Kasbes Tht Muntaha

7/21/2019 Kasbes Tht Muntaha

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LAPORAN KASUS BESARILMU KESEHATAN THT-KL

SEORANG PRIA 47 TAHUN DENGANDISFAGIA e.c MASSA OROFARING SUSPEK

CA OROFARING

Pembimbing !". Din# $%"&#ning"%m' S(. THT-KL

O)e*

M+c*#m#! m%n,#*#///0//4



IDENTITAS PENDERITA

N#m# Leng1#( Tn.T

P#nggi)#n ,in,%$

TTL Pe1#)+ng#n' m#"e, /237

eni$ Ke)#min L#1i-L#1iAg#m# I$)#m

5#"g# Neg#"# In!+ne$i#

S%1% #6#

A)#m#, P#n#ng 6e,#n (e1#)+ng#n #6#,eng#*

Pe1e"##n M+n,i" 1#(#)

Pen!i!i1#n SMP

N+. RM C47247



DAFTAR MASALAH

M#$#)#*

A1,i8 • Di$8#gi#• Un!e"6eig*,

M#$#)#*

P#$i8



AUTOANAMNESIS(TANGGAL 5 JUNI 2014 PUKUL 14.00)

KELUHAN UTAMA : SULIT MENELAN

9 /': ,#*%n &#ng )#)% (#$ien menge)%* $%)i,mene)#n'#6#)n&# $e(e",i #!# &#ng mengg#n#)!i,engg+"+1#n'$%#"# m%)#i ,i!#1 e)#$ $e(e",ibe"1%m%";$eng#%'#6#)n&# m#$i* bi$# m#1#n !#n min%m

$e(e",i bi#$#'$e1#"#ng *#n&# bi$# m#1#n m#1#n#n )%n#1$e(e",i b%b%"' ,e"$e!#1 <-=' )%!#* be"c#m(%" !#"#* <>= 1#!#ng1#!#ng' n&e"i $##, mene)#n <>=' !em#m <-=' $e$#1 <-=' $e"#1 <-=. 9 4 b%)#n &#ng )#)% m%nc%) ben+)#n !i )e*e" 1#n#n(#$ien m#1in )#m# m#1in be$#"' n&e"i ,e1#n <-=' n&e"i 1e(#)# <-='

!em#m <-=' *i!%ng ,e"$%mb#, <-;-=' ,e)ing# gemb"ebeg <-;-='(#n!#ng#n 1#b%" <-;-=' 1em%!i#n (#$ien be"+b#, 1e (eng+b#,#n#),e"n#,i n#m%n ,i!#1 #!# (e"b#i1#n' )#)% (#$ien mem%,%$1#n%n,%1 be"+b#, 1e "%m#* $#1i, !".1#"i#!i $em#"#ng %n,%1men!#(#,1#n (en#ng#n#n )ebi* )#n%,.



• Ri6#&#, mene)#n ?#, 1+"+$i8 <-=• Ri6#&#, #$m# <-=• Ri6#&#, *i(e",en$i <-=•

Ri6#&#, DM <-=• Ri6#&#, TB <-=• Ri6#&#, 1+n$%m$i +b#, <>=

Riwaya P!"ya#i Da$%&%

• Ri6#&#, 1e)%#"g# men!e"i,# (en&#1i, &#ng $#m# <-=•

Ri6#&#, *i(e",en$i <-=• Ri6#&#, DM <-=

Riwaya P!"ya#i #!&%a'a

• P#$ien be1e"# $eb#g#i (e,#ni !eng#n (eng*#$i)#n 9R(4.' (e b%)#n !#n m#$i* men#ngg%ng 0 +"#ng

#n#1 &#ng be)%m m#n!i"i. S%#mi $%!#* )#m# ,i!#1membe"i n#81#*. Bi#&# (eng+b#,#n !i,#ngg%ng #m1e$m#$• Ke$#n $+$i#) e1+n+mi 1%"#ng

Riwaya S*ia& E#"+i

• Ri6#&#, men&em("+, *#m# ,i!#1 mem#1#i m#$1e" <-=•

Ri6#&#, me"+1+1 <-=• Ri6#&#, min%m #)1+*+) <-=

Lai",&ai"



PEMERIKSAAN FISIK TGL : UNI /4 PKL /4. 5IB

• Ke$#!#"#n c+m(+$men,i$• A1,i@i,#$ 1%"#ng #1,i8• K++(e"#,i@i,#$ 1++(e"#,i8• S,#,%$ gi?i BB 04 1g' TB /:

cm <IMT /4'7/

%n!e"6eig*,=• K%)i, ,%g+" 1%)i, c%1%(• T#n!# i,#)• N#!i ;meni,• Ten$i /; mmHg

• N#8#$ /;meni,•

S,#,%$ Gene"#)i$



K+n%ng,i@# (%c#, <-;-=

P#"% R+n1*i b#$#* 1#$#" !i b#$#)(#"% 1#n#n

#n,%ng !#)#m b#,#$ n+"m#)

H#,i ,#1 ,e"#b#

Lim(# ,#1 ,e"#b#

Angg+,# Ge"#1 $ime,"i$'

