morning report hipertensi emergency
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morning report hipertensi emergencyTRANSCRIPT
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Morning Report
Ryan ArifinI 11110011
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Keluhan Utama
• Pasien datang ke IGD RS Anton Soedjarwo Bhayangkara pukul dengan keluhan utama nyeri kepala
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Primary Survey
• A: Bersih, tidak ada sumbatan jalan napas• B: RR 24 kali/menit, Sp02 99%, O2 2 lpm• C : Nadi 98 kali/menit, kuat angkat, reguler; akral
hangat; CRT < 2 detik; TD: 180/120. Dipasang infus, pasang monitor, ttv setiap 5 menit
• D : GCS E4V5M6, Pupil isokor• E : (-)
• Pasien masuk prioritas 2
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Secondary Survey (Identitas)
• Nama : Ny. M• Jenis Kelamin : Perempuan• Umur : 58 tahun • Alamat : Jl. Perdana Pontianak • Pekerjaan : Ibu Rumah Tangga
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Secondary Survey
• Keluhan UtamaNyeri Kepala
• Riwayat Penyakit Sekarang Pasien datang dengan keluhan nyeri kepala sejak 1 minggu yang lalu kemudian memberat sekitar 1 hari yang lalu. Nyeri kepala dirasakan diseluruh bagian kepala. Pasien merasakan nyeri kepala paling terasa berat saat bangun pagi disertai adanya nyeri tengkuk. pandangan kabur (+), Mual (+), Muntah (+) sebanyak 4 kali dalam sehari, demam (-), kejang (-), pingsan (-), BAK kemerahan (-)
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Secondary Survey
• Riwayat Penyakit DahuluRiwayat minum obat-obatan (-), riwayat hipertensi (+) sejak 3 tahun yang lalu
• Riwayat Penyakit Keluarga Ibu pasien mengalami hipertensi
• Riwayat Sosial-EkonomiMerokok (-), minum alkohol (-)
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Pemeriksaan Fisik (Secondary Survey)
• Status Generalis o Keadaan Umum : Tampak sakit sedango Kesadaran : Compos mentis o TTV :
Tekanan darah : 180/120 mmHg Nadi : 98 kali/menit, teratur, kuat angkat Pernapasan : 24 kali/menit, reguler Suhu : 37,2oC
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Pemeriksaan Fisik (Secondary Survey)
• Kepala: Normosefal (+)• Mata : konjungtiva anemis (-/-), sklera ikterik
(-/-), refleks cahaya (+/+), isokor d:3mm• Hidung: perdarahan (-), fraktur (-)• Telinga : inflamasi (-), nyeri tekan (-), KGB (-)• Mulut : kering, lidah kotor, faring hiperemis (-),
T1/T1• Leher : KGB (-), distensi vena (-)
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Pemeriksaan Fisik (Secondary Survey)
• Jantung:Ictus cordis terlihat dan teraba di SIC 5 Linea Mid Klavikularis SinistraBatas jantung kanan di SIC 4 linea parasternalis dextraBatas jantung kiri di linea mid klavikularis sinistra ICS 5Suara jantung I, II tunggal, m(-), g(-)
• Paru:Bentuk dada normal, dada kiri dan kanan simetris, fremitus taktil normal, perkusi sonor di seluruh lapang paru (+). Auskultasi
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Pemeriksaan Fisik (Secondary Survey)
• Abdomen: Datar (+), benjolan (-) Sikatrik (-), BU (+) normal 8 kali/menit, Nyeri tekan (-)
• Extremitas: akral hangat, CRT <2 detik, edema tungkai (-)
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Pemeriksaan DarahPemeriksaan Hasil Rentang normal
WBC 9,32x103/μL 5,00-10,00
RBC 3,63x106/ μL 3,60-6,50
HGB 10,0 g/dL 12,00-18,00
MCHC 34,56 g/dL 32,00-36,00
MCH 29,85 pg 27,80-33,80
MCV 79,88 pg 83,90-99,10
HCT 28,93% 35,00-56,00
PLT 377 x103/μL 150,00-450,00
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Saran Pemeriksaan Penunjang
• Pemeriksaan Urinalisis• Pemeriksaan EKG• Pemeriksaan CT Scan• GDS• Serum lipid• Foto polos Thorax• Pemeriksaan Tonometri• Pemeriksaan oftalmoskop
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Cue and Clues
• Nyeri Kepala diseluruh bagian kepala memberat di pagi hari
• Nyeri tengkuk• Mual (+)• Muntah (+) 4x dalam sehari• Pandangan kabur• Hb = 10 g/dl Anemia
Hipertensi Emergency
Sindrom Peningkatan
TIK/Encephalopathy
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Diagnosis
• Diagnosis Kerja : Hipertensi Emergensi
• Diagnosis Banding : Sindrom Peningkatan Tekanan Intrakranial
Planning diagnosis :• Pemeriksaan CT scan kepala
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Terapi
IVFD RL: D5 = 2000 cc/24 jam (3:1)IVFD NaCl 100 cc drip nicardipine (tensilo) 1 amp rate 5-15 mg/jam mulai dari 5 mg per jam dinaikkan bertahap maksimal 15 mg/jam. Target 1 jam pertama diastol 100 mmHg, 2-6 jam berikutnya 160/100 mmHg. Tensi tiap 5-10 menit (menggunakan monitor).Ketorolac 3x1 amp ivRanitidin 2x1 amp ivHemafort 1x1 tab
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RAASSYSTEM
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Esential Hipertensi
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End Organ Dysfuntion
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