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Afternoon
ReportC 514 JANUARI 2015
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Identitas Pasien
Nama : Ny TS Umur : 51 tn
A!amat : "esa Tontu!on dusun # $!%Trans Su!a&esi
A'ama : Is!am
Pe(er$aan : IRT
Pendidi(an : S)TA
Su(u*+an'sa : ,oronta!o*Indonesia
-RS tan''a!: . Januari 2015
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Anamnesis
/e!uan utama : Sesa( nafas Pasien ru$u(an dari RS a!oe Saoe ,oronta!o%
RPS :Sesa( nafas 4 u!an3 memerat # arisee!um masu( ruma sa(it3 atu( 6 er!endir
6 &arna puti (enta!% -ua! munta 63 10 ariS-RS3 isi 7airan3 nafsu ma(an menurun%
en'(a( di payudara se$a( 10 taun sudadisaran(an (emoterapi tetapi meno!a(%
Pusin' dirasa(an terus menerus
+A+ tera(ir 1 min''u S-RS
+A/ norma!
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Ri&ayat penya(it dau!u :
Ri& en$o!an di mammae 10 taun y!!%+en$o!an sema(in memesar% Sudadisaran(an (emoterapi tetapi meno!a(
ri&% 8ipertensi 63 as% Urat 63 (o!estero! 63"-63 peny% ,in$a! dan paru disan'(a!
Ri&ayat penya(it (e!uar'a : anya penderitayan' sa(it seperti ini
/eiasaan : -ero(o( 63 minum minumanera!(oo! 6
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Pemeri(saan 9isi(
/U : Tampa( sa(it sedan' /es : 7ompos mentis T : 100*0 mm8' N : ;4
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Pemeri(saan Penun$an'
)aoratorium "ara 10*12*2014 )eu(osit : 20000 4000100006
?ritrosit : #3@ 432053406
8emo'!oin : 1234 121.6
8emato(rit : #.3@ #@4@6 Tromosit : 2.@000 1500004500006
,"S : 100 @01256
Ur : .4 20406
Cr : 132 03.1316 Na : 14# 1#515#6
/ : 434 #354356
C! : 110 ;;10;6
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?/,
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Pro!em )ist
Sesa( nafas
Tumor di payudara
-unta
Penurunan nafsu ma(an
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"ia'nosa /er$a :
Ca mammae de
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Terapi :
B2 4 )*m I9" NaC! 03; : "5 D14 'tt*m
in$% Ranitidin 2
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P!annin' :
9NA+Sputum +TA
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