Laporan Jaga Dokter Muda 1 2[Autosaved]

8/17/2019 Laporan Jaga Dokter Muda 1 2[Autosaved]

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LAPORAN JAGA DOKTER

MUDA

PROGRAM STUDI PENDIDIKAN DOKTERFAKULTAS KEDOKTERAN

UNIVERSITAS PALANGKA RAYA

RSUD dr. DORIS SYLVANUS PALANGKA RAYA

2015


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Hari, Tana! " S#!a$a, 1% &'!i

2015

P'('! " 1%.00 ) 0*.00 +I

P#-'a$ &aa " REGINA IGD/

FRANS VK/

NITA MARTA H ANGSAL/


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I. Jumlah Pasien/Resume Pasien

N. Da-a &'!a

1 ar' Ma$'(

2 a/ Par-'$ Nra!3/ Par-'$ Pa-!i$4/ Tinda(an"

•) S•) K'r#-•) Man'a! P!a$#n-a

6

66

7Pa$i#n di an$a!• P#ra8a-an Kn$#r9a-i:

% Pa$i#n di IU 1

5 Pa$i#n di 3an$a! !ain 6

; R#n4ana O


4/38

PASIEN BARU (1

1. N=. Li!i$ S, 7; -a'n a$'( >a 17.0? +I

ANAMNESIS"

KU! Os "a#an$ in$in melahi%&an ana& &e '

RPS!

Os men$a&ui hamil ana& &e"ua mulas () mulai"i%asa&an se*a& &ema%in #e#a+i *a%an$. Kelua% Len"i%"a%ah (, ai% (,

Os men$a&ui hamil ana& &e"ua %i-aa# a0%#us (,%i-aa# S () 2 #ahun an$ lalu.

Ri-aa# AN () USG () &ema%in "en$an "% Mi&&0 S+.OG#$l 13/45/'412 hasil le#a& sun$san$ "an "isa%an&an un#u&S

6P6T! ''/14/'417 8 TP! '9/4:/'412 (USG 8 UK! 3;,39 m$$


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PEMERIKSAAN /m6IS! ()

=T! #i"a& "ila&u&an


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6ASIL LABORATORIUM (1

PEMERIKSAAN HASIL

Da%ah Len$&a+ Leu&0si#! 2.514E%i#%0si#! 7'56em0$l0in! 95

T%0m0si#! ';;.444

Kimia Klini& Glu&0sa se-au! :'


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DIAGNOSA (1

• G2P1A0, ai! 7?67@ in', &IUTH ,


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TERAPI IGD (1

A"?ise "%. Mi&&0 S+.OG!

• P%0 S ha%i ini(12,4:,'412 *am 49.44-i

• Pe%sia+an #%ansCusi ' &0lC PR

• Pe%sia+an S "a%i %uan$an


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PASIEN BARU ('

2. N=. S'!i$ S, 2; -a'n a$'( >a 17.25 +I

ANAMNESIS"

KU! &elua% ai% "a%i *alan lahi%

RPS!

Os men$a&ui hamil ana& +e%#ama Os men$a#a&an &elua% ai%"a%i *alan lahi% se*a& *am ''.44 IB enin$ "an me%emes.Pu&ul 4'.44 ai% &e#uan ana& &elua%. Mules () GJ ()se*a& +u&ul 44.44 -i.len"i% "a%ah (, +en$liha#an &au% (,ne%i ulu ha#i (,.

%i-aa# a0%#us (, Ri-aa# AN () USG () #$l 17/4:/'412hasil &e#uan +eah *an#un$ ai lemah.0s me%u+a&an&i%iman "a%i "% Si$i# S+.OG "en$an +%0 S a/i KPD "en$an%i- S 5 #ahun an$ lalu.

6P6T! 8 TP! '4/4:/'412 (USG 8 UK! 39,74 m$$


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PEMERIKSAAN /m

S#a#. Gene%alis Ma#a! anemis (,0%! S1 S' %e$ mu% (, $al(,Pulm0! ?esi&ule% )/) %0n (, -he (,

S#a#. Os#e#%i L1! T


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6ASIL LABORATORIUM ('

PEMERIKSAAN HASIL

Da%ah Len$&a+ Leu&0si#! :.''4E%i#%0si#! 39;6em0$l0in! 113

T%0m0si#! 3:5.444

Kimia Klini& Glu&0sa se-au! :2


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DIAGNOSA ('

• G2P1P0 '( 7@6%0 in' B in


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TERAPI IGD ('

A"?ise "%. Mi&&0 S+.OG!

• NST

• RL '4 #+m

• eC#%ia>0ne '> 1$% ST "ulu

• On"anen#%0n 3>; m$ i?

• Rani#i"ine '>1 $% i?

• P%0 "a%ah ' &0lC u/ #%ansCusi• P%0 S *am '4.44 -i 17/4:/'412

• Puasa


14/38

PASIEN BARU (3

7. N=. R#ni-a, 21 -a'n a$'( >a 1%.1* +I

ANAMNESIS"

KU! Os "a#an$ "en$an in$in melahi%&an ana& +e%#ama

RPS!