!#)#m b#,#$ n+"m#)



Ka"a" Ki'i

M#$,+i! N&e"i ,e1#n <-=' n&e"i1e,+1 <-=' ,#n!# "#!#ng<-=

N&e"i ,e1#n <-=' n&e"i1e,+1 <-=' ,#n!# "#!#ng<-=

P"e #%"i1%)# N&e"i ,e1#n <-=' $,e) <-='#b$e$ <-=

N&e"i ,e1#n <-=' $,e) <-='#b$e$ <-=

Re,"+ #%"i1%)# N&e"i ,e1#n <-=' $,e) <-='#b$e$ <-=

N&e"i ,e1#n <-=' $,e) <-='#b$e$ <-=

A%"i1%)# N&e"i ,#"i1 <-='N&e"i ,e1#n ,"#g%$ <-='Hi(e"emi$ <-=

N&e"i ,#"i1 <-='N&e"i ,e1#n ,"#g%$ <-='Hi(e"emi$ <-=

CAE ; MAE O!em# <-=' *i(e"emi$ <-='$e"%men <-=

O!em# <-=' *i(e"emi$ <-='$e"%men <-=

Di$c# <-= <-=

Memb"#n# Tim(#ni

5#"n# P%,i* meng1i)#, $e(e",im%,i#"#

P%,i* meng1i)#, $e(e",im%,i#"#

Ree c#*#&# <>= #m : <>= #m 7

Pe"8+"#$i <-= <-=

L#in-)#in B%)ging <-=' "e,"#1$i <-= B%)ging <-=' "e,"#1$i <-=

TELINGA



•P#)#,%m $ime,"i$' m#$$# <-=' (#)#,%mb+mb#n$ <-=

• A"1%$ F#"ing $ime,"i$' %@%)# !i ,eng#*' "eem%n,#* <>=

• M%1+$# *i(e"emi$ <-=' g"#n%)#$i <-=' $e1"e,<-=

• T+n$i) Ka"a" Ki'i• U1%"#n T/ T/• 5#"n# *i(e"emi$ <-=

*i(e"emi$ <-=

• Pe"m%1##n g"#n%)#$i <-= g"#n%)#$i-

O"+8#"ing



• M%1+$# e!em# <-=' *i(e"emi$ <-=• #)e1%)# e!em# <-=' *i(e"emi$ <-=• Re$e$%$ (i"i8+"mi$ e!em# <-=' *i(e"emi$ <-=• P+",# e$+8#g%$ e!em# <-=' *i(e"emi$ <-=•

L#in-)#in "e$i!% m#1#n#n !i $in%$(i"i8+"mi$

L#"ing+8#"ing

• E(ig)+,i$ e!em# <-=' *i(e"emi$ <-=• T%m+" <-=• L#in-)#in -

S%("#g)+,i$



GIGI DAN

MULUT



RINGKASAN

9 /': ,#*%n &#ng )#)% (#$ien menge)%* $%)i,mene)#n'#6#)n&# $e(e",i #!# &#ng mengg#n#)!i,engg+"+1#n'$%#"# m%)#i ,i!#1 e)#$ $e(e",ibe"1%m%";$eng#%'#6#)n&# m#$i* bi$# m#1#n !#n min%m

$e(e",i bi#$#'$e1#"#ng *#n&# bi$# m#1#n m#1#n#n )%n#1$e(e",i b%b%"' )%!#* be"c#m(%" !#"#* <>= 1#!#ng 1#!#ng'n&e"i $##, mene)#n <>=.

9 4 b%)#n &#ng )#)% m%nc%) ben+)#n !i )e*e"1#n#n (#$ien m#1in )#m# m#1in be$#"' 1em%!i#n (#$ienbe"+b#, 1e (eng+b#,#n #),e"n#,i n#m%n ,i!#1 #!#

(e"b#i1#n' )#)% (#$ien mem%,%$1#n %n,%1 be"+b#, 1e"%m#* $#1i, !".1#"i#!i $em#"#ng %n,%1 men!#(#,1#n(en#ng#n#n )ebi* )#n%,.



•Di*-aia -a*! !*-a!a& !.• A#a&a*ia• Ma**a i"'a/!'a&%+!"• S'i#%' !*-a%*

Dia"*i*a"i"

• Di*-aia -a*! !*-a!a& !.a#a&a*ia

Dia"*i*S!+!"a'a

DIAGNOSIS



RENCANA PENGELOLAAN

Peme"i1$##n Di#gn+$,i1 Bi+($i #"ing#n (eme"i1$##n *i$,+(#,+)+gi

Te"#(i A$#m me8en#m#, 0: mg

i,#min b c+m()e / ,#b ; #m

i,#min c 0 mg ; #m

Pem#n,#%#n K+n!i$i %m%m' ,#n!# @i,#)'("+g"e$i,#$ 1e)%*#n



•D%bi# A!

b+n#m

%+ A!

@i,#m•D%bi# A!

b+n#m

%+ #!

$#n#m•D%bi# A!b+n#m

%+ #!8%ng$i+n#m

PROGNOSIS



TERIMA KASIH

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