Lapjag 14maret Deza Nova Fathan

8/16/2019 Lapjag 14maret Deza Nova Fathan

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LAPORAN JAGA MINGGU , 13 MARET 2016A. Deza FaristaFatha I!tihaz"#iN$%a A &&ar


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+ANAMNE'I'

+e "ha "ta(a ) N-eri a#a /ari (a is ta &ase e ah iri se/a /a( 'MR'

+e "ha ta( aha ) *


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+RI A4AT PEN4A+IT 'E+ARANG

Pasie #ata & e IGD R'. P$ ri #e &a e "ha -eri a#a /ari(a is ta &a iri se/a /a( 'MR'. N-eri #ise a a ter e a&ear se e#a ($t$r. A5a -a asie se#a & (e &e #araise e#a ($t$r #a (e i tasi &e a &a air se a /a & 20 (eter,a i at ter e a &e a &a ($t$r asie hi a & esei( a &a#a a hir -a ter/at"h. La " asie (e a /"t a er/a a a ,saat i &i (e(i #ah a &i&i ($t$r ter -ata erse e i & -a

atah, e("#ia ta &a iri asie (e $ a " t"(e(i #ah a &i&i #e &a ta &a -a. Ter -ata -a &

ter e&a & $ eh ta &a asie &ear ($t$r -a. Pasie (e &a "sa ah sat" /ari -a ter e a "tara &ear, e("#ia asie(e ari ert$ $ &a a " #i a5a e r"(ah sa it #aerah

i i $ &, a(" are a !asi itas ti#a (e(a#ai asie #i a5ae R' POLRI


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+RI A4AT PEN4A+IT DA7ULU

Ri5a-at 7i erte si 8*9

Ri5a-at Dia etes 8*9

Ri5a-at A er&i 8*9


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+PRIMAR4 'UR:E4

A ) ; ear

< ) a/" a!as 21 =>(e it, er&era a th$ra= si(etris

; ) a/" a#i ?0 =>(e it, TD 110>@0 ((7&

D ) G;' 1 8E M6 : 9

E ) *


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+'E;ONDAR4 'UR:E4

A) *M) *

P) *L) *E) *

7


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+'TATU' GEENRALI'

+ea#aa "("( ) Ta( a esa ita

+esa#ara ) ;$( $s Me tis

TT:

Te a a Darah ) 110>@0 ((7&

La/" Na#i ) ?0=>(e it

La/" Na as ) 21=>(e it

'"h" ) 36.@ 0 ;


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+PEMERI+'AAN FI'I+

Kepala ) N$r($ e ha

Mata ) ;A *>*, 'I *>*, " "ra " i B 3 ((>3((, is$ $r, reCe s aha-a >

Leher ) Pe( esara +G< 8*9


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+PEMERI+'AAN FI'I+

Thoraks (pulmo)I ) Per&era a #a#a si(etris #a a( ea#aa statis #a#i a(is

P ) Fre(it"s ta t #a !re(it"s %$ a si(etris i ateraP ) '$ $r a#a e#"a a a & ar"A ) :es > , Rh *>*, h *>*

;$r )


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+PEMERI+'AAN FI'I+

AbdomenI ) #atar, (assa 8*9, esi 8*9, hi ere(is 8*9

P) -eri te a 8*9, (assa 8*9P) ti( a i a#a e* "a#raA) isi & "s"s 8 9

Ektremitas ) A ra ha &at, ;RT 2 #eti


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+'tat"s L$ a is Re&i$ Ma "s

'i istra L O O + • " 1 a t e r 0 " 1 a 8 D 9 0 e t " 1 t i # a 1 0 e r a t " r a , t e i

t i # a 1 r a t a , # a s a r $ t $ t , e r # a r a h a a 1 t i ! 8 D 9 a # a s e 1 i t a r # i & i t i I : , # e ! $ r ( i t a s 8 D 9 5 a r a 1 e ( e r a h a .

F E E L • N - e r i t e 1 a 8 D 9 , a r t e r i r a # i a i s # a " a r i s

t e r a 0 a , a 1 r a h a & a t 8 D 9 ; R T 2 # e t i 1 .

