CHOLELITASIS
Oleh
Alfian Hasbi, S.Ked
Pembimbing
DR.Dr. Alsen Arlan, Sp.B (K)BD
LAPORAN KASUS
I.
Identifikasi..........................................................................................
..........................................................................................................3
II. Anamnesis....................................................................................... 3
III. Pemeriksaan Fisik.............................................................................. 4
IV. Pemeriksaan Penunjang.....................................................................
................................................................................................................4
V. Diagnosis Kerja..................................................................................
..................................................................................................................5
VI. Penatalaksanaan.................................................................................
................................................................................................................5
VII. Prognosis............................................................................................
................................................................................................................5
BAB II TINJAUAN PUSTAKA
II.1. Definisi
... .
6
II.2. Epiedemiologi....................................................................................
..................................................................................................................7
II.3. Anatomi..............................................................................................
..................................................................................................................7
II.4. Etiologi...............................................................................................
................................................................................................................12
II.5. Klasifikasi..........................................................................................
................................................................................................................13
II.6. Patofisiologi.......................................................................................
................................................................................................................14
II.7. Manifestasi klinis...............................................................................
................................................................................................................17
II.8. Diagnosis............................................................................................
................................................................................................................20
II.9. Penatalaksanaan.................................................................................
................................................................................................................22
II.10. Komplikasi......................................................................................
................................................................................................................27
II.11. Prognosis..........................................................................................
................................................................................................................27
DAFTAR PUSTAKA.................................................................................................
28
BAB I
REKAM MEDIS
1.1. Identifikasi
Nama
: Tn. S
Jenis kelamin
: Laki-laki
Usia
: 69 Tahun
Kebangsaan
: Indonesia
Agama
: Islam
Status perkawinan
: Sudah Menikah
Alamat
MRS
: 30 November 2011
timbul bila os makan makanan yang berminyak. Os juga mengeluh menggigil (+),
berkeringat dingin (+), nyeri ulu hati (+), mual (-), muntah (+) isi apa yang dimakan,
BAB dan BAK biasa.
2 hari SMRS penderita masih demam, menggigil (+), berkeringat dingin (+), nyeri ulu
hati makin sering. Setiap makan banyak penderita langsung merasa senap/penuh diperut,
mual (-), muntah(+) 1x isi apa yang dimakan, BAK dan BAB biasa. Lalu OS dibawa ke
poli dan dianjurkan untuk dirawat untuk mendapat perawatan.
Riwayat Penyakit Dahulu
- Riwayat penyakit yang sama sebelumnya disangkal
- Riwayat BAK seperti teh (+)
-
: Tampak sakit
Sensorium
: Compos Mentis
Tinggi badan
: 156 cm
Berat badan
: 42 kg
Nadi
: 78x/menit
Pernafasan
: 19x/menit
Tensi
: 130/80 mmHg
Suhu
: 36,2 0C
Pupil
Kepala
Kelenjar - kelenjar
Thoraks
Abdomen
n
Murphys sign
Ekstremitas atas
Status Lokalis
Regio abdomen
I : datar
P : lemas, murphys sign, hepar teraba 4 jari, lien teraba schupner 1
P : tympani
A : bunyi usus (+)
1.4 Diagnosis Banding
cholelitiasis
Cholesistitis
Hepatitis kronik
pankreatitis
: 13,6 g/dl
Hematokrit
: 38 vol %
Leukosit
: 11.500 /mm3
Hitung jenis
: 0/3/1/63/25/8 %
LED
: 20 mm/jam
Trombosit
: 252.000/mm3
BSS
: 92 mg/dl
Ureum
: 16 mg/dl
Kreatinin
: 0,9 mg/dl
Natrium
: 137
Kalium
: 3,9
SGOT
: 26
SGPT
: 27
Protein total
: 9,4 g/dl
Albumin
: 3,8 g/dl
5
Globulin
: 4,5 g/dl
Bilirubin total
: 27,68 mg / dl
Bilirubin direk
: 22, 32 mg / dl
Bilirubin indirek
: 5,23 mg / dl
CT
: 8 menit
BT
: 3 detik
: Dubia ad bonam
: Dubia ad malam