Intepretasi data klinik

Lucia Vita Inandha D, M.Sc.,Apt.

PEMERIKSAAN FISIK DAN LABORATORIUM
DILAKUKAN PADA SAAT PASIEN MASUK KE
RUMAH SAKIT, TUJUANNYA ADALAH UNTUK
MENGEVALUASI KONDISI PASIEN DALAM
RANGKA PENEGAKAN DIAGNOSA OLEH
DOKTER
Medical History :
ID = Identifiying Data
CC = Chief Complaint
HPI = History of Present Illnes
PMH = Past Medical History
FS/SH = Family and Social History
ROS = Review of Systems
 Tanda dan Gejala (Signs and
symptoms)
Characteristic Question

Location Where is it located in the body ?

Chronology/Duration When does it occur and for how long ?

Quality / Intensity How often does it occu and how intense is it

? What does it feel like ?

Aggravating What makes it better or worse ?

Related symptoms What other symptoms are present ?

Organization of the physical
examination
1. General appearance
2. Vital signs : suhu, TD, RR, HR
3. Skin and nails
4. Lymph nodes
5. HEENT (Head Eyes, ears, nose, throat)
6. Neck
7. Back
8. Chest (general, lung, breast exam)
9. Cardiovascular system (CV)
10. Gastrointestinal system (GI)
11. Genitourinary and rectal system (GU)
12. Pheripheral vasculer system (MSK)
13. Musculoskeletal system (MSK)
14. Neurological system (neuro)
15. Mental status
TANDA VITAL ( Vital Signs)

1. Temperature (T)
2. Pulse (P) = Nadi
3. Blood Presure (BP) = Tekanan Darah (TD)
4. Respiratory Rate (RR)
5. Height and Weight (H/W)
Temperature (T)

Body temperature is measured in the mouth,

rectum, axilla.
Normal adult body themperature = 35,8 C-37,3 C
(96,4-99,1 F)
When measured in the mouth = 35,3-36,8 C (95,9-
99,6 F)
When measured in the axilla = 36,3 37,8 C (91,9-
99,6)
Generally 37,8 C or greater (>100 F) indicate fever
Pulse (P) nadi

Rate, rhythm, strength

Normal HR 60-100 x/menit
Takikardi > 100x/menit
Bradikardi < 60 x/menit
HR<60x (bradikardi) = vagal tone, cardiact
conduction defects, atau efek negatif kronotropik
beta bloker dan digoxin
Takikardi = pasien cemas, kehilangan vol cairan,
kesakitan, atau efek simpatomimetik dan
antikolinergik
Rhythm / irama jantung sulit dideteksi tanpa
bantuan ECG, namun kecepatan nadi dapat ditebak
:
Irregulary irregular === Atrial fibrilasi
Regularrly iregular === PAC (Prematur Atrial
Constraction ) atau PVC (Premature Ventricular
Constraction)
Cara deteksi pulse == palpasi
Blood Presure

Tekanan darah berbeda-beda berdasar usia, jenis

kelamin, dll
TD normal < 140/90 mmHg
Sistolic turun 10 mmHg, pulse naik 10-20 x
menandakan : intravasculer volume depletion,
autonomic disfunction, antihypertensive drug
therapy, or side effect of medication
Respiratory Rate (RR)

Kecepatan bernafas menggambarkan kondisi kardio

dan paru, dan penyakit neurologi.
Angka normal RR dewasa = 11-18 x/menit
RR > 20 = tachypnea dapat disebabkan :
kecemasan, nyeri, gangguan jantung dan pulmo
RR < 10 = Bradipnea , menandakan adanya depresi
nafas, drug induces respiratory depression (misal
pada penggunaan opiat)
Chyne Stokes Breathing ditandai dengan Apneu =
henti nafas, suatu periode nafas berhenti namun
kemudian meningkat lagi hingga maksimal
(Hyperpnea, atau deep rapid breathing)
Terjadi pada pasien trauma otak, CHF, dll
Kussmaul respiration == deep regular respiration
that occur independent of the rate.
Height and Weight

Ukuran yang dapat digunakan untuk menghitung :

BSA
LBW
TBW
LABORATORY TESTS

1. Routin Hematology ( Darah Rutin)

a. Hematocrit (Hct)

description Normal value

Perbandingan sel darah merah Male = 40%

terhadap volume darah merah Female = 35-45%

40% = terdapat 40 ml sel darah

merah dalam 100 ml darah
 Clinical implication

Decreased values Anemia, hemoityc

reactions, leukimia,
cirrhosis, masive
blood loss

Increased values Erytrocytosis,

dehydration,
polycitemia, shock
Hemoglobin (Hgb)
description Normal value

Metaloprotein , Male = 13-18 gm/dL SI unit =

protein yang 8,1-11,2 mmol/L
mengandung zat
besi di dalam sel Female 12-16 gm/dL SI unit =
darah merah 7,4-9,9 mmoL/L
yang berfungsi
mengangkut
oksigen dari
paru-paru ke
seluruh tubuh
Clinical implication

decreased Anemia , iron

deficiency anemia,
hyperthyroidism,
cirrhosis,
hemorrhage,
hemolytic reactions,
increased fluid
intake, pregnancy
increased Polycythemia, burns,
CHF
Hgb fluctuative Hemorrhages and
concentration burn
Red Blood Cell (RBC) or erythrocyte

description Normal values

6

The main function of Male = 4,4-5,6.10

3

the RBC is to carry cells/mm3

oxygen from the lungs Female = 3,8-5. 10
to the body tissue and cells/mm3
to transfer CO2 from
tissue to the lungs by
hemoglobin

