NTE ( " ): n9er le;as ( " ): assa ( " ): 0e@ans usular ( " )
a# , T0a! #eraa
L;a , T0a! #eraa
-njal , $allo#een# ( " ): n9er !e#o! CVA ( " )
Lan"lan , T0a! a0a
%er!us , T;an: s<@#n+ 0ullness ( " ): un0ulas ( " )
Aus!ul#as , $sn+ usus ( B ): noro;ers#al#!
#ungkai !an Kaki
O#o# (#onus 0an asa) , Noro#onus
Sen0 , T0a! a0a !elanan
-era!an , T0a! a0a !elanan
Ke!ua#an , B?
Lan"lan , T0a! a0a
8
33 &e 3? &e 37 &e 3= &e 5 Jun
$" 2:4 25:= sA+
Eritr%it 5:77 5:>4 5:?4 5:>?
&euk%it 345677 835947 845:77 485477
#r%m"%it 9:5377 2>6.244 25.444 274.=44
Natrium 348 25? 34; 257 25
Kalium 5:7 4<4 4<3 4<4 :?
Cl%ri!e 98 243 244 == 243
1DS >? =2 I+&
Al"umin 8<>3 4<7= 4<8=
1l%"ulin ;<;7 4<43 4<4:
*iliru"in #%tal 8;<8; ;<36 ;<>;
*iliru"in Direk 39<3> 4<87 4<43
Pr%tein #%tal 7:42 6:65
R%ntgen #h%ra?
Kesan sesua 0en+an +aaran e@us ;leura la#eral.
S1 A"!%men
Kesan sesua +aaran <e;a##s !rons 0an as#es nal.
/,&&,- P
O TSS: C&
%ulo , R<on! B*B
A0oen , &eun#: enjolan 0 e;+as#ru: <e;ar #eraa 3 jar 0a1a<
arus os#ae: #eraa ln: #e; #u;ul: n9er #e!an (B)
Jens %eer!saan asl Nla Ruju!an
eo+lon 25:= 25.4 " 26.4 +*0L
ea#o!r# 4:> 56 " 6 G
Le!os# 32=54H 444 " 24444 *uL
Troos# 2>6244 2?4444 " ?4444 *uL
Na#ru 25? 25? 2?4 E*L
Kalu 5:5H 5:6 ?:? E*L
Clor0a 243 = 222 E*L
-ula Dara< Se1a!#u =2 24
S-OT 23>H 4 U*L
S-%T ?7H 2 U*L
Ureu 36 2? ?4 +*0L
Krea#nn 4:63 4:6 2:5 +*0L
$lrun To#al :?>H 2:2 +*0L
$lrun Dre! 5:53H 4:6 +*0L
%ro#en To#al 7:42 6: >:5 +*0L
Alun 3:62H 5:? ?:3 +*0L
-louln :4H 2:? 5:4 +*0L
A E@us ;leura la#eral e T ;aru ;o!alea
T ;aru !asus aru ;oalunea
Os as#es e <e;a##s !rons 00* <e;a#oa
% R@a;sn 2 / ?4 + Aro/ol 5 / 2
IN 2 / 544 + $6 3 / 2
E#<au#ol 2 / 2444 + Ce@o Sul 3 / 2 +r
8> Mei 873:
O TSS: C&
TD 224*74 R >3 /* RR 33 /* S 56: oC
&a#a , SI B*B
%ulo , R<on! B*B

asl US- A0oen !esan sesua <e;a##s !rons 0an as#es nal
% R@a;sn 2 / ?4 + Aro/ol 5 / 2
IN 2 / 544 + $6 3 / 2
E#<au#ol 2 / 2444 + Ce@o Sul 3 / 2 +r
86 Mei 873:
O TSS: C&
TD 224*>4 R >6 /* RR 34 /* S 56: oC
&a#a , SI B*B
%ulo , R<on! B*B
E!s#re#as , oe0e !e0ua #un+!a
% R@a;sn 2 / ?4 + Aro/ol 5 / 2
IN 2 / 544 + $6 3 / 2
E#<au#ol 2 / 2444 + Ce@o Sul 3 / 2 +r
8= Mei 873:
S Sesa! 0an a#u! su0a< er!uran+: !a! en+!a!
O TSS: C&
TD 234*>4 R >3 /* RR 34 /* S 56:>oC
%ulo , R<on! B*B
E!s#re#as , oe0e #un+!a: a!ral <an+a#

sA+ NON REAKTIF NON REAKTIF
An# CV REAKTIFH NON REAKTIF
Den+ue I+- Ne+a#@ Ne+a#@
Den+ue I+& Ne+a#@ Ne+a#@
Na#ru 25? 25? 2?4 E*L
Kalu 5:5H 5:6 ?:? E*L
Clor0a 243 = 222 E*L
Os as#es e e;a##s C !rons 00* <e;a#oa
% R@a;sn 2 / ?4 + Aro/ol 5 / 2
IN 2 / 544 + $6 3 / 2
E#<au#ol 2 / 2444 + Ce@o Sul 3 / 2 +r
$;l 0ar ;aru
89 Mei 873:
S $a#u! 0ara< 2/ #a0 ;a+: sesa! ( " ): !a! su0a< #0a! en+!a!
O TSS: C&
&a#a , SI B*B
%ulo , R<on! B*B
Na#ru 257 25? 2?4 E*L
Kalu 5:5H 5:6 ?:? E*L
Clor0a == = 222 E*L

