Case Based Discussion Hipertensi Grade I

8/18/2019 Case Based Discussion Hipertensi Grade I

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IDENTITAS PASIEN

Nama : Ny. T

Umur : 47 th

Jenis kelamin : Perempuan

Agama : Islam

No. Medical Record : 100!1"

Alamat : #enu$ Sar% &T 00'(001) #enu$) Semaran*

Ruang raat : Ba%tul I++ah 1

Tgl masuk : 0 N,-emer /01'

Tgl keluar : Desemer /01'

Status Care : N N,n PBI



ANAMNESIS

Pas%en 2atan* $e P,l% Penya$%t Dalam &SI Sultan

A*un* pa2a tan**al 0 N,-emer /01' 2en*an $eluhan

mual pus%n* 2an lemas. Pus%n* 2an mual 2%rasa su2ah

se3a$ har% yan* lalu. emu2%an pas%en merasa lemas

se3a$ / har% yan* lalu. Pas%en merasa nyaman $et%$a

t%2uran 2an terasa pus%n* saat er3alan.



!elu"an Utama # mual

$nset # se3a$ har%

!ualitas dan !uantitas # 5ual 2an %n*%n muntah h%lan* t%mul

%aktor mem&er'erat dan mem&eringan #

ertamah pus%n* saat an*un 2an er3alan.

(e)ala lain # Pus%n* 2an terasa lemas.

ANAMNESIS



&%6ayat Penya$%t

RPD

&%6ayat D5 :

&%6ayat 8%pertens% :

&%6ayat #astr%t%s : 9

&%6ayat antun* : 9

&%6ayat aler*% ,at : 9

RP!

&%6ayat 8%pertens% :

&%6ayat D5 :

&%6ayat #astr%t%s : 9

&%6ayat antun* : 9

Ria*at Sosial Ekonomi

Pas%en merupa$an pas%en N N,n PBI



PE5E&ISAAN ISI

Umum : Pas%en terl%hat sa$%t

!ulit : *atal ;9<) lu$a ;9<) $un%n* ;9<) pu=at;9<.

!e&ala : mes,=ephal) pus%n* ;<

Mata : mata merah;9<) $,n3un*t%-a anem%s ;<) s=lera %$ter%$ ;9<) mata $aur ;9<

Telinga : er2en*%n* ;9<) $uran* pen2en*aran ;9<

+idung : s%metr%s) septum 2e-%as% ;9<) na>as =up%n* h%2un* ;9<) m%m%san ;9<) se=ret ;9<

Mulut : s%metr%s) s%an,s%s ;9<) %%r pu=at;9<) %%r $er%n* ;9<) mu$,sa h%perem%s ;9<) 2e-%as%

l%2ah ;9<) l%2ah trem,r ;9<) l%2ah $,t,r ;9<) *us% er2arah ;9<) st,mat%t%s ;9<

Tenggorokan : nyer% ten**,r,$an ;9<) sera$ ;9<) nyer% telan ;9<

,e"er : 2e-%as% tra=hea ;9<) pemesaran thyr,%2 ;9<) pemesaran $elen3ar l%m>e ;9<

Dada : sesa$ na>as ;9<) nyer% 2a2a ;9<

Sistem (I : mual ;<) muntah ;<) nyer% ep%*astr%$ ;9<



-ital Sign

Te$anan 2arah : 10("0 mm8*

Na2% : ! ?(men%t

Suhu : ),

= && : // ?(men%t

Status (ii

BB : ' $*

• TB : 10 =m ;1. m<@

• B5I : '(/)' /0)7 ;n,rm,6e%*ht<

PE5E&ISAAN ISI



PE5E&ISAAN DADA



Ins&ection : I=tus =,r2%s t%2a$ terl%hat.

Pal&ation : thr%ll ;9<) ep%*astr%= pulse ;9<) parasternal pulse ;9<)

sternal l%>t ;9<.

Percussion : 2ull s,un2

Upper ,r2erl%ne ,> heart : ICS II le>t sternal l%ne

a%st ,> heart : ICS III le>t parastern l%ne ,6er r%*ht ,r2erl%ne ,> heart : ICS r%*ht sternal l%ne

,6er le>t ,r2erl%ne ,> heart : ICS le>t m%2 =la-%=le l%ne

PE5E&ISAAN ANTUN#



...CONT

Aus=ultat%,n

A,rtal -al-e : S1 F S/ stan2ar2) a22%t%,nal s,un2 ;9<

Pulm,nary -al-e : S1 F S/ stan2ar2) a22%t%,nal s,un2 ;9<

Tr%=usp%2 -al-e : S1 F S/ stan2ar2) a22%t%,nal s,un2 ;9<

5%tral -al-e : S1 F S/ stan2ar2) a22%t%,nal s,un2 ;9<

Intepretasi : normal



PE5E&ISAAN ABDO5EN

Ins&ection : symetr%=) sy=atr%=;9<) str%ae;9<)enlar*ement ,> -ena ;9<)

=aputme2usa ;9<.

