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7/23/2019 LAPORAN JAGA 01 DES 2015 (Ileus Obstruktif)
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LAPORAN JAGA
TANGGAL 01 DESEMBER 2015
Disusun oleh:
Astri Flun
Asri Ali!
7/23/2019 LAPORAN JAGA 01 DES 2015 (Ileus Obstruktif)
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" #$ #%entits
" N& : Tn$ S
" 'si : (2 Thun
" Run)n : *en%n ##
7/23/2019 LAPORAN JAGA 01 DES 2015 (Ileus Obstruktif)
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" An&nesis se+r uton&nesis ,% tn))l
0-.12.2015 ,u/ul 1($-0 #B$
"eluhn 't& : Perut /e&un) se3/ 5 hri 4n) llu$
" eluhn T&hn:
7/23/2019 LAPORAN JAGA 01 DES 2015 (Ileus Obstruktif)
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RPS :
" Psien %tn) %en)n /eluhn ,erut /e&un) se3/ 5hri 4n) llu %ii/uti rs n4eri ,% ulu hti n4eri se,erti
%itusu/6tusu/ %n n4eri %irs/n hiln) ti&ul n4eri is
&en3lr /e ,erut /nn %n /iri ts$ Psien &en)/u
se&en3/ ,erutn4 /e&un) i &ers &ul %n &unth758 erisi +irn enin) %rh 96 %l& /urun ;/tu 2(
3&$
" Psien 3u) ti%/ is un) n)in %n BAB se3/ 5 hri
4n) llu$ N&un st %i RS$Polri setelh ,sien%ieri/n !leet ene& ,sien BAB +ir ;rn hit& 18$
7/23/2019 LAPORAN JAGA 01 DES 2015 (Ileus Obstruktif)
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" 2 hri SMRS ,sien erot /e /lini/ 2( 3& %n
%ieri/n &etroni%<ole %n ,ro&) n&un ti%/ %
,eri/n llu ,sien /e #GD RS$Polri
" BA nor&l !re/uensi (658 sehri %rh 96
" St %i RS$Polri ,sien %i,sn) NGT +irn er;rn
hi3u /e+o/ltn = 500++$ >ri r;t /e - %i RS$Polri
,sien &en)eluh/n ses/ n!s %n %e&& suhu
%iu/ur -?@ +⁰
7/23/2019 LAPORAN JAGA 01 DES 2015 (Ileus Obstruktif)
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" RPD
" >i,ertensi %isn)/l
" Dietes &elitus %isn)/l
" Aller)i %isn)/l
" Ri;4t tru& ,% ,erut %isn)/l
7/23/2019 LAPORAN JAGA 01 DES 2015 (Ileus Obstruktif)
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Pe&eri/sn Fisi/
" ' : T&,/ s/it se%n)
" es%rn : *o&,os &entis
" TT
" TD : 1(0.@0 &&>)" N : @58 .&enit
" RR : 228 .&enit
" Suhu : -5 *
7/23/2019 LAPORAN JAGA 01 DES 2015 (Ileus Obstruktif)
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Sttus Generlis
" e,l : %e!or&its 96 nor&o+he,li
" Mt : on3un)tiC Ane&is 96.6 S/ler #/teri/ 96.6
" Leher : Pe&esrn GB 96
" Thor8
" Pul&o# : ,er)er/n %% si&etris %l& /e%n sttis %n %in&is$
P : !re&itus t/til Co/l si&etris ilterl
P : sonor ,% /e%u l,n) ,ru
A : sur n!s Cesi/uler Rhon+i 6.6 ;hee<in) 6.6
" *or : s1s2 re)uler )llo, 96 &ur&ur 96
7/23/2019 LAPORAN JAGA 01 DES 2015 (Ileus Obstruktif)
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" A%o&en# : Distensi si/tri/ 96 %r& +ontour 96 %r& stei!un) 96
