Laporan Jaga Dokter Muda 29 November 2015

7/25/2019 Laporan Jaga Dokter Muda 29 November 2015

1/43

LAPORAN JAGA

DOKTER MUDA

MINGGU, 29 NOVEMBER 2015

IGD PONEK

VK

BANGSAL

IDA YOSOPA & DINAWULANDARI

HASANAH & APRIADI

RUGAS PRIBAWA &VITROSA


2/43

I. Jumlah Pasien/Resume Pasien

No. Data Jumlah

1 Bau !a"u# $

% a Patu" Nomal' Patu" Patolo()"* T)+,a#a+-

) S) Ku/t

) !a+ual Pla"/+ta

%0

%0

0

Pa")/+ ,) Ba+("al

P/a2ata+ Ko+"/3at)4 0

5Pa")/+ ,) IU

HU

%

06 Pa")/+ ,) 'a+("al la)+ 1

7 R/+*a+a O8/a")a OK PONEK-

) S) Ku/t

' OK IBS

0

0


3/43

PASIEN BARU (1 !".##

ANA!NESIS -

Pasien : Ny. DW, 32 tahn

K/luha+ Utama -Nye!i U" #ati

RPS - Pasien $atan% $en%an &e"han nye!i " hati se'a& ta$i(a%i )*+, nye!i $i!asa&an se(e!ti $its&, ntah )*+ 1- isi

a&anan. Pasien se$an% hai" ana& &e ti%a, "es"es )*+

ta$i a"a (&". 19.00, "en$i! $a!ah )+, ai!ai!)+, /N )*+, !i.

its 3 ha!i y"", !i. Maa% )*+, !i. DM )+, !i. /""e!%i )+,

!i. # )+, U4G )*+ "an &te! $en%an $!. 4(. OG hasi" U6

30 in%%, (!es&e(, B7 : 800 %!a, P : aa" 'ana!i.

#P# : (a.


4/43

Peme$i%saan &si%K/a,aa+ Umum

K/"a,aa+

TTV

K/8ala

Thoa9

A',om/+

Tam8a# Sa#)t S/,a+(

om8o" !/+t)"

TD - 11:;$: mmH( RR - %:9;m

N - $5 9;m T - 7

!/"o*/8hal

!ata - A 0;0< SI 0;0< RP =;=

S)m/t)"< /ta#") 0;0

Pulmo - V/")#ul/< ho+#) 0;0< 2h//>)+( 0;0

/m'u+( ?=< BU ?=< NT ?0

4atts stet!i B&n% U 2 'a!i $iaah (- )M;D : 28 ;+, P6i,P!es&e(, e" as& P/PD77 : 125-


5/43


6/43

DIaGNOSA

Gast!itis &!nis e- a&t (a$a

G3P2/0 U6 3=35 in%%.


7/43

Te$a'i i)*

In. RL ! -m'

In. Ke-0$0la% 1 am'l

In. On*anen-$0n (K/P


8/43

PASIEN BARU ( !".##

ANA!NESIS -

Pasien : Ny. P6, 33 tahn

K/luha+ Utama -M"esM"es

RPS - Pasien $atan% $en%an &e"han "es"es se'a&(&". 10.00 i )= 'a 4MR4+, "en$i! $a!ah )*+, ai!ai! )+,

%e!a&an 'anin )*+. Pasien en%a& hai" ana& &e ti%a,

Ri.# )+, Ri.DM )+, Ri.a"e!%i )+, Ri.asa)+, U4G

)*+ t%" 3


9/43


K/"a,aa+

TTV

K/8ala

Thoa9

A',om/+

Tam8a# Sa#)t S/,a+(

om8o" !/+t)"

TD - 11:;@: mmH( RR - %:9;m

N - $$ 9;m T - 7)+( 0;0

/m'u+( ?=< BU ?=< NT ?0

4atts stet!i 6sn% U = 'a!i $iaah (- )M;D : 2= ;+D77 : 1=1-


10/43

Peme$i%saan 'enunan)

WBCRBCHGBPLT

13.63 x 10^3/uL4.01 x 10^6/uL12.0 g/dL230.000

GDS!

