Case Conference

Modul VIII : Miastenia Gravis

Terapi Gizi Laki-laki 40 tahun dengan Malnutrisi Sedang p

ada Myastenia Gravis dd Krisis Myastenia dengan Pt
osis, Disfagia, Pneumonia

Fasilitator
Insert the title: Prof.Dr. dr. Hertanto
of your subtitle Here WS, MS, Sp.GK (K)
Presentan: Rizky Fauzia Ratnasari Surya
IDENTITAS PASIEN
Nama : Tn. N
Umur : 40 tahun
No CM : C789655
Your Text Here
Agama : Islam
Pendidikan : Tamat SMTP
Pekerjaan : Petani
Your Text Here
Ruangan : ICU
Alamat : Desa Ngoho, Kel. Kemitir,
Kec. Sumowono, Kab.Semarang
Pembiayaan : JKN Non PBI
DPJP : dr. Johan Arifin,Sp.An-KIC
MRS : 17/04/2020 (HCU),
21/04/2020 (ICU)
Your Text Here
Tgl Assment : 23/10/2019
 Subjective Global Assessment

Perubahan Berat Badan Pasien merasa lebih C

kurus sejak didiagnosis MG. BB 1 minggu yll 51 kg
Perubahan Asupan Full liquid diet B
Gejala Gastrointestinal Mual - muntah - diare - anoreksia - A
Kapasitas fungsional Bedridden 1 minggu C
Metabolic demand/stress Hipermetabolik C
Muscle wasting: (+2 /+2)
Pemeriksaan fisik Loss of subcutaneous fat: (+2 /+2) B
.
Edema (-/-), ascites (-)
Tingkat SGA Malnutrisi Sedang B
 ANAMNESA

1
Keluhan Utama : Sesak nafas

Riwayat penyakit sekarang :

Pasien dari IGD dengan keluhan sesak nafas sejak 3 hari SMRS.
5 hari smrs pasien mengeluh kesulitan menelan,pasien hanya mampu
menelan makanan yang dihaluskan, minum baik, sesak nafas
disangkal,kelemahan anggota gerak disangkal, demam (-), batuk (-), sesak
disangkal, BAB dan BAK baik, pasien hanya beristirahat dan minum obat
rutin 3 hari SMRS pasien mengeluh sesak nafas, terasa terutama saat
aktivitas ringan, keempat anggota gerak terasa lemah, sulit menelan (+) ,
kesemutan (-), BAB dan BAK baik, pasien kemudian dibawa keluarga
berobat ke RSDK
 ANAMNESA

2
Riwayat Penyakit Fahulu
Riwayat didiagnosa Myasthenia gravis, dirawat bulan Februari 2020
Hipertensi (-), DM (-),
Riwayat timoma (-)

Riwayat Penyakit Keluarga

Tidak ada anggota keluarga dengan sakit serupa

Riwayat Sosial Ekonomi

Pasien sudah menikah tinggal bersama istri dan memiliki satu anak
Pasien sebelumnya bekerja sebagai Petani .
Istri bekerja sebagai Petani.

Kesan ekonomi : kurang

 Riwayat Asupan

Saat Sehat Saat Sakit Di RSDK

(± 1250 kkal)
 PEMERIKSAAN FISIK
Keadaan Umum ANTROPOMETRI

Kontak (+)
LLA 27.5cm
BB 58kg
GCS : E4M5V5
TL 44cm
Tekanan Darah : 149/83 mmHg TB 159cm
(MAP 97)
BBI 53kg
Nadi : 61 x/menit
Pernapasan : 23x/mnt IMT 23 kg/m2

Saturasi O2 100% Muscle Wasting (+2/+2)

Suhu : 36.5 ◦C LOSF (+1/+1)

 PEMERIKSAAN FISIK
MW supraklavikula (+), deltoid -biseps
(+), triseps (+)
Kepala :
Konjungtiva anemis (+/+),
Sklera ikterik (-/-),
LOSF infraorbita (-),
Jantung MW Zygomaticus (-),Temporal(+)
I : iktus kordis tidak tampak
Pa : ic teraba (+) Terpasang NGT
Pe : batas jantung dbn Residu NGT : -
Au : BJ I-II normal,
murmur (-), gallop (-),

Gluteus : ulkus decubitus + Paru

I : Gerakan dinding dada
Abdomen simetris
I : perut datar Pa : stem fremitus kiri = kanan
Au : BU + normal
Palpasi : supel Pe : redup kedua lapang paru
Perkusi : timpani Au : suara napas vesikuler +/
MW quadriceps (+), +, rhonki +/+, wheezing +/+
gastrocnemius (+)
MOTORIK SUPERIOR INFERIOR

