Presentation 1

7/18/2019 Presentation 1

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MORNING REP TANGGAL 15 DESE



IDENTITAS PASIENNama : tn. Ari mistowomr: !0 ta"n

A#amat: $%mnin& RT 0'(R) 02

A&ama : is#am

P%$%r*aan : ti+a$ a+a

Sstats marita#: ,%#m $awin

P%n+i+i$an t%ra$"ir : STM

Ban&sa : in+on%sia

S$: *awa

Tan&&a# MRS : 14 +%s%m,%r 2014



ANAMNESA

-%t%roanamn%sa n/. Misna i, $an+n& tin&&a# s%rma"

%#"an tama : mara" mara"

Riwa/at %n/a$it s%$aran& : asi%n mara"3mara" $%a+a i,n/a *i$a $%in&inti+a$ +itrti.

Pasi%n s+a" ms%%rti ini s%*a$ 5 ta"n /an& #a# asi%n mara"3mara" +%n&am%rsa$ ,aran& ,aran& rma" +an m%m$# i,n/a +irma"



G%*a#a tam,a"an : asi%n s%rin& mi$3mi$ s%n+iri t%tai *i$a +itan/a asi%nsa*a

Pasi%n s%rin& m%n/%n+iri +i,awa" o"on ,am, sam,i# m%n#is +itana"

Pasi%n s%rin& n&tan& +iwarn& t%tan&&a +an *i$a ti+a$ +itrti asi%n mara"

Pasi%n s%rin& m%rsa$ t%m,o$ +an &%nt%n& rma"

ADL a6ti7it/ Dai#/ #i7in&: ma$an 23!8 %r "ari tana +isr"

Man+i ! "ari s%$a#i

Pasi%n s#it ti+r

Pasi%n ti+a$ %rna" s"o#at

A$ti7itas ti+a$ ma ,%$%r*a "an/a ma$an ++$ +an ti+r



• rono#o&i : s%#ama 5 ta"n ini asi%n mata"3mara" s%%rti m%m,antin& t7 m%m$# i,n/a *i$a ti+a$ +itrti $%maann/a. a+a,& asi%n m%n&an6am%m,a$ar rma" +sn m%n&sir oran& rma"

• S%#ama 5 ta"n ini asi%n "an/a ,%ro,at +i $/ai +an +$n. -an/a +i,%ri ainamn ti+a$ a+a %r,a"an. S%*a$ 2 min&& #a# asi%n +i,awa $% +o$t%r $a+a t%tan&&a /an& n/a &%*a#a /an& sama. S%t%#a" $% +o$t%r asi%n +isar

$% RS9 M%nr +an a$"irn/a +i,awa "ari ini.

• S%,%#m sa$it asi%n ,%$%r*a +i *an+a t%tai $#ar $ar%na &a*in/a $%6i#. Sit asi%n ,%$%r*a s%,a&ai $#i ,at namn asi%n ti+a$ +i,a/ar. B%,raa s$%m+ian asi%n m#ai ,%rri#a$ mara" mara"



• Atoanamn%sa asi%n t%r;$sasi

• T: a&i mas sa/a DM /an& *a&a "ari ini. Nama mas siaa.<

• 9: tan/a oran&3oran& it a*a m%nn*$ $%a+a %n&antar

• T: i/a mas tai sa/a ma tan/a sam mas.

• 9:asi%n "an/a t%rs%n/m

• T: mas ari /a naman/a<

• 9: i/a it ta masi nan/asam,i# t%rs%n/m

• T: mr mas ,%raa<

• 9: !5



• T: +# mas s%$o#a" samai aa<

• 9: SMP sam,i# m%nt mata

• T: mas $o$ m%r%m<

• 9: a= n&ant$.

• T: mas ari $ran& ti+r ta<

• 9: +iam

• T: mas ari +irma" n&aain a*a<

• 9: /a m%ro$o$ main.

• T: main saa siaa mas<

• 9: s%n+iri.



• T: $a#a +irma" mas ari ,i6ara +%n&an siaa<

• 9: /a sama siaa a*a /an& ,isa +ia*a$ n&omon&.

• T: tai mas ti+a$ n&omon& s%n+iri $an<

• 9: &imana $o$ n&omon& s%n+iri /a n&a$ #a">sam,i# t%rs%n/m

• T: mas +%n&%r sara3sara ,isi$an &a$<<

• 9: &a a+a

• T? mas $%naa +i,awa $%sini<

• 9: &a$ ta.

• T: mas $atan/a s$a mara"3mara" /a +irma"<

• 9: mara" $% siaa<<t%rs%n/m masa$ oran& mara"3mara"



• T: t%rs a+a masa#a" aa +irma"<

• 9: asi%n +iam +an wa*a" asi%n ti+a$ ma ,i6ara #a&i

• T: trima $asi" /a mas.



RI)A@AT PEN@AIT DA-L

• Trama $%a#a

• %*an&

• M%ro$o$

• A#$o"o# +isan&$a#

• NAPCA +isan&$a#

• Dm

• -T

• Riwa/at %n+i+i$an : STM

• Riwa/at %$%r*aan : $#i

• Riwa/at %rni$a"an : ,%#m m%ni$a"



• Riwa/at $%#ar&a : asi%n ana$ $%3! +ari $%%mat ,%rsa+ara. A+i$ $%%mam%n+%rita &an&&an *iwa.



• . Pr%mor,i+ : %n+iam t%rtt

• . P%n6%ts : ,%#m +it%m$an

• . %trnan : a+i$

• . Lin&$n&an : ti+a$ +it%m$an

• .or&ani$ : ti+a$ +it%m$an



PEMERISAAN ISI

• Stats int%rna

• TD : 120(0mm"&

• Na+i: 1208 %rm%nit

• S" : !'5 6

• RR : 18 %r m%nit

• Lain3#ain : +a#am ,atas norma#



• Stats n%ro#o&i

• GFS : 45'

• %sa+aran $omosm%ntis

• Pi# ( r%%$ 6a"a/a : iso$or ! mm ( ! mm? (

• R%%$ ;sio#o&i : +,n

• R%%$s ato#o&i : 3



• Stats si$iatri

• %san mm : #a$i3 #a$i w wa*a" s%sai sia ti+a$ rai ti+a$ ,%rsi" stats&iHi6$ &i&&#in&

• %sa+aran : ,%r,a"

• onta$ : 7(r(# ((3

• Ori%ntasi: w(t(o (3(

• Moo+ a: +an&$a#

• PB B: non r%a#siti$

• A: t%rts

• I: ,%#m ,isa +i%7a#asi



• P%rs%si : -A(-J

• Psi$omotor : +,n

•

%maan : m%nrn



DIAGNOSIS

• A8is I : K20.!1 s$iHoKr%nia ta$ t%rin6i

• A8is II : t%rtt %n+iam

• A8is III: ti+a$ +it%m$an

•

A8is IJ : ,%#m +it%m$an• A6is J : GA s6a#% 403!1



TERAPI

• F"#orromaHin% 0303100m&



PROGNOSIS

• D,ia at ma#am

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