2" m)/*L0.88 %


11/43

DIaGNOSA

eta& sn%san% (a$a G3P2/0

hai" 38 @ 39 in%% * 7#


12/43

Te$a'i i)*

1. Pa$an-e$al

inus RL 3 4! -'m

Sia'%an 5B 1 %0l

P$0 S6 ele%-i


13/43

PASIEN BARU (4 1.17

ANA!NESIS -

Pasien : Ny. D , 29 tahn

K/luha+ Utama -Pasien !'&an $a!i R4 6a"a &!n $% G=P1/2

U6 3230 in%%, 'anin tn%%a" hi$( ante (a!t * "ee$in%

("asenta (!eia * (e!$a!ahan e!"an% * %aat 'anin

RPS - Pasien $atan% $en%an &e"han (e!$a!ahan se'a& = ha!i ini,

$a!ah se%a! a&tiC)*+, Pasien se$an% hai" ana& &e =. Ge!a&an 'anin

$i!asa&an ti$a& a$a se'a& ta$i (a%i, !i./N )*+ Ri. # )+, Ri.

DM )+, Ri.a"e!%i )+ Ri. O(nae )*+ $en%an (e!$a!ahan, !i.U4G)*+ t%" 2


14/43


K/"a,aa+

TTV

K/8ala

Thoa9

A',om/+

Tam8a# Sa#)t S/,a+(

om8o" !/+t)"

TD - @:;8 mmH( RR - %:9;m

N - : 9;m T - 7

!/"o*/8hal

!ata - A =;=< SI 0;0< RP =;=

S)m/t)"< /ta#") 0;0

Pulmo - V/")#ul/< ho+#) 0;0< 2h//>)+( 0;0

/m'u+( ?=< BU ?=< NT ?0

4atts stet!i B&n%, U = 'a!i $iaah (- )M;D : 2= ;+ P6i ,e" as& P/PD77 : 115-


15/43


WBCRBCHGBPLT

11.68 x 10^3/uL1.76 x 10^6/uL5.3 g/dL183.000

GDS!UR

11# m)/*L0.82 %


16/43

DIaGNOSA

P"asenta (!eia (a$a G=P1/2

U6 32 @ 33 in%%

4y& hi("ei&

/neia


17/43

Te$a'i i)*

1. Pa$an-e$al

inus alu$

8 Na6l I9 %0l

8 5i*ahes ! -'m

8 6e0-a:ime :1 )$ I9 (Lanu- *a$i RS %u$un8 De:ame-as0n 4:1 )$ I9

. D0'amin s' 2 Me;/ %) BB (2!%) / meni-

4. P$0 -$ansusi 5B s' +,


18/43

PASIEN BARU (# 11.=2

ANA!NESIS -

Pasien : Ny. R , =1 tahn

K/luha+ Utama -Os &e'an% 2-

RPS - Pasien $atan% $en%an &e"han &e'an% 2 &a"i$i!ah. Pasien se$an% hai" ana& &e 2. /B)*+ 1-. s

en%a& hai" > "an. Psin% )*+, (an$an%an &a!)+,

Ri. # )+, Ri. DM )+, Ri.a"e!%i )+, Ri. /sa

)+Ri. /N )+, Ri.U4G)+. Os a$a in niCe$i(ine 5

% 'a 0.00 i.

