laporan jaga
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7/17/2019 Laporan Jaga
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LAPORAN JAGA
03 Januari 2015
ERIKA FITRIANI (I11110046)STASE EMERGENCY MEDICINE
RUMAH SAKIT TNI AU LANUD SUPADIO
7/17/2019 Laporan Jaga
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Identitas Pasien
• Nama : By. A
• Usia : 1 ari
• Jenis !e"amin : La#i$"a#i
• A%ama : Is"am
• A"amat : &s. 'u#andarsi(
1
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Anamness
Ke!"#an U$ama%&a' $a menan*s saa$ !a#+
R,a'a$ -en'a$ sea+an*%
1 .am SMRS /a' !a#+ $a !an*s"n*menan*s *e+aan /a' "+an* a$
/a' !a#+ $2!2n* 2!e# /an -2ss/a' saa$ !a#+ $a e$a#" ,a+nae$"/an $a e$a#"
7/17/2019 Laporan Jaga
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• R,a'a$ -e+sa!nan% P1A03 Pa+$"ss-2n$an ""- /"!an $2!2n* 2!e#/an3 && 500 *+am P& 70m3
• R,a'a$ e#am!an% R,a'a$ese#a$an /" $a e$a#"+,a'a$ m"nsas /" $a e$a#"
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Pemeri#saan )isi#
• !eadaan umum : *am+a# sa#it sedan%• !esadaran : ,-m+-s entis
• )re#uensi nadi : 12/menit
• )re#uensi na+as : 5menit• 'u(u : 3/2-,
• BB : 3200 %ram
• PB : 50 4m
• L! : 3 4m
• L& : 32 4m
7/17/2019 Laporan Jaga
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Pemeri#saan )isi#
• !e+a"a : 4a+ut su#sedanum 678na+as4u+in% (idun% 6$8
• u"ut : da"am 9atas n-rma"re"e# (isa+ 678
• &ada : retra#si dindin% dada 678 suaranaas 9r-n#-;esi#u"er 6778 '1$'2 re%u"er.
• A9d-men : BU 678
• <#stremitas : 4rt = 2 deti#a#ra" din%inu>un% >ari +u4at
7/17/2019 Laporan Jaga
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Da*n2ss Ke+.a
• S"s-3 As8sa +n*an
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Ta$a!asana
? O nasa! an"! 07 !9m
? Han*a$an
? D10 10 $-m m+2
? Ne2 K 1 am-"!
? Ce2$a:m : 170 m*
? Gen$amn : ; m*
? Amn28!n 5: < m* ? De:ame$as2n 5: 07m*
? OGT
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P+2*n2ss
• A =$am % "/a a /2nam
• A F"n$2nam % "/a a /2nam
• A Sana$2nam % "/a a ma!am
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Identitas Pasien
• Nama : Ny. A
• Usia : 51 *a(un
• Jenis !e"amin : Perem+uan
• A%ama : Bud(a
• 'tatus : 'uda( meni#a(• A"amat : !u9u Raya
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Anamness
Ke!"#an U$ama%Pasen a$an* a!am eaaan $a saa+an +
R,a'a$ -en'a$ sea+an*%
Pasen a$an* en*an eaaan $a saa+an +1 .am 'an* !a!" -asen -e+* e a-2$e "n$" mene/"s2/a$ a+a# $n** sam-a +"ma# -asen memn"m 1/"$+ 2/a$ 2/a$ /e+""+an e! /"a# 50 men$em"an -asen $/a>$/a $e+.a$"# an $a saa+an
+3
R,a'a$ Pen'a$ Da#"!"% H-e+$ens (?) DM (>)Gas$+$s (>) Asma (>)3
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Pemeri#saan )isi#
• !eadaan umum : *ida# sadar • !esadaran : G,' 3 6<1@118
• *e#anan dara(: $
• )re#uensi nadi : *ida# tera9a• )re#uensi na+as : *ida# ada
• 'u(u : 35/ ,
7/17/2019 Laporan Jaga
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Pemeri#saan )isi#
• ata: Pu+i" midriasis ma#sima" re"e##-rnea 6$8 re"e# 4a(aya 6$8.
• Le(er : Pu"sasi arteri 4ar-tis 6$8
• &ada : Gera#an dada 6$8BJ 6$8
• <#stremitas : a#ra" din%in u>un% >ari
tan%an +u4at.