M O : E • P e r & e r a 1 a s e # i s e 6 a r a a s i ! a # a e 1 s t r e ( i t a s

- a & t e r " 1 a t e r 0 a t a s 1 a r e a - e r i , 1 r e i t a s i 8 * 9 .


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+DIAGNO'I'

Fra t"r ter " a ha a & #ista #i&iti I: (a "s si istra&ra#e 3


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+ TATALA+'ANA

+$ s" #r. ;ar es ' ' .OTRe a a $ erasi ;it$ es$ " " 0@,00

I:FD RL 20 t (I /. ;e!tria=$ e 1 = 2 &r

I /. +et$r$ a 2 = 1 a(

I /. Ra iti#i 2 = 1 a(

;e a e & a ) 72TL, UR>;R, 'GOT>PT, ;T>


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+IDENTITA'

Na(a ) A . F

Usia ) 16 tah"

R"a &a ) *


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+ANAMNE'I'

+e "ha "ta(a ) N-eri a#a /ari te &ah ta &a irise/a 2 /a( 'MR'.

+e "ha ta( aha ) *


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Pasie #ata & e IGD R'. P$ ri #e &a e "ha -eri a#a /arite &ah ta &a se e ah iri 2 /a( 'MR'. N-eri #irasa a a i at

e e a aa a " i tas. A5a -a asie se#a & (e &e #araise e#a ($t$r, a " terse &&$ ($t$r #ari e a a & e("#ia

asie ter/at"h. Pasie ti#a i &at a&ai(a a $sisi /at"h -a,a " asie #it$ $ & #a #i a5a e R' POLRI. +ehi a &aesa#ara , ("a (" tah #isa & a asie .


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Ri5a-at A er&i 8*9


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+PRIMAR4 'UR:E4

A ) ; ear

< ) a/" a!as 22 =>(e it, er&era a th$ra= si(etris

; ) a/" a#i ?6 =>(e it, TD 120> 0 ((7&

D ) G;' 1 8E M6 : 9

E ) *


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+'E;ONDAR4 'UR:E4

A) *M)*

P) *L) *E) *

21


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+'TATU' GEENRALI'



TT:

Te a a Darah ) 120> 0 ((7&

La/" Na#i ) ?6=>(e it


'"h" ) 36. 0 ;


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+PEMERI+'AAN FI'I+

Kepala ) N$r($ e ha




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+PEMERI+'AAN FI'I+



;$r )


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+'tat"s L$ a is Re&i$ Ma "s'i istra

L O O + • " 1 a t e r 0 " 1 a 8 D 9 0 e t " 1 t i # a 1 0 e r a t " r a , t e i t i # a 1 r a t a , s e 0 a & i a " 1 a # e & a # a s a r t " a & , e r # a r a h a a 1 t i ! 8 D 9 a # a s e 1 i t a r # i & i t i I I I , # e ! $ r ( i t a s 8 D 9 , 0 e & 1 a 1 8 D 9 .

F E E L • N - e r i t e 1 a 8 D 9 , a r t e r i r a # i a i s # a " a r i s t e r a 0 a ,

a 1 r a h a & a t 8 D 9 ; R T 2 # e t i 1 .

M O : E • P e r & e r a 1 a s e # i s e 6 a r a a 1 t i ! a # a e 1 s t r e ( i t a s

- a & t e r " 1 a t e r 0 a t a s 1 a r e a - e r i , 1 r e i t a s i 8 * 9 .


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+DIAGNO'I'

Fra t"r ter " a ha a & #ista #i&iti III (a "s si istra&ra#e 3


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+ TATALA+'ANA

+$ s" #r. ;ar es ' ' .OTRe a a $ erasi ;it$ es$ " " 0@,00

I:FD RL 20 t (I /. ;e!tria=$ e 1 = 2 &r

I /. +et$r$ a 2 = 1 a(

I /. Ra iti#i 2 = 1 a(

;e a e & a ) 72TL, UR>;R, 'GOT>PT, ;T>


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+IDENTITA'

Na(a ) A . AA

Usia ) 13 tah"

R"a &a ) *


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+ANAMNE'I'

+e "ha "ta(a ) N-eri a#a a i a a #a iri se/a2 /a( 'MR'