#P# : (a


19/43


K/"a,aa+

TTV

K/8ala

Thoa9

A',om/+

L/mah

om8o" !/+t)"

TD - 1$:;1: mmH( RR - %%9;m

N -: 9;m T - 7

!/"o*/8hal

!ata - A 0;0< SI 0;0< RP =;=

S)m/t)"< /ta#") 0;0

Pulmo - V/")#ul/< ho+#) 0;0< 2h//>)+( 0;0

/m'u+( ?=< BU ?=< NT ?0

4atts stet!i U se(sat )M;D : 2= ;+ P6i , e" as& P/PD77 : 15=-


20/43


WBCRBCHGBPLT

19.21 x 10^3/uL5.32 x 10^6/uL12.3 g/dL300 x 10^3/uL

GDS!

m)/*L0.5= %


21/43

DIaGNOSA

E&e"asia (a$a G2P0/1 U6 >

"an


22/43

Te$a'i i)*

1. in. RL =!! M)SO# 2 )$am (1= 4! -'m

. M)SO# #!C (1! *iene$%an*en)an a;ua*es (1!

4. Ine%si *e:ame-as0n 4 : 1 am'l

P/O 3 Nie*i'ine 4 : 1! m)

D0'ame* 4 : =!! m)

Be-a0ne =m) 1 : 1/#


23/43

PASIEN BARU (= 14.

ANA!NESIS -

Pasien : Ny. 7 , = tahn

K/luha+ Utama -iatia (in%san

RPS -Pasien $atan% $en%an &e"han tiatia (in%san,e!asa e"ayan% )*+, sesa& )+, nye!i $a$a )+,

(e!$a!ahan a%ina )+. Pasien en%a& ei"i&i

!iayat ia te!i se'a& 2 "an yan% "a", $an saat ini

setia( &a"i enst!asi (asien en%a"ai (e!$a!ahan,

setia( &a"i &a"i enst!asi (asien en%%anti (ea"t

"eih $a!i 10 &a"i seha!i.


24/43


K/"a,aa+

TTV

K/8ala

Thoa9

A',om/+

Tam8a# Sa#)t S/,a+(

om8o" !/+t)"

TD - 1:;$: mmH( RR - %:9;m

N - % 9;m T - 7

!/"o*/8hal

!ata - A =;=< SI 0;0< RP =;=S)m/t)"< /ta#") 0;0

Pulmo - V/")#ul/< ho+#) 0;0< 2h//>)+( 0;0

/m'u+( ?=< BU ?=< NT ?0< ma""a ?=

4atts stet!i D77 : -


25/43


WBCRBCHGBPLT

1.82 x 10^3/uL2.17 x 10^6/uL3.9 g/dL6 x 10^3/uL

GDS!

"= m)/*L0.88 %


26/43

DIaGNOSA

4in&(

/neia

Mya Ute!i


27/43

Te$a'i i)*

1. Pa$an-e$al

8 inus Na6l !@ C

8 T$ansusi PR6 %0l/# am sam'ai *en)an

+, 7)/*L8 In. Kalne: 4 :=!! m)

Renana USG Gine%0l0)i ele%-i se-elah KU

mem,ai%.

O,s. Ke-a- -an*a8-an*a 'e$*a$ahan a%-i.


28/43

PASIEN BARU (2 1=.!

ANA!NESIS -

Pasien : Ny. 7M , 23 tahn

K/luha+ Utama -"es"es

RPS - Pasien $atan% $en%an &e"han "es"es

se'a& (&" 12.00 i, D )+, ai!ai! )+, /N )*+,

U4G)+, Ri. /B)+, Ri. #)+, Ri.DM )+, Ri.

4)*+ ana& (e!taa a


29/43


K/"a,aa+

TTV

K/8ala

Thoa9

A',om/+

L/mah

om8o" !/+t)"

TD - 1:;$: mmH( RR - %%9;m

N -$6 9;m T - 7)+( 0;0

/m'u+( ?=< BU ?=< NT ?0

4atts stet!i B&n% U 3 'a!i $iaah (- )M;D : 2= ; + P6a,P!es&e(, as& (int atas (an%%"D77 : 15115= -


30/43


WBCRBCHGBPLT

11.10 x 10^3/uL3.84 x 10^6/uL10.0 g/dL370 x 10^3/uL

GDS!

