fds lapjag igd ii
TRANSCRIPT
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7/25/2019 Fds Lapjag Igd II
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LAPORAN JAGA IGD26-27 Desember 2015
15.00 - 06.00 WIB
Oleh:
Fa!llah D"sra #!$"rma%
&'%s!le%:
$r. (!l)a #!%$ar"* #+.PD
KEPANITERAAN KLINIK ILMU PENYAKIT DALAM
RSUD Dr. M. Yunus BENGKULU
2015
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&A#,# 1
I$e%"as Pas"e%:
Nama : %. &
,s"a : 52 ah!%
Alama : Be%/!l!Aama : Islam
Pe/eraa% : Pea%"
#a!s +er/a"%a% : (e%"/ah
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ANA(N#I#
3 Keluhan Utaa :
#a/" +er! )a% membera sea/ 12 am #(R#
3 RPS
12 am #(R#* +as"e% me%el!h sa/" +er! )a% sema/"%membera. #a/" +er! er!ama $"rasa/a% $" ba"a% +er! /a%a%.
Pas"e% !a me%el!h erasa m!al ea+" "$a/ sam+a" m!%ah.
Pas"e% me%a/! sa/" +er! leb"h $"rasa/a% saa seelah
me%a%/a beba% )a% bera. Demam 4-* BAB %'rmal* BA&
%'rmal* m!al $a% m!%ah 4. R"a)a m"%!m 'ba-'baa% 4-.
Pas"e% bel!m +er%ah ber'ba !%!/ me%'ba" /el!ha% erseb!.
b!la% #(R#* +as"e% +er%ah me%alam" /el!ha% )a% ser!+a*
seelah be/era me%a%/a be%$a-be%$a bera. Pas"e%
me%a/! s!$ah +er%ah me%'ba" +e%)a/"%)a erseb!.
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3 RPD : 8"+ere%s" 4-* /e%9"% ma%"s 4-.
3 RP& : /el!ha% $a% sa/" )a% sama $"sa%/al
3 R"a)a s's"al : Pas"e% be/era sebaa" b!r!h
ba%!%a% $e%a% sa!s e/'%'m" )a% se$a%*
$a% sa%"as" l"%/!%a% )a% ba"/.
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P(RIAAN FI#I&
3 &, : sa/" se$a%3 &esa$ara% : 'm+'s me%"s
3 a%$a ;"al : D0 mm8
N< ?0@=m%
R< 2 @=m% #< 6*5
3 &e+ala :
- '%!%";a Pal+ebra +!9a -=-
- #/lera I/er"/ -=-
3 Leher :
+embesara% &GB 4-* +embesara% /ele%ar "r'"$4-
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3 h'ra@
Par!
I: sa"s $"%am"s s"mer"s /a
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3 Ja%!% :
I : "/!s /'r$"s "$a/ erl"haP : "/!s /'r$"s "$a/ eraba
P : baas /a%a% a%!% l"%ea +araser%al"s $e@ra
I# E
baas /"r" a%!% l"%ea m"$/la;"/!la s"%"sraI# E
baas aas a%!% I# II
A : BJ1 $a% BJ2 re!ler 4 %'rmal* all'+ 4-* m!rm!r 4-
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3 Ab$'me%:
I : $aar
A : B, 4 %'rmalP : %)er" e/a% re"' l!mbal $a% "l"a/a /a%a%4
he+ar $a% l"e% "$a/ eraba
bal'eme% 4-=-
%)er" /e'/ EA 4-=-P : "m+a%" $"sem!a re"' ab$'me%
3 /srem"as :
a/ral ha%a
+""% e$ema 4-=-
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8A#IL P(RIAAN LABORAORI,(
3 8b : 1*2 =$L
3 8 : >
3 r'mb: 255.000 sel=mmA
3 Le! : >.200 mmA
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DIAGNO#I#
D"a%'s"s /era :
3 /'l"/ ab$'me% e.9 s!s+. B#&
D"a%'s"s ba%$"% :
3 &'lel""as"s
