07 Juli 2013
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Transcript of 07 Juli 2013
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No.RM : 14.53.54 Name : Mrs.SM Age : 28 thn Sex : Female Adress : Sawo RT 4 RW 8 Dukun Gresik Work: Employee Date : July 07th 2013
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ANAMNESA: CHIEF COMPLAINT :
Mass in neck PRESENT ILLNESS HISTORY :
patients come with a mass in the right neck that became known only since 2 weeks ago. patients also complained of frequent sweating and palpitations. Pain -, headache +, complaint of a mass elsewhere denied. Shortness of breath, a hoarse voice and difficulty swallowing denied.
BB, nafsu makan, cuaca, PAST ILLNESS HISTORY :- FAMILY ILLNESS HISTORY : -
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GCS : 456 Vital sign
• BP : 112/70mmHg• RR : 18x/menit• PR : 85x/menit• Temp : 37C
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• Head and Neck:a/i/c/d: -/-/-/-mass in the thyroid gland, moves while swallowing
• Thorax:Simetris, retraksi -, ves/ves, rh-/-, wh -/-, S1S2 single, Murmur -, Gallop -
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• ABDOMENFlat, Soepel (+), Met (-), BU + N, Hepar lien difficult to evaluate.
.Ekstrimitas: warm, dry,red, edema -
• Status Lokalis:• Inspeksion : mass in the right thyroid gland, moves while swallowing
• Palpasion : dextra lobe, there ф mass measuring 3x3cm, chewy consistency,, mobile, tenderness - and the part moves while swallowing (+)
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JENIS PERIKSA HASIL PEMERIKSAAN
NORMAL
HAEMATOLOGI
Diffcount 2/1/58/30/9 1-2/0-1/49-67/25-33/3-7
Hematokrit 40,3 L 40-54% P 35-47%
Haemoglobin 13,8 P 13,0-18,0 mg/dl L 14,0-18,0 mg/dl
ESR 17/33 L 0-5/jam P 0-7/jam
Lekocyte 9.000 4000-11000
Trombosyte 201.000 150.000 – 450.000
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JENIS PERIKSA HASIL PEMERIKSAAN
NORMAL
FAAL HATI
SGOT 21 L 37 U/L P 31 U/L
SGPT 15 L 41 U/L P 31 U/L
JENIS PERIKSA HASIL PEMERIKSAAN
NORMAL
FAAL GINJAL
Creatinin Serum 0,6 P 0,7-1,2 mg/dl L 0,8-1,5 mg/dl
Urea 21 10-50 mg/dlFAAL HEMOSTASIIS
APTT 42,4 24,2 – 38,2 detik
PT 14,7 10,3 – 16,3 detik
Hormon Tiroid
T4 1,35 0,95 nmol/l – 2,5 nmol
T3 56,80 60 nmol/l – 120nmol/l
TsHs 1,32 0,25 – 5,0
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Female, 28 Mass in right neck Sweating (+) Palpitation (+) Head and neck : mass in the thyroid gland,
moves while swallowing dextra lobe, there ф mass measuring 3x3cm,
chewy consistency, flat surface, mobile, tenderness -, and the part moves while swallowing (+)
T4 : 1,35 ; T3 : 56,80, TsHs 1,32
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Struma Nodusa non Toxica Lobus Dextra
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Hashimoto’s Disease
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FNAB Follicular Neoplasm
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IVFD Assering 1500 cc/24 jam Antrain 1 amp, prn
Konsul: SpBKL Pro Fokal Lobectomy
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TTV Keluhan Subjektif pasien
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Menjelaskan kepada pasien dan keluarga pasien tengan diagnosis penyakit pasien, pemeriksaan penunjang yg akan dilakukan, terapi yg diberikan, komplikasi dan prognosis penyakit pasien.
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