laporan jaga 01 des 2015 (edh)

7/23/2019 Laporan Jaga 01 Des 2015 (Edh)

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LAPORAN JAGA

TANGGAL 01 DESEMBER 2015Disusun oleh:

Astri Flun

Asri Ali!



" #$ #%entits

" N& : An$ '

" (si : 11 thun

" Run)n : #*( B



" An&nesis +Allon&nesis,

" -eluhn (t&: Psien ru.u/n RS(P Ft&ti %en)n /eluhn

enurunn /es%rn

" -eluhn T&hn: Ti%/ % /eluhn t&hn$



" RPD" As& %isn)/l

" Aller)i %isn)/l



Sttus Generlis

" -( : T&/ s/it se%n)$

" -es : G*S 13 +EM>?5,

" TT?

" N : @29&enit

" S : =*" TD : 1100&&<)

" P : 229&enit

" -el : nor&o;heli6 ter%t en.oln % rieto

o;;iitl %e9tr6 .e.s +7,

" Mt : -on.un)tiC Ane&is +77, 6 S/ler #/teri/ +77,6 uil

ult iso/or &&&&6 R*L 446 R*TL 44

" Leher : Pe&esrn -GB +7,



" Thor9

" Pul&o

# : er)er/n %% si&etris %l& /e%n sttis %n %in&is$P : !re&itus t/til Co/l si&etris ilterl

P : sonor % /e%u ln) ru

A : sur n!s Cesi/uler6 Rhon;i 776 heein) 77

" *or : s1s2 re)uler6 )llo +7, &ur&ur +7,

" A%o&en :

# : %tr6 lesi +7,

P : n8eri te/n +7,

P : ter%en)r th8&ni /e 3 /u%rn %o&en

A : B( +4, Nor&l

" E9tre&its : A/rl hn)t6 e%e& +7,6 *TR 2 %eti/



Mini Neurolo)i; E9&intion" -es: GS* 13 +EM>?5,

" Puil: ult iso/hor6 &&&&6 R*L 446 R*TL 44

" Pe&eri/sn &otori/ : 5555 5555

5555 5555

" Lterlissi : 7

" Tonus : Nor&otonus Nor&otonus

Nor&otonus Nor&otonus



Pe&eri/sn Penun.n) +RS(P Ft&ti,

t)l 01115 u/ul 11:3?riel Te&un Nili Nor&l

<e&tolo)i

< 12$ )%l 10$ H 15$> )%l

Leu/osit 1=$000 ul 5000713$000 ul

<t @I 735I

Tro&osit >2$000ul 13$00073$000ul

-i&i -lini/

Glu/os Drh 103 >0 7 100 &)%L

<e&ostsis

APTT 0$ %eti/ 2$0 H =$@ %eti/

PT 1$2 %eti/ 12$= H 1>$1 %eti/

Fun)si <ti

SGOTSGPT

2> ul12 ul

0 H 3 ul0 H 30 ul

Fun)si Gin.l

(reu& 31 &)%l 0 H 3 &)%l



Di)nosis

" ED< rieto o;;iitl %e9tr

" *-R



Pentl/snn

-onsul %r$ Sleh A$ M6 S$BS6 M<-es

" Oersi ;ito

" *e!tri9one 192 )



Lorn Oersi

" #nsisi % rieto o;;iitl %e9tr6 t&/ tuln) !r/tur

" T&/ ED<6 eC/usi 4 =0 ;;6 /ontrol lee%in)6 .hit

%ur&ter %n sn) %rin

" Tutu lis %e&i lis

" Oersi selesi

" Ju&lh er%rhn 4 100 ;;



#nstru/si Post Oersi

" Pus s&i B( +4, nor&l

" #?FD RL 1=00 ;;23 .&

" #n. ;e!tri9one 192 )

" #n.$ -eterol; 90 &)" #n.$ Rniti%in 291 &



" #$ #%entits

" N& : Tn$ A

" (si : >1 Thun

" Run)n : Mhoni #



RPS :

" Psien %tn) /e #GD RS$POLR# %en)n /eluhn ut&n8eri erut /nn h se./ 5 hri SMRS6 n8eri

%irs/n ti H ti6 n8eri seerti %itusu/ 7 tusu/6 n8eri

%irs/n &enet6 sien &ers erutn8 se&/in

s/it il tu/ %n er.ln$ Psien .u) &en)eluh&ul +4,6 &unth +7,6 %e&& +7,$ BA- !re/uensi 375 9hri6

ti%/ n8eri st BA-6 ti%/ ersir6 ti%/ errn &erh

%n ti%/ n8n)7n8n)n$ BAB sien !re/unsi 17

29hri6 %t6 len%ir +7,6 %rh +7,$ Psien su%h erot

/e /lini/ 23 .& 2 hri SMRS %n %ieri/n ot nti n8eri

%n nti &ul6 n&un /ren rs s/it % erut /nn

%irs/n ti%/ er/urn) sien &e&utus/n untu/

erot /e RS POLR#$



" An&nesis +Auton&nesis,

" -eluhn (t& : N8eri erut /nn h.

" -eluhn T&hn: 7



" RPD

" <iertensi %isn)/l

" Dietes &elitus %isn)/l

" Aller)i %isn)/l



Pe&eri/sn Fisi/

" -( : T&/ s/it se%n)

" -es%rn : *o&os &entis

" TT?

