Case Besar 1.pptx

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  Pembimbing: dr. Handoko, Sp.PD, FINASIM  Nama: Ny. PUsia: 57th 7bl 30hr Jenis Kelamin: Perempuan Alamat: PecekelanNo. RM: 00465708   Riwayat Penyakit Sekarang Keluhan Utama : Nyeri Perut1. Onset: Nyeri perut sejak 2 minggu lalu, memberat 1 hari ini2. Lokasi: Nyeri perut kanan atas dan ulu hati3. Karakteristik: Nyeri seperti di tusuk-tusuk, hilang timbul4. Kuantitas: Skala 7-85. Faktor pemberat: Berat: saat pasien makan-makanan berlemakRingan: saat istirahat6.Komorbid: Mual (+), refluks (+), dysuria (+), poliuria (+)  7.Kronologi: Nyeriperutkananatassejak2minggulaluyangdirasakanhilangtimbulterutamasaatmakan-makananberlemak(santan,goreng-gorengan),namunsaatberistirahatOSjugadapatmerasakannyeriyangmasihbisaditoleransi.OSjugamerasakannyeridiuluhatisejak1mingguterakhirdisertaimual(+), danadarasaasamlambungyangnaik.OSjugamengalamipenurunanberat badan10kgdalam1bulanini.OSjugamerasakannyerisaatberkemihsejak1 mingguini,OSseringmenahankencingdanjarangminumairputih.Kemudian1hariSMRSpasienmerasakesakitanpadaperutbagiankananatas yangmenjalarkebahukananhinggamembuatpasienjalanmembungkuk,mual(+),karenasakityangtidakbisaditahanOSdibawakeIGDRSKNgesti Waluyo.
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