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    The document describes the results of a physical examination and lab tests for a patient presenting with general pallor, fatigue, jaundice, and gum bleeding. Vital signs showed tachycardia and elevated blood pressure. Examination found enlarged thyroid, cardiomegaly, and petechiae on the extremities. Lab tests showed anemia, thrombocytopenia, elevated liver enzymes and bilirubin, hypoalbuminemia, and atrial fibrillation on EKG. The patient was diagnosed with hyperthyroidism, autoimmune disease, diabetes, congestive heart failure, and intrahepatic cholestasis.

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    grave disease

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    The document describes the results of a physical examination and lab tests for a patient presenting with general pallor, fatigue, jaundice, and gum bleeding. Vital signs showed tachycardia and elevated blood pressure. Examination found enlarged thyroid, cardiomegaly, and petechiae on the extremities. Lab tests showed anemia, thrombocytopenia, elevated liver enzymes and bilirubin, hypoalbuminemia, and atrial fibrillation on EKG. The patient was diagnosed with hyperthyroidism, autoimmune disease, diabetes, congestive heart failure, and intrahepatic cholestasis.

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    3 views15 pages

    Tutor AF

    Uploaded by

    EldoTaufila
    The document describes the results of a physical examination and lab tests for a patient presenting with general pallor, fatigue, jaundice, and gum bleeding. Vital signs showed tachycardia and elevated blood pressure. Examination found enlarged thyroid, cardiomegaly, and petechiae on the extremities. Lab tests showed anemia, thrombocytopenia, elevated liver enzymes and bilirubin, hypoalbuminemia, and atrial fibrillation on EKG. The patient was diagnosed with hyperthyroidism, autoimmune disease, diabetes, congestive heart failure, and intrahepatic cholestasis.

    Copyright:

    © All Rights Reserved
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    of 15

    Pemeriksaan Fisik

    Keadaan umum

    Kesan umum : sedang tampak pucat


    Kesadaran : CM
    Vital sign
     Tekanan Darah : 159/80 mmHg
     Nadi : 112 x/menit, regular
     Respirasi : 24 x/menit (Spo2 97%nk 2 lpm)
     Suhu : 37 ◦c
    Kepala dan Leher

    Mata : konjungtiva anemis (+), sklera ikterik (+),


    Exofthalmus (+/+)
    Hidung : nafas cuping hidung (-), discharge (-)
    Mulut : mukosa kering (-), sianosis (-), Gusi
    berdarah (+)
    Tenggorokan : pharyngitis(-), tonsilitis(-)
    Telinga : tidak ada discharge, pendengaran baik
    Leher: limfonodi tak teraba, meningeal sign (-),
    Nodul tiroid teraba (+)
    Thorax (Dinding dada dan Paru)

    • Inspeksi : Ketinggalan gerak paru (-), retraksi (-)


    • Palpasi : Fremitus taktil normal, pengembangan paru simetris
    • Perkusi : Sonor di semua lapang paru
    • Auskultasi : suara dasar vesikuler
    Ronkhi basah kasar +/-
    Ronkhi basah halus -/-
    Wheezing -/-
    Thorax (Jantung)

    • Inspeksi : Ictus Cordis tidak tampak


    • Palpasi : Ictus Cordis teraba pada SIC 5 LMCS
    • Perkusi : kardiomegali (+)
    • Auskultasi : S1-S2 normal, bising (-), gallop (-)
    Abdomen

     Inspeksi : dinding perut = dinding dada, luka (-)


     Auskultasi : bising usus (+) 10x/ menit
     Perkusi : perkusi timpani di 13 titik, shifting dullness (-),
    hepatomegali (-)
     Palpasi : nyeri tekan (-), ascites (-), hepar dan spleen
    tidak membesar
    Ekstremitas

     Ekstremitas Atas • Ekstremitas Bawah


     Akral hangat • Akral hangat
    • Edema (-/-)
     Edema (-/-) • WPK <2”
     WPK <2” • Peteki (+)
     Peteki (+) • Hematom multiple
     Hematom Multiple
    Diagnosis Kerja

    Grave Disease
    Bisitopenia ec Autoimun disease
    Atrial Fibrilasi
    DM2NO
    CHF II
    Hipoalbuminemic
    Hiperurecemic
    Kolestasis Intrahepatal dd extrahepatal
    Gum bleeding
    Pemeriksaan Penunjang
    Darah (22 Februari 2017)

    Leukosit : 7.300 Na : 142


    Eritrosit : 2.24 (menurun) K : 4,13
    Hemoglobin : 6,6 (menurun) Cl: 111
    Hematokrit : 20,6 (menurun) Total Bilirubin 2,14
    MCV : 92 (menurun) Direct Bilirubin 1,68
    Trombosit : 2.000 GDS : 322
    Netrofil% : 89,6 Albumin: 2,06
    Limfosit% : 10 (rendah) SGPT 54
    Basofil%: 0 SGOT 66
    Eosinofil%: 0 BUN 40 Cre 0,88
    Monosit% : 6,4 PTT 17 APTT 27,2
    EKG
    Bacaan Ekg
    Irama : Atrial Fibrilasi
    Axis : Normal
    Rate : 113 kpm
    Hipertrofi : (-)
    Iskemia (-)
    TERIMAKASIH, MOHON ASUPAN

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