2# m)/*L0.8> %


31/43

DIaGNOSA

G3P2/0 U6. 3839 in%%

in(a!t &a"a I Case a&tiC * Be&as 4


32/43

Te$a'i i)*

1. Pa$an-e$al

8 Inus RL 3 4! T'm

8 6TG8 O,s 'a$-us 'e$?a)inam


33/43

Tin*a%an i)*

1. 9T am 1=. #! 'em,u%aanlen)%a'

. I,u *i'im'in men)e*an am 12.!= *iIGD@ ,ai se)e$a menan)is A/S 3 7/@,ai 'e$em'uan@ BBL 3 .7!!@ PB 3 #"m@ LK/LD 3 4/44 m.

4. Plasen-a -elah lahi$ '%l. 12.1! i,len)%a' *en)an sela'u-na.


34/43

PASIEN BARU (" 1=.4=

ANA!NESIS -

Pasien : Ny. E4 , 19 tahn

K/luha+ Utama -nye!i (e!t

RPS - Pasien $atan% $en%an &e"han nye!i

(e!t)*+, se'a& ta$i sian%, D )*+, (&" 12.30 i,

ai!ai!)+, Ri./B )+, Ri.# )+, Ri.DM )+,

/N )*+, U4G )+ "an &te!B7 :2800 %,P : 2112015, (asien hai" ana& (e!taa.

#P# : 20022015.


35/43


K/"a,aa+

TTV

K/8ala

Thoa9

A',om/+

L/mah

om8o" !/+t)"

TD - 1%:;$: mmH( RR - %:9;m

N -$$ 9;m T - 7)+( 0;0

/m'u+( ?=< BU ?=< NT ?0

4atts stet!i B&n% U 3 'a!i $iaah (- )M;D : 30 ; + P6i,P!es&e(, as& (int atas (an%%"D77 : 153 -


36/43


WBCRBCHGBPLT

9.48 x 10^3/uL3.92 x 10^6/uL9.9 g/dL310 x 10^3/uL

GDS!

" m)/*L0.90 %


37/43

DIaGNOSA

G1P0/0 U6. =0=1 in%%

in(a!t &a"a I Case "aten


38/43

Te$a'i i)*

1. Pa$an-e$al

8 Inus RL 3 4! T'm

6TG *i$uan)an

P$0 In*u%si 'e$salinan


39/43

PASIEN BARU (7 1!.4

ANA!NESIS -

Pasien : Ny. E M , 33 tahn

K/luha+ Utama -Pasien !'&an $!. 4(. OG $en%an %ae""i

t!i("et

RPS - Pasien $atan% $en%an &e"han ;a(e& 1 "an ini )*+,

"es"es )+, en$i! $a!ah )+, ai!ai! )+, %e!a&an 'anin )*+,

sesa& )*+, (sin% )+, a" )+, nye!i " hati )+, (asien !i. 3

tahn )&ehai"an hasi" (!%!a inseinasi $is!aaya+. U4G

t%" 21


40/43


K/"a,aa+

TTV

K/8ala

Thoa9

A',om/+

Tam8a# "a#)t "/,a+(

om8o" !/+t)"

TD - 1%:;: mmH( RR - %%9;m

N -% 9;m T - 7)+( 0;0

/m'u+( ?=< BU ?=< NT ?0

4atts stet!i B&n% U 2 'a!i $iaah (- )M;D : = ; +, I : P6i, II : P6i, III : P6i, P!es&e(, as& (int atas(an%%"D77 I : 1== -


41/43


WBCRBCHGBPLT

7.41 x 10^3/uL3.70 x 10^6/uL9.2 g/dL318 x 10^3/uL

GDS!

22 m)/*L0.99 %


42/43

DIaGNOSA

G1P0/0 U6. 3>3 in%% *

Gae"i t!i("et


43/43

Te$a'i i)*

1. Pa$an-e$al

8 Inus RL 3 4! T'm

P$0 S6 Bes0%

Laporan Jaga Dokter Muda 29 November 2015

Documents