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Case study LAPORAN KASUS

Case study LAPORAN KASUS

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LAPORAN KASUS

PERAWATAN ICU

Oleh :

Mayandra Mahendrasti (03009148)

Nur Hanisah Bt. Mohd Khair (03006333)

Pembimbing :

dr. Sabur N. Sp.An

dr. Ucu N. Sp.An

dr. Ade N. Sp.An

KEPANITERAAN KLINIK ILMU ANESTESI

RUMAH SAKIT UMUM DAERAH KARAWANG

PERIODE 17 FEBRUARI 2014 – 22 MARET 2014

FAKULTAS KEDOKTERAN UNIVERSITAS TRISAKTI

JAKARTA

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BAB I

LAPORAN KASUS

IDENTITAS PASIEN

Nama : Bp. S

Jenis Kelamin : laki-laki

Usia : 38 tahun

Pekerjaan : Pedagang

Pendidikan : SMA

Status : Menikah

Agama : Islam

Alamat : Babakan Ngantai RT 04/02, Kecamatan Cikampek, Karawang

PEMERIKSAAN PRE-OPERASI

ANAMNESIS

Auto dan alloanamnesis dilakukan pada tanggal 5 Maret 2014, pukul 09.00 WIB di ICU

RSUD Karawang

Keluhan Utama

Pasien datang pada tanggal 1 Maret 2014 ke IGD RSUD Karawang dengan keluhan

nyeri perut sejak semalam.

Riwayat Penyakit Sekarang

Pasien datang pada tanggal 2 Maret 2014 ke IGD RSUD Karawang dengan keluhan

nyeri perut sejak semalam. Nyeri perut bersifat terus menerus hampir di seluruh bagian perut,

nyeri pertama kali dirasakan setelah pasien perutnya diurut semalam. Pasien memiliki riwayat

benjolan di daerah perut kiri bawah, kemudian dua hari yang lalu benjolan tersebut turun ke

kantung kemaluan kiri sehingga pasien meminta benjolan diurut agar dapat dimasukkan lagi

ke perutnya. Setelah diurut benjolan terasa sakit sekali dan menyebar ke perutnya. Pasien juga

merasa mual dan muntah 3x berisi makanan dan cairan, tidak bisa BAB ataupun kentut, dan

perutnya terasa tegang sampai sesak. Tidak ada demam.

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