Laporan Kasus

CHOLELITASIS

Oleh
Alfian Hasbi, S.Ked

Pembimbing
DR.Dr. Alsen Arlan, Sp.B (K)BD

DEPARTEMEN ILMU BEDAH

RUMAH SAKIT MUHAMMAD HOESIN PALEMBANG
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA
2011
DAFTAR ISI

HALAMAN JUDUL .....................................................................................................1

DAFTAR ISI...............................................................................................................
...................................................................................................................................2
BAB I

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

: Dusun 3 Tanjung kerang sungai lilin Banyuasin

MRS

: 30 November 2011

1.2. Anamnesis ( 1 Desember 2011)

Keluhan Utama
Nyeri perut kanan atas
Riwayat Penyakit Sekarang
2 bulan SMRS penderita mengeluh nyeri perut kanan atas yang hilang timbul, nyeri
3

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 (+)
-

Riwayat Penyakit dalam Keluarga

- Riwayat penyakit dengan keluhan yang sama dalam keluarga disangkal
1.3. Pemeriksaan Fisik
Status Generalis (1 Desember 2011)
Keadaan umum

: 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

: Isokor, refleks cahaya +/+

Kepala

: Tidak ada kelainan

Kelenjar - kelenjar

: Tidak ada kelainan

Thoraks

: tidak ada kelainaan

Abdomen

: datar, lemas, hepar teraba 4 jari, lien teraba schupner 1, BU (+)

n
Murphys sign
Ekstremitas atas

: Tidak ada kelainan

Ekstremitas bawah: tidak adaa kelainan

4

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

1.5. Pemeriksaan Penunjang

Laboratorium: (Tanggal 2 Desember 2011)
Hemoglobin

: 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

1.6. Diagnosa Kerja

cholelitiasis
1.7. Penatalaksanaan
cholesisitectomy
1.8. Prognosis
Quo ad vitam
Quo ad fungtionam

: Dubia ad bonam
: Dubia ad malam