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Peme+saan Pen"n.an* EKG
As's$2!
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Da*n2ss Ke+.a
• Dea$# 2 A++@a!
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Ta$a!asana
• A+,a'
• &+ea$#n*
• C+"!a$2n
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Identitas Pasien
• Nama : Ny. '
• Usia : 2 *a(un
• Jenis !e"amin : Perem+uan
• A%ama : Is"am
• 'tatus : 'uda( meni#a(• A"amat : !u9u Raya
5
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Ke!"#an "$ama
• Ke!"a+ a+an a+ @a*na
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R,a'a$ -en'a$ sea+an*
• Pasen men*a!am m"!es>m"!es n*nme!a#+an se+$a e!"a+ a+an a+
.a!an !a#+ se.a -a* 4 .am SMRS
a+a# (>) !en+ (>) $a /e+,a+na*e+aan .ann (?) HPHT 0>4>014+,a'a$ $+a"ma (>) emam (>)
7/17/2019 Laporan Jaga
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• R,a'a$ Pen'a$ Da#"!"% R,a'a$KPD (?) H-e+$ens (>) an DM (>)
• R,a'a$ -e+sa!nan ana -e+$ama!a#+ s-2n$an &&L ;00 *+am anP& 71 m3
• R,a'a$ O/s$e$+ % GP1A0
7/17/2019 Laporan Jaga
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Pemeri#saan )isi#
• !eadaan umum : *am+a# sa#it sedan%• !esadaran : ,-m+-s entis
• *e#anan dara(: 1000 mm%
• )re#uensi nadi : 0menit• )re#uensi na+as : 22menit
• 'u(u : 3/3-,
7/17/2019 Laporan Jaga
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Pemeri#saan )isi#
• ata: !-n>un%ti;a anemis 6$8 s#"erai#teri# 6$8
• ** : )arin% (i+eremis 6$8 *-nsi" *1*1
• Le(er : J@P 6$8 !GB 6$8
• &ada : 'imetris
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Pemeri#saan )isi#
• Paru: ? Ins+e#si : Gera#an dada simetris 9ai# da"am
#eadaan statis mau+un dinamis
? Pa"+asi : )emitus ta#ti" #anan C #iri
? Per#usi : '-n-r se"uru( "a+an% +aru
? Aus#u"tasi: suara na+as dasar : ;esi#u"er
suara na+as tam9a(an: r-n#i 6$$8 D(eeEin%
6$$8
7/17/2019 Laporan Jaga
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Pemeri#saan )isi#
• Jantun% : ? Ins+e#si : i#tus 4-rdis tida# ter"i(at
? Pa"+asi : i#tus 4-rdis tera9a di 'I, @ "inea
mid4"a;i4u"a sinistra ? Per#usi : Batas >antun% da"am 9atas n-rma"
? Aus#u"tasi : '1'2 re%u"er %a""-+6$8 murmur6$8
7/17/2019 Laporan Jaga
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S$a$"s O/s$e$+
• Ins-es % Pe+"$ mem/"n$ s$+ae *+a@"m (?)
• Pa!-as %
Le2-2! I % Te+a/a /a*an /esa+ /"!a$ an !"na TFU 54 m3
Le2-2! II % P"n**"n* $e+a/a /a*an + anan$e+a/a /a*an $"n*a
Le2-2! III % Te+a/a /a*an /"!a$ an e+as
Le2-2! I= % K2n@e+*en
• Hs % 910men$
• D% 14:9men$
7/17/2019 Laporan Jaga
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Peme+saan La/2+a$2+"m
• H/ % 11 *+B
• HT % 5B
• Le2s$ % 103000• T+2m/2s$ % 3000
• E+$+2s$ % 45
7/17/2019 Laporan Jaga
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Da*n2ss
• GP1A0 #am! 40 mn**" a!a 1 asea$ en*an KPD .ann $"n**a!#"-3
7/17/2019 Laporan Jaga
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Ta$a!asana
• In"s RL 0 $-m
• Am-!n 1 : 1 *+am
•O/se+@as $ana @$a! $anaema."an -e+sa!nan
7/17/2019 Laporan Jaga
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P+2*n2ss
• A =$am % "/a a /2nam
• A F"n$2nam % "/a a /2nam
•A Sana$2nam % "/a a /2nam
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TERIMA KASIH
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