P: NT 9 R' %n L' %e!ns &us/ulr 96 &ss 96
P: N 9 R' %n L' hi,erti&,ni %i /e ( /u%rn %o&en
A: B' 9 le&h &etli+ soun% 96
" E8tre&its : /rl hn)t *RT 2 %eti/
7/23/2019 LAPORAN JAGA 01 DES 2015 (Ileus Obstruktif)
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7/23/2019 LAPORAN JAGA 01 DES 2015 (Ileus Obstruktif)
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Re+tl tou+her
" Tonus s,hin+ter ni i/
" A&,ull re+ti ti%/ /ol,s
" Mu/os li+in
" Mss 96" N4eri te/n 96
" Prostt : rh 3& 12 /onsistensi /en4l ,er&u/n
rt ,ole ts ter sul+us &e%inus ter$
" >n%s+oen: !eses 9 %rh 96 len%ir 96
7/23/2019 LAPORAN JAGA 01 DES 2015 (Ileus Obstruktif)
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T)l 01.12. 2015riel Te&un Nili Nor&l
>e&tolo)i
> 1$1).%l 1261( ).%l
Leu/osit 15$000 u.l 5000610$000 u.l
>t (5H -?6(-H
Tro&osit 2I-$000 .ul 150$0006(00$000.ul
i&i lini/
Ntriu& 1-5 1-561(5 &&ol .l
liu& -I -$@ 5$0 &&ol . l
*hlori% 102 I@ 10 &&ol . l
GDS 125
7/23/2019 LAPORAN JAGA 01 DES 2015 (Ileus Obstruktif)
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T)l 0-.12.2015
riel Te&un Nili Nor&l
>e&tolo)i
> 15$).%l 1261( ).%l
Leu/osit 10$@00 u.l 5000610$000 u.l
>t (H -?6(-H
Tro&osit 2(@$000 .ul 150$0006
(00$000.ul
riel Te&un Nili Nor&l
SGOT 1?$0 -? '.L
SGPT 10$@ (0 '.L
*holestrol totl 1-5 200 &).%l
tri)liseri% @- 200 &).%l
Renl Fun)si test
'reu& (1 10650 &).%l
*retinin 1$0 05 15 &).%l
As& urt 5$- -( ?0 &).%l
7/23/2019 LAPORAN JAGA 01 DES 2015 (Ileus Obstruktif)
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T)l 0-.12.2015
ANALISA GAS
DARAH
,> ?- ?-5 ?(5
,*O2 2I -5 -(&&>)
Po2 I0 @5 I5 &&>)
O2 stursi I? @5 I5H
>*O- 1 21 25 &&ol.L
Bse E8+ess 6? 62 6 25 &&ol.L
SB* 1I 22 2 &&ol.L
Totl *O2 1? 21 2? &&ol.L
SBE 6@ 62( 6 2- &&ol.L
7/23/2019 LAPORAN JAGA 01 DES 2015 (Ileus Obstruktif)
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7/23/2019 LAPORAN JAGA 01 DES 2015 (Ileus Obstruktif)
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7/23/2019 LAPORAN JAGA 01 DES 2015 (Ileus Obstruktif)
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esn :
" G&rn &ss %uo%enu&
" Diltsi usus esr %n usus /e+il s&,i /e%istl %n
%iserti ,en4e&,itn %erh re+tu& 9+olitis
7/23/2019 LAPORAN JAGA 01 DES 2015 (Ileus Obstruktif)
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Di)nosis
" Prtil ileus ostru/ti! e$+ &ss %uo%enu&
7/23/2019 LAPORAN JAGA 01 DES 2015 (Ileus Obstruktif)
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Pentl/snn
" onsul %r$it S,$B
" Psn) NGT %n ,us
" #FD RL : A&ino!lui% K 2 : 1
" #n3 +e!tri8one 1 8 2)r
" #n3 on%nsentron 9/.,