Sel darah merah (

didalamnya
mengandung
White blood cell, leukocyte (WBC)
description Normal values
Leukosit diproduksi pada 3200-10.000/mm3
sumsum tulang, disimpan
dalam jaringan limfa (spleen, SI=3,2-10x 109
thymus, tonsil), ditranspor ke
dalam jaringan melalui aliran
darah. Masa hidup leukosit = Pada bayi 10.000 20.000,
13-20 hari. menurun pada usia dewasa
Pembentukan leukosit
memerlukan bahan-bahan :
vitamin, asam folat, asam
amino.
Sistem endokrin mengatur
pembentukan,penyimpanan
n, dan pengeluaran leukosit.
 Clinical implications
Kadang terjadi hanya kenaikan
Increase neutrofil

(Leukositosis) Tidak adanya anemia membantu

membedakan dengan infeksi
20.000 = slight akibat leukimia

30.000 = Pendarahan, trauma, obat (

merkuri, epinefrin,
moderat kortikosteroid), nekrosis, toksin
(eklamsia) dan leukimia
50.000= high
makanan, stres, emosi,
menstruasi dapat meningkatkan
WBC
Infeksi virus, leukimia
Leukopenia (< Drugs ( antibiotik, antimetabolit,
antikonvulsan, kemoterapi)
4000) Anemia aplastika
WBC differential (diff count)

Neutrofil = melawan infeksi bakteri dan inflamasi

Eosinofil = melawan alergi dan infeksi parasit
Basofil = melawan diskrasia dan myeloproliferative
disease
Limfosit = melawan infeksi virus dan bakteri
Monosit = melawan infeksi berat
 Normal value of WBC diff
Seg bands EOS Basos Lymph Alymph Mono

persenta 36-73 0-12 0-6 0-2 15-45 0-10 0-11

se

Absolute 1260- 0-1440 0-500 0-150 800-4000 0 100-800

7300
 Clinical implications
descriptions Clinical implication

Neutrophilia infeksi bakteri, kelainan

metabolik, pendarahan,
gangguan sumsum tulang

Neutropenia Infeksi viral, kelainan

hormon, agen toksik, infeksi
masiv

Shift to left Immature cells ( banyak sel

masih muda dalam sirkulasi
) disebabkan : infeksi,
kemoterapi, leukimia,
hemoraghi
description Chlinical
implication
Shift to right Banyak sel
mature dlm
sirkulasi (segs
meningkat)
Terjadi Infeksi
dan
Inflamasi berat
description Clinical Implication

Eosinofilia = eosinofil Addison disease, alergi,

meningkat > 6% collagen vascular
disease
eosipenia Glucocorticosteroid
merespon stres jaringan

basofili Basofili leukimia,

myeloid metaplasia,
reaksi alergi
basopenia Infeksi akut, stres,
steroid jangka panjang
 platelets

description Normal value

Bagian sangat 170-380.
kecil dari sel 103/mm3
darah yang
berfungsi
membantu
proses
pembekuan
darah (blood
clothing)
description Clinical implication

Increased (trombositosis) Kanker, polisitemia, splenectomy,

trauma, sirosis, lukemia, active
rheumatoid arthritis
Decreased (trombositopenia)
Idiopathic Trombocytopenic
purpura (ITP)
Anemia pernisiosa, aplastika,
hemolitika
Reaksi alergi, keruskan sumsum
tulang.

Decreased below 20.000 Obat (antineoplastic agen,

penisilin, gold salt

Drug induced trombositopenia Spontaneus bleeding, ptechiae, GI

bleeding, hematuria

Asam valproat, aspirin, NSID

Electrolytes and Chemistry Survey

Sodium (Na+)
Normal value = 135-144 mEq/L SI = 135-144
mmol/L
sodium is the most abundant cation in extracellular
fluid. It maintains osmotic pressure and acid base
balance, aids in the squence of tranmission of nerve
impulses.
Sodium is regulated by the kidneys, CNS, and the
endocrine syst.
Clinical implications of Hyponatremia

1. Hyponatremia
2. SIADH (Syndrome of inappropriate antidiuretic
hormone)
3. Drug induced = thiazide, chlorpropamide,
carbamazepin, clofibrate, cyclophospamid
4. Pulmonary disorder = tbc, pneumonia, cystic
fibrosis
Clinical signs = nausea, fatique, cramps, psychosis,
seizures and coma.
Clinical implication of hypernatremia