S-%T 63H 2 U*L
$lrun To#al :27H 2:2 +*0L
$lrun Dre! 5:34H 4:6 +*0L
%ro#en To#al 6:5=H 6: >:5 +*0L
Alun 5:4>H 5:? ?:3 +*0L
-louln 5:52H 2:? 5:4 +*0L
% R@a;sn 2 / ?4 + Aro/ol 5 / 2
IN 2 / 544 + $6 3 / 2
E#<au#ol 2 / 2444 + Ce@o Sul 3 / 2 +r
%lasne/ 5 / 2 Co0;ron# 5 / 2
3 'uni 873:
S Kelu<an ( " )
O TSS: C&
A0oen , &eun#
S-OT 76H 4 U*L
S-%T 62H 2 U*L
$lrun To#al :6H 2:2 +*0L
$lrun Dre! 5:52H 4:6 +*0L
%ro#en To#al 6:65 6: >:5 +*0L
Alun 5:3>H 5:? ?:3 +*0L
-louln 5:5?H 2:? 5:4 +*0L

% R@a;sn 2 / ?4 + Aro/ol 5 / 2
IN 2 / 544 + $6 3 / 2
E#<au#ol 2 / 2444 + Ce@o Sul 3 / 2 +r
%lasne/ 5 / 2 Co0;ron# 5 / 2
8 'uni 873:
S Kelu<an ( " )
O TSS: C&
A0oen , &eun#
Na#ru 25H 25? 2?4 E*L
Kalu :? 5:6 ?:? E*L
A E@us ;leura la#eral e T ;aru ;ona#rea
% R@a;sn 2 / ?4 + Aro/ol 5 / 2
IN 2 / 544 + $6 3 / 2
E#<au#ol 2 / 2444 + Ce@o Sul 3 / 2 +r
%lasne/ 5 / 2 Co0;ron# 5 / 2
4 'uni 873:
S Kelu<an ( " )
O TSS: C&
eo+lon 2:4 25.4 " 26.4 +*0L
ea#o!r# 5=:5 56 " 6 G
Le!os# 53544H 444 " 24444 *uL
Troos# 274=44 2?4444 " ?4444 *uL
A E@us ;leura la#eral e T ;aru e;a##s C !rons
T ;aru !asus aru Se;ss

% R@a;sn 2 / ?4 + Aro/ol 5 / 2
IN 2 / 544 + $6 3 / 2
E#<au#ol 2 / 2444 + Ce@o Sul 3 / 2 +r
%lasne/ 5 / 2 Co0;ron# 5 / 2
; 'uni 873:
TD 224*74 R >4 /* RR 34 /* S 56:>oC
A E@us ;leura la#eral e T ;aru e;a##s C !rons
T ;aru !asus aru Se;ss
% R@a;sn 2 / ?4 + Aro/ol 5 / 2
IN 2 / 544 + $6 3 / 2
E#<au#ol 2 / 2444 + Ce@o Sul 3 / 2 +r
Leo@lo/an 2 / ?44 + Co0;ron# 5 / 2
RESME
Seoran+ ;ra usa 3= #a<un 0a#an+ 0en+an !elu<an esa! seja! !earn sore. Sesa!
0a#an+ #a"#a #an;a os #a<u sean9a. $eera;a ja S&RS sesa! 0rasa eera#.
Kelu<an #aa<an eru;a a#u! 9an+ #a! !unjun+ seu< seja! 2 ulan S&RS. OS
en+a#a!an leas 0 seluru< a0an. Os en+a#a!an na@su a!an er!uran+ seja! 2 ulan
9an+ lalu se<n++a en+ala ;enurunan era# a0an.
%a0a ;eer!saan @s! !ea0aan uu ;asen #a;a! sa!# se0an+ 0en+an !esa0aran
o;os en#s. %a0a ;eer!saan #an0a"#an0a #al 0#eu!an #e!anan 0ara< 254*>4 +:
na0 =4/: na@as 3 /: su<u 56:> OC. %a0a aus!ul#as ;aru: 0#eu!an ron! asa< !asar ;a0a
!e0ua ;aru. %a0a ;eer!saan 0ara< 0#eu!an 2:4 +r*0l : ea#o!r# 5>:>G : Leu!os#
25.744*5: #roos# =?.244*5: Na#ru 253 ol*L: Kalu 5:7 ol*L: Clor0e =3
ol*L: -DS >? +*0L: Ureu 25 +*0L: Krea#nn 4:>6 +*0L: S-OT 342 U*L: S-%T 6=
U*L.

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