Auscultation : per%stalt%= ;<

Pal&ation :

Super>%s%al : t%*ht ;9<) mass ;9<

Deep : a2,m%nal pa%n ;9<) l%-er) $%2ney) an2 spleen

6erenGt palpale) 5urphyGs s%*n ;9<

Percussion : tympan%) s%2e ,> 2ea> ;9<) sh%>t%n* 2ullness ;9<

%-er : 2ea>;<) r%*ht l%-er span 10 =m) le>t l%-er span

=m

Spleen : Thr,e spa=e per=uss%,n ;< tympan%

Intepretasi : normal



E$strem%tas super%,r %n>er%,r

• Oe2ema 9(9 9(9

• C,l2 9(9 9(9

• aun2%=e 9(9 9(9

PE5E&ISAAN EST&E5ITAS



PE5E&ISAAN ABO&ATO&IU5

Interpretasi :Anemia

HiperglikemiaAzotemia

&ematoloi &asil

H !"! g#$l

Ht 2!"6 %

&e'ko(it 10"! ri'#'&

Tromo(it )1* ri'#'&

'imia &asil

+D, 410 mg#$l

-re'm 12) mg#$l

reatinin $ara/ 2"68 mg#$l

atri'm 1)0 mmol#&

Kali'm 4.2! mmol#&

/lori$e 10).*mmol#&

Imunoloi &asil

H(AgK'alitati

on Reakti



ABNO&5AITAS DATA

Anamnesis

1. Mual dan muntah

2. Kepala terasa

pusing

3. Badan terasa

lemas

Pemeriksaan fisik

4. Konjungtiva

anemis5. Tekanan darah

tinggi

Lab

Hematology

. !" #$# g%dl

Chemistry

&. '() 41*

+. ,reum 123 mg#$l

#. -reatinin serum

2$+ mg#$l



P()B*EM *IS+

DM TIP3 II*5

HIP3RT3,I+RAD3 1 2 $an 5

A3MIA) " 4 $an 65

A7OT3MIA8 $an !5



DM tipe IIAss : makroangiopati pen9 :ant'ng koroner" pen9akit

arteri perier"

pen9 ;erero<a(;'ler5

mikroangiopati retinopati $iaetik" neropati

$iaetik"

ne'ropati $iaetik5

IP D, : ='n$'(kopi" angiograp/9 arteri ;oroner

mikroal'min'ria" T

(;an ;rani'm" API



Ip +, :

> -armaoloi

o<omi? 2 ? 2 'nit5

+li@'i$one 1 0 15

=l'narizin mg 2 ? 15

> /on farmaoloi

Meng'rangi kon('m(i karo/i$rat a(i" roti" kentang5

Diet ren$a/ g'la

IpM, B +'la $ara/ (eCakt' (etiap /ari" HA1;" +DPP" +DP





(umus BrocaBB Ideal !0% ? 1601005 ? 1

0"! ? 60 4 kg

'alori Basal 4 ? 2

1)0 ;al

Ativitas 10% ? 1)0 1)

Istirahat

!mur 40 60 ta/'n

% ? 1)0 6*"

+otal 1)0 E 1) 6*" 141*" kalori per /ari



Ass:

1.Maligna /9pertention

2.enigna /9pertention

IP D, : 'n$'(kopi" Mi;roal'min'riaIP +, :

1. =armakologi( B

Amlo$ipin 10 mg 1 ? 15

2. on armakologi( B

Diit loC (alt

Hiperten(i gra$e I





Ass B KD" neropat9

Ip D, B -rin R'tin" T ,A A$omenIp +,B

/on -armaoloy B Diet loC protein 0"60"8g#kg#/ari

Diet loC (alt 1 gram Diet F'i$ 00;; E /oC m';/ 'rine m&#/ari

-armaoloy B

aO) ) ? 00mg to pre<ent /ipero(atemia

i;nat ) ? 00mg to pre<ent a;i$o(i( metaoli;on$an;entron ) ? 4mg to (top na'(ea

Keto(teril 2 ? 1 protein ('plement

Hemo$iali(a C/en ;reatinin ;learen;e toleran;e

$e;re(e 'ntil G1

Azotemia



Ip M, B alan;e o F'i$" $i're(i(" <ital (ign" aCarene((" ;/emi;al loo$ te(t("

o<er/i$ro(i( (ign

Ip E, B 3?palin ao't $i(ea(e 3?plain ao't Hemo$iali(a



#&(#140 age5 ? eig/t ? 0"8

*2 ? ;reatinin pla(ma

140 4*5 ? ) ? 0"8 *2 ? 2.68

418!"6 21"*1 ml#mnt#1"*)m

1!2"!6

Interpretation B KD

,tage IJ5



Kriteria $iagno(i( KD

ker'(akan gin:al lei/ $ari ) 'lan aik (tr'kt'ral

ma'p'n 'ng(ional $engan ata' tanpa pen'r'nan

+=R $an a$a kelainan patologi(" kelainan 'rin"

kelainan $ara/" kelainan te( pen;itraan

la:' ltra(i glomerol'( k'rang $ari 60 ml # menit#1"*)

(elama ) 'lan $engan ata' tanpa ker'(akan gin:al

A i



Ass : Anemia /ipokrom mikro(iter

Anemia normokrom normo(iter

Anemia makro(iter

IP.D, : MJ" MH" MH" TI" =eritin" retik'lo(it" olat.

IP.+, :

1. on =armakologi B

3at <egetale (pina;/" et;.5

2. =armakologi B

,'la( =ero('( )00mg ) ? 15

Anemolat 1mg ) ? 15

IP.M, : <ital (ign" H" Anemi; ,ign

IP.E, : 3at more <egetale( (pina;/" et;.5

De;rea(ing /ar$ a;ti<it9

Anemia



Case Based Discussion Hipertensi Grade I

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