Gerak menurun/menurun menurun/menurun

Kekuatan 444/444 444/444

Tonus N/N N/N

Trofi E/E E/E

Refleks fisiologis ++/++ ++/++

Refleks patologis -/- -/-

 Keseimbangan Cairan
Input: Output:

Infus = 3500 ml Urine = 1750 ml

NGT = 100 ml IWL = 675 ml
Obat-obatan = 225 ml Drain = 500 ml

Total = 3825 ml Total = 2925 ml

Balance cairan = + 900 ml

Diuresis =
 Pemeriksaan 2/12/16 9/12/16 19/12/16 Nilai Rujukan

HEMATOLOGI
Hemoglobin (g/dL) 7,5 11,2 9,9 13,0 – 16,0
Hematokrit (%) 27,6 36,1 32,7 40 – 54
Eritrosit (106/µL) 4,14 4,72 4,36 4,4 – 5,9
MCH (pg) 18,1 23,7 22,7 27,0 – 32,0
MCV (fL) 66,7 76,5 75 76 – 96
MCHC (g/dL) 27,2 31,0 30,3 29,0 – 36,0
Lekosit (103/µL) 9,5 12,1 12,9 3,8 – 10,6
Trombosit (103/µL) 662 456 512 150 – 400
RDW (%) 26,1 25,8 24,1 11,6 – 14,8
MPV (fL) 9 4,61 9,3 4,0 – 11,0
 KIMIA KLINIK 22/10 02/11 Nilai Rujukan
GDS 228 170
Albumin 2,6 2,9 3,4-5.0 g/dL
ELEKTROLIT
Na 141 130 136-145 mmol/L
K 3,1 2,7 3,5-5,1 mmol/L
Cl 102 86 98-107 mmol/L
Mg - 0,84 3,5-5,1 mmol/ L
Ca - 1,8 2,12 – 2,52 mmol/L
 23/4
LABORATORIUM
24/4 25/4 26/4 27/4 Nilai Rujukan
KIMIA KLINIK

BGA Kimia
pH 7,486 7,509 7,557 7,509 7,506 7,37-7,45
pCO2 44,7 45,1 35,5 37,4 39
PO2 224,7 51,9 158,4 121,5 108,4 83-108
FIO2 52% 60,0% 60,0% 50,0% 50,0%
pH(T) 7,483 7,514 7,536 7,511 7,494 7,37-7,45
PCO2(T) 47,4 44,6 37,5 37,3 40,4 35-45
PO2(T) 225,7 50,9 166,2 120,9 113,5 83-108
HCO3- 35,8 36,3 31,8 30,1 31,2 22-29
TCO2 37,3 37,7 32,9 31,2 32,4 23-27
BEecf 12,2 13,1 9,3 6,9 7,9
BE (B) 11,8 12,7 9,6 7,2 8,2 (-2) - (+3)
SO2c 99,8 89,1 99,6 99,0 98,8 94%-98%
A-aDO2 91,8 329,2 218,6 194,2 196,8 mmHg
RI 0,4 6,3 1,4 1,6 1,8
 terapi
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 EDUKASI saat di Rumah Sakit
• Menjelaskan mengenai kondisi, penyakit ,komplikasi dan terapi
pasien saat ini kepada pasien dan keluarga
• Menjelaskan pentingnya konsumsi pengobatan sesuai anjuran
dokter
• Membantu dan memberi dukungan terhadap penderita dalam
upaya melaksanakan diet sesuai anjuran dokter.
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• Optimalisasi asupan saat keluhan minimal
• Menghindari faktor pencetus eksaserbasi, seperti suhu panas,
infeksi, dan stress
 EDUKASI saat pasien pulang

Makan dalam porsi kecil tapi sering.

Minum obat yang diberikan secara teratur.
Tetap beraktivitas sesuai kemampuan.
Istirahat/tidur cukup sekitar 6-8 jam sehari, hindari kelelahan dan stress
EDUKASI saat di Rumah
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 ALUR PIKIR
Myasthenia Gravis

Ptosiss Disfonias Disfagia Kelelahan otot

Depresi
Napass

Depresis Imobilitas Sesak

LOSF, MW Ventilators
HAP, Efusi
Malnutrisi Pleura

↑ Mortalitass
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