Hypernatremia
Predisposing factor : dehydration, aldosteronism,
diabetes, osmotic diuretics
Potassium ( K+)

Normal value = 0-17 yr = 3,6 5,2 mEq/L

> 18 yr = 3,6 4,8 mEq/L
Potasiium is the principle intracelluler fluid cation
wich (with bicarbonate) serves as the primary buffer
within the cell. Aproximately 80 90% of poitassium
is excreted in the urine by the kidney
Clinical implication

Hyperkalemia :
Renal failure, cell damage (burns, surgery),
acidosis, addisons disease, uncontrolled diabetes,
and RBC tranfusions
Hypokalemia :
Serum potassium concentration < 3.5 mmol/L
Predisposing factor : vomiting/diarrhea, severe
burns, primary aldosteronism, renal tubular acidosis,
diuretics, steroids, cisplatin, ticarcilin, cronic stres,
steroid, liver disease with ascites.
Clinical sign : no symptoms
Latihan soal

Seorang anak berusia 16 tahun dengan diagnosa

ITP ( idiopathic thrombocytopenia purpura ) memiliki
kadar platelet sebesar 30.000/ mm3. Pasien
mengalami petechiae dan epistaksis. 1 hari yang
lalu hematuria. Tekanan darah (TD = 100/70
mmHg), RR 27 x/menit, HRT 100x/menit
Intepretasikan data klinis pasien tersebut.
Make assessment and care plan

S= headache, feels childed and shorth of breath, IV

site burns during administration

O= T=38,6, productive cough, WBC 16.000 (segs

58%, bands 17%) infiltrate on chest X-ray but no
effusion, IV site red and tender
S = dull headache but otherwise more comfortable,
No complaints about IV site
O = fever spike x1, cough still produce 20 ml green
sputum, WBC decreased slightly, new IV siter on
left looks good with IV infusing well
A = day 3 of erythromicyn, I fever spike but
decreased WBC. Klebsiella pneumoniae sensitive
to gentamicyn, cefazolin, TMP sulfamethoxazole,
but resistance to ampicillin.
P =.................
 Tugas kelompok
1. Tn S 62 thn MRS dengan keluhan lemah tangan dan kaki kiri,
tak bisa bicara sejak 7 jam yll. Isteri mengaku bahwa Tn S
memiliki riwayat penyakit jantung, obat terakhir yang diminum
adalah digoxin 1x250 mcg, noperten 1x10 mg, amlodipin1x5
mg, Q-ten 1x1 tab. Didukung hasil CT scan, pasien didiagnosa
stroke embolik. Selanjutnya pasien diterapi dengan enoxaparin
2x0,4 U sc, Brainact 3x500 mg, plavix 1x75 mg, neurobion
injeksi 1x1 im. Pada hari ke 3 muncul komplikasi berupa kejang
dan sesak nafas, disertai panas tinggi hingga 38,2 C. TD yang
semula 170/90 turun menjadi 100/70 mmHg. Pasien didiagnosa
Suspect pneumonia. Hasil lab : AL 17.0000/mm3, Cr 2,3
mg/dL, BUN 29 mg/dL
Intepretasikan data klinik pasien tersebut, analisalah pengobatan dengan SOAP
2. Seorang ibu berusia 70 tahun mengalami ascites,
dengan kadar Kalium 2,5 mEq/L, Natrium 100
mEq/L. Diagnosa Decompensasi Cordis, disertai
edema dan efusi pleura. TD = 90/60 mmHg.
Pengobatan yang diberikan digoxin 0,25 mcg 1x1,
furosemid injeksi 20 mg 1x1 iv drip. Pada hari ke 2
pasien mengalami kram kaki hingga menjalar ke
atas, nausea dan vomiting, serta sesak nafas.
Pengobatan ditambah dengan pemberian
metoklopramid 10 mg iv.
Intepretasikan data klinik pasien tersebut, analisalah
pengobatannya dengan SOAP
3. Pasien a berusia 20 tahun mengalami demam 3 hari,
nyeri tulang dan sendi, mual muntah, suhu rata-rata
39-40 C, hari ke 2 muncul petekie, hari ke 3 pasien
epistaksis. hasil pemeriksaan laboratorium :
Haemoglobin = 9,8 gr/dL, leukosit 11.000 /mm3
Eos =3,3 %, baso = 0,2 %, segmen 73,5 %, limfosit 19
%, monosit 5,0, hematokrit 30,3 %, eritrosit 3,37 %,
trombosit 60.000/mm3
Dengue NS 1 +. === hari ke 3 dirawat inap
Pengobatan : Ibuprofen 400 mg 3x1, asam mefenamat
500 mg 1x1, neurosanbe 1x1.
Intepretasikan data klinik, dan analisalah pengobatan
pasien diatas.