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RAPI
N'%Carma/'l'"s :
"rah bar"%
Farma/'l'"s
IEFD RL =m%
&e'r'la9 am+ @1 4IE
B!s9'+a% am+ @1 4IE
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PLANNING
1. e/ ,r"% le%/a+
2. R'%e%
. &'%s!l ba"a% be$ah
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&A#,# 2
I$e%"as Pas"e%:
Nama : %. #
,s"a : 50 ah!%
Alama : /eb!% beler* Be%/!l!Aama : Islam
Pe/eraa% : PN#
#a!s +er/a"%a% : (e%"/ah
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ANA(N#I#
3 &,:
Demam sea/ 1 har" #(R#
3 RP# :
1 har" #(R#* +as"e% me%el!h/a% $emam* $emam
$"rasa/a% er!ama +a$a malam har"* me%""l 4-*
/er"%a 4-* b"%"/-b"%/ merah4-. Pas"e% !a m!al $a%m!%ah* m!%ah ber"s" a"r $a% ma/a%a%. %)er" !l! ha"
4* #a/" /e+ala 4-* %aCs! ma/a% me%!r!% 4* BAB 4
@ sehar"* /'%s"se%s" lembe/* $arah $a% le%$"r 4-. BA&
4* %)er" saa BA& 4-. Ba!/ +"le/ 4-
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3 RPD :
"$a/ +er%ah me%alam" /el!ha% ser!+a sebel!m%)a.
3 RP& :R"a)a /el!ara )a% me%$er"a +e%)a/" )a% sama
$"sa%/al.
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P(RIAAN FI#I&
3 &, : sa/" se$a%
3 &esa$ara% : 'm+'s me%"s3 a%$a ;"al : D
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3 h'ra@
Par!
I: sa"s $a% $"%am"s s"mer"s. rera/s" sela "a $a% s!+ra/la;"/!la 4-
+e%!%aa% '' ba%! %aCas 4-
P: semCrem"!s De@ra #"%"sra s"mer"s.
e/s+a%s" $"%$"% $a$a $e@ra s"%"sra s"mer"s.P: s'%'r $"sem!a la+a% +ar!.
A: ;es"/!ler 4 %'rmal.
hee"% -=-. R'%/" -=-
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3 Ja%!% :
I : "/!s /'r$"s "$a/ erl"ha
P: "/!s /'r$"s eraba $" l"%ea m"$/la;"/!la s"%"sra I# E.
hr"ll 4-
P: baas /a%a% a%!% l"%ea ser%al"s $e@ra* baas /"r"
a%!% l"%ea m"$/la;"/!la s"%"sra I# E $a% baas aas
a%!% I# II
A: 8R: 6@=m%* re!ler. #1 $a% #2 4N* all'+ 4-* m!rm!r4-
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3 Ab$'me%:
I: $aar
A:B, 4 me%"%/aP: %)er" e/a% 4 re"' e+"asr"!m
P: "m+a%" $"sem!a re"' ab$
3 /srem"asa/ral ha%a
!r'r /!l" 4N
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DIAGNO#I#
3 D"a%'s"s /era :
Obs. Febr"s e.9 s!s+. Demam )+h'"$
3 D"a%'s"s ba%$"% :
- (alar"a- Demam De%!e
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RAPI
N'%Carma/'l'"s
3 "rah bar"%
3 D"e lamb!% II
Farma/'l'"s3 I%C!s RL =me%"
3 Dr"+ O%$a%ser'% 1 am+!l
3 P @ 500 m
3 De@a%a s)r!+ @ 1
3 J"/a has"l W"$al 4* 9hl'ram+he%"9'l ab @500 m
4sam+a" 7 har" bebas $emam
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PLANNING
3 Darah r!"%: hem'l'b"%* hema'/r"* r'mb's"* le!/'s"
3 Per"/sa "$al
3 !be/s 4"$a/ erse$"a
3 DDR
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RI(A &A#I8