" TD : 120=0 &&<)" N : @>9 &enit

" RR : 239 &enit

" Suhu : >$5 *



Sttus Generlis

" -el : nor&o;heli

" Mt : -on.un)tiC Ane&is +77, 6 S/ler #/teri/ +77,


" Thor9

" Pul&o# : er)er/n %% si&etris %l& /e%n sttis %n %in&is$

P : !re&itus t/til Co/l si&etris ilterl






" A%o&en# : %tr$

P: NT +4, N8eri les +4, %i erut /nn h6 %e!ns &us;ulr +4,

P: ti&ni %i /e 3 /u%rn %o&en

A: B( +4, nor&l

" E9tre&its : /rl hn)t6 *RT 2 %eti/



Sttus Lo/lis

" Re)io RL' A%o&en

# : %tr$

P: NT +4, %i titi/ &;$ Burne86 n8eri les +4,6 %e!ns &us;ulr +4,

P: N- +4,

A: B( +4, nor&l



Re;tl tou;her

" Tonus shin;ter ni i/

" A&ull re;ti ti%/ /ols

" Mu/os li;in

"Mss +7,

" N8eri te/n +4, rh .& 10711

" Prostt : rh .& 126 /onsistensi /en8l6 er&u/n

rt6 ole ts ter6 sul;us &e%inus ter$

" <n%s;oen: !eses +7, %rh +7, len%ir +7,



Pe&eri/sn Penun.n)

?riel Te&un Nili Nor&l

<e&tolo)i

< 15)%l 171> )%l

Leu/osit 1$500 ul 5000710$000 ul

<t 32I =73I

Tro&osit 01$000 ul 150$0007300$000ul

-i&i -lini/

Glu/os Drh 12 130 &)%L



Di)nosis

" Aen%i;itis ;ute



Pentl/snn

" -onsul %r$it S$B

" Oersi ;ito

" #n. ;e!tri9one 1 9 2)r

" #n. rniti%in 2 9 1 &

" *e/ l len)/" Ront)en thor9

" -onsul S$JP



Lorn oersi

" Asesis %n ntisesis

" #nsisi % titi/ &;urne86 eritoniu& %iu/6 en%i/s

%iliuti o&entu&6 erlen)/etn %ies/n us +4, 4

2;;

" Aen%i/s )n)renous6 er!usi %iten)h %il/u/n

en%i/to&i

" Ron)) %o&en %i;u;i %en)n N*l

" Lu/ o %itutu6 o selesi$

" Ju&lh er%rhn 20;;

" Di)nosis ost o : en%i;itis er!orsi



#nstru/si ost o

" Asi TNSP

" #?FD RL 2 /ol! 23.&

" #n. ;e!tri9one 1 9 2 )r +3hri,

"&etroni%ole 9 1 %ri +3 hri,

" #n.$ -etorol; 9 1 &

" Diet is

" Moilissi setelh 23 .&$



" #$ #%entits

" N& : Tn$ D

" (si : 21 Thun

"Run)n : Melti ##



" An&nesis +Auton&nesis %n llon&nesis,

" -eluhn (t& : Psien ru.u/n RS$Su&er rs

%en)n /eluhn n8eri % .h )in /nn.

" -eluhn T&hn: 7



RPS :

" Psien %tn) /e #GD RS$POLR# %en)n ru.u/n %riRS$Su&er rs %en)n /eluhn ut& n8eri %

.h )in /nn se./ 3 hri SMRS$ N8eri %irs/n

setelh -LL6 sien &en)/u se%n) &en)en%ri &otor

%en)n /e;etn tin))i 0 /&.&6 /e&u%in sien&enr/ &oil 8n) in)in erelo/ rh6 %n setelh itu

sien ter.tuh %n ti%/ s%r/n %iri$

" Menurut /etern)n olisi6 st sien %ieri/s

i%entitsn8 %i #GD RS$Su&er rs6 olisi &ene&u/n

rn) u/ti nr/o eru )n.$

" Psien %iru.u/ /e RS$olri /ren run) rt RS$Su&er

rs enuh$



" RPD

" <iertensi %isn)/l

" Dietes &elitus %isn)/l

" Aller)i %isn)/l



Pe&eri/sn Fisi/

" -( : T&/ s/it se%n)

" -es%rn : *o&os &entis

" TT?

"TD : 1200 &&<)

" N : 9 &enit

" RR : 229 &enit

" Suhu : >$5 *



Sttus Generlis

" -el : nor&o;heli

" Mt : -on.un)tiC Ane&is +77, 6 S/ler #/teri/ +77,


" Thor9

" Pul&o# : er)er/n %% si&etris %l& /e%n sttis %n %in&is$

P : !re&itus t/til Co/l si&etris ilterl






" A%o&en# : %tr6 .e.s +7,

P: NT +7,

P: ti&ni %i /e 3 /u%rn %o&en

A: B( +4, nor&l

" E9tre&its : /rl hn)t6 *RT 2 %eti/



Sttus Lo/lis

" Re)io orlis %n u;llis %e9tr

#: /rust +4,6 ter%t lu/ erentu/ ti%/ erturn

eru/urn 1$5;& 9 0$5;& K 1;& 9 0$5;& %sr /utis

" Re)io oritlis:

# : ter%t lu/ 8n) su%h %i.hit %en)n n.n)

2$5;&

" Re)io tri)onu& su&entl

#: ter%t lu/ 8n) su%h %i.hit %en)n n.n) 1$5;&



Pe&eri/sn Penun.n)

?riel Te&un Nili Nor&l

<e&tolo)i

< 156)%l 171> )%l

Leu/osit $=00 ul 5000710$000 ul

<t 3>I =73I

Tro&osit 3$000 ul 150$0007300$000ul

-i&i -lini/

Glu/os Drh =5 130 &)%L



Di)nosis

" Multile lsersi .h



Pentl/snn

" -onsul %r$<untl S$BP

" #?FD RL 1500;;23.&

" #n.$ Tr&l 9 1 &

" Ren;n oersi

laporan jaga 01 des 2015 (edh)

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