+e "ha ta( aha ) *


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Pasie #ata & e IGD R'. P$ ri #e &a e "ha -eri a#a a ia a #a iri 2 /a( 'MR'. N-eri #ia i at a are a terti( a

r" t"ha te( $ e( atas a a &a . A5a -a asie se#a &er(ai $ a #i a a &a , a " $ a terte #a & e "ar a a &a ,

e("#ia asie i &i (e &a( i $ a terse "t #a (e(a /ata&ar e( atas a a &a . Ti a*ti a te( $ terse "t r" t"h

#a (e i( a e#"a a i asie . 'aat e/a#ia asie (asihsa#ar a #iri, e("#ia #it$ $ & $ eh te(a te(a -a #a#ia tar er"(ah -a. 'esa( ai -a #ir"(ah a i asie

#i a "ri ra i a eras e "r $ eh i " -a e("#ia #i a5a ei i #a #i eri $ at a ti -eri. La " asie #ir"/" e R'POLRI. Ri5a-at i &sa , ("a (" tah #isa & a .


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Ri5a-at A er&i 8*9


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+'E;ONDAR4 'UR:E4

A) *M) A a &eti .P) *L) *E) *

36


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+'TATU' GEENRALI'



TT:

Te a a Darah ) 120>@0 ((7&

La/" Na#i ) 0=>(e it


'"h" ) 36 0 ;


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+PEMERI+'AAN FI'I+

Kepala ) N$r($ e ha




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+PEMERI+'AAN FI'I+



;$r )


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+PEMERI+'AAN FI'I+

AbdomenI ) #atar, (assa 8*9, esi 8*9, hi ere(is 8*9

P) -eri te a 8*9, (assa 8*9P) ti( a i a#a e* "a#raA) isi & "s"s 8 9

Ektremitas ) A ra ha &at, ;RT 2 #eti


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+'tat"s L$ a is Re&i$ Pe#isDe=tra

L O O + • 3 a r a 1 " i t ( e r a h 1 e 0 i r " a , 0 e & 1 a 1 8 D 9 h e ( a t $ ( 8 D 9 e r # a r a h a a 1 t i ! 8 * 9 # e ! $ r ( i t a s 8 * 9 .

F E E L • N - e r i t e 1 a 8 D 9 , a r t e r i # $ r s a i s e # i s # a t i 0 i a i s $ s t e r i $ r t e r a 0 a , a 1 r a h a & a t 8 D 9 ; R T 2 # e t i 1 .

M O : E • P e r & e r a 1 a s e # i s e 6 a r a a 1 t i ! a # a e 1 s t r e ( i t a s - a & t e r " 1 a t e r 0 a t a s 1 a r e a - e r i , a s i e h a - a # a a t ( e a 1 " 1 a a t a r C e 1 s i , 1 r e i t a s i 8 * 9 .


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+'tat"s L$ a is Re&i$ Pe#is'i istra

L O O + • 3 a r a 1 " i t ( e r a h 1 e 0 i r " a , 0 e & 1 a 1 8 D 9 h e ( a t $ ( 8 D 9 e r # a r a h a a 1 t i ! 8 * 9 # e ! $ r ( i t a s 8 * 9 .

F E E L • N - e r i t e 1 a 8 D 9 , a r t e r i # $ r s a i s e # i s # a t i 0 i a i s $ s t e r i $ r t e r a 0 a , a 1 r a h a & a t 8 D 9 ; R T 2 # e t i 1 .

M O : E • P e r & e r a 1 a s e # i s e 6 a r a a 1 t i ! a # a e 1 s t r e ( i t a s - a & t e r " 1 a t e r 0 a t a s 1 a r e a - e r i , 1 r e i t a s i 8 * 9 .


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+Pe(eri saa

e " /a &

Pemeriksaan Hasil NilaiRujukan

atuan

7e($& $ i 13 13*16 &>#

Le" $sit 1?.100 .000*10.000 ">

7e(at$ rit 3? 0* ?

Tr$( $sit [email protected] 1 0.000*00.000

>"

Eritr$sit ,23 , H , J"ta>"


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+DIAGNO'I'

Fra t"r tert"t" ha a & r$ si(a #i&iti I, II, III, I:e#is #e=tra

Fra t"r tert"t" ha a & r$ si(a #i&iti I e#issi istra

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Lapjag 14maret Deza Nova Fathan