Os men$a&ui hamil ana& +e%#ama+e%u# mules (, &elua%ai%,ai% (, len"i% "a%ah (, +en$liha#an &au% (, ne%i uluha#i (, $e%a&an *anin ().

%i-aa# a0%#us () 1 &ali.

Os men$a&u hamil 14 ulan Ri-aa# AN () USG ()

''/45/'412 "i RSUD Ka+uas "i&a#a&an +0sisi &e+ala ai"i a-ah elum masu& PAP "an ai% &e#uan e%&u%an$.

6P6T! 13/49/'417 8 TP! '4/45/'412 8 UK! 7',73 m$$


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PEMERIKSAAN


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PEMERIKSAAN HASIL

Da%ah Len$&a+ Leu&0si#! 11.:14E%i#%0si#! 35:6em0$l0in! 113

T%0m0si#! 372.444



17/38

DIAGNOSA (3

• G2P0A1 '(. %26%7 in', 4'ria PD


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TERAPI IGD (3

• P%0 s / %au 12/1:/12 +&l 49.44

• Sia+ "a%ah ' &0lC


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PASIEN BARU (7

%. N=. N'r$#!!a, 72 -a'n a$'( >a 15.15 +I

ANAMNESIS"

KU! Os "a#an$ "en$an &eluhan +e%u# mules

RPS!

Os men$a#a&an mules +a"a +e%u# se*a& +a$i +u&ul 45.44&elua% ai%,ai% (, len"i% "a%ah () $e%a&an *anin ().

Os men$a&ui hamil ana& &e 3 %i-aa# a0%#us (,.

Ri-aa# AN () USG () #an$$al 11/4:/'412 "en$an "%.si$i# S+.OG → hasil ai& le#a& "ia-ah

6P6T! 1:/14/'417 8 TP! '7/43/'412 8 UK! 3;,39 m$$


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PEMERIKSAAN


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PEMERIKSAAN HASIL

Da%ah Len$&a+ Leu&0si#! 1'.''4E%i#%0si#! 3:96em0$l0in! 1''

T%0m0si#! ':'.444

Kimia Klini& Glu&0sa se-au! ;3


22/38

DIAGNOSA (7

• G2P2A0 '(. 7?67@ in',


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TERAPI IGD (7

• InC. RL '4 #+m (Pasien men0la& +asan$inCus

• Os. +e%salinan n0%mal


24/38

PASIEN BARU (2

5. N=. Ra3ia-'!, 71 -a'n a$'( >a 1*.7; +I

ANAMNESIS"

KU! &e*an$ &e*an$ +0s# melahi%&an

RPS!

Os &e*an$,&e*an$ +0s# +a%#um +u&ul 4'.44 -i &emu"ian#i"a& sa"a% 0s melahi%&an "en$an i"an "i PKM. Ri-aa##%ansCusi "a%ah ; &an#0n$ ' ha%i ll a%u &elua% RS&a%ena anemia.


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PEMERIKSAAN


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PEMERIKSAAN HASIL

Da%ah Len$&a+ Leu&0si#! 9.224E%i#%0si#! 7'76em0$l0in! 1'7

T%0m0si#! ''5.444

Kimia Klini& Glu&0sa se-au! 99

Kimia U%in P%0#ein! (,


27/38

DIAGNOSA (2

• E(!a$i


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TERAPI IGD (2

• InC. RL '4 #+m


• Pan#au DJJ


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PASIEN BARU (5

;. N=. H#rnani S, 2; -a'n a$'( >a 17.25 +I

ANAMNESIS"


RPS!



6P6T! 8 TP! '4/4:/'412 (USG 8 UK! 39,74 m$$


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PEMERIKSAAN /m

S#a#. Gene%alis Ma#a! anemis (,0%! S1 S' %e$ mu% (, $al(,Pulm0! ?esi&ule% )/) %0n (, -he (,

S#a#. Os#e#%i L1! T


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PEMERIKSAAN HASIL


T%0m0si#! 3:5.444



32/38

DIAGNOSA (5

• G2P1P0 '( 7@6%0 in' B in


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TERAPI IGD (5

• InC. RL '4 #+m


• Pan#au DJJ


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PASIEN BARU (:

*. N=. S'!i$ S, 2; -a'n a$'( >a 17.25 +I

ANAMNESIS"


RPS!



6P6T! 8 TP! '4/4:/'412 (USG 8 UK! 39,74 m$$


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PEMERIKSAAN


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6ASIL LABORATORIUM (:

PEMERIKSAAN HASIL


T%0m0si#! 3:5.444



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DIAGNOSA (:

• G2P1P0 '( 7@6%0 in' B in


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TERAPI IGD (:

• InC. RL '4 #+m


• Pan#au DJJ

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