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LAPORAN JAGA IGD

KAMIS, 14/04/2016SUPERVISOR JAGA:dr. Lenny Sihotn!, S"PD

TIM JAGA:

dr. #rdi, dr. $ithri, dr. Ihd, dr. #ryndi, dr. $%&i

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Daftar Pasien MasukNo Nama/ JK/

Umur

Dianosis Ruanan DPJP

1 #r"n'i((%r

Li)er *'e' dd he"to( +hi"o*%(ine(i

RA2II.-.1

Dr. rn'i'%',S"PD

2 M%i* eendi PSM e )rie' *eedin! R-II.-.2

Dr. Leonrdo. Diri,

S"PDKG3#

- John#%t&%%

PSMA e er *eedin! +#i"o*%(ine(i + Go%t Artriti'

RA- II.2 Dr. Leonrdo. Diri,S"PDKG3#

4 A*di(n

'i(!%n!'on!

Pne%(oni 5#AP +D( ti"e 2 1.2.1 Dr. A7in'yh,

S"PD

8 9ern! *rtri!n

:KD 't!e ; e #N RA1III.2.4

Dr. &o'i!intin!, S"PD

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No Nama/ JK/Umur

Dianosis Ruanan DPJP

6 In!nt *r"%r*

%' "e"ti%( + "o't dehidr'i*ert

RA1III.2.6

Dr. &o'i,S"PD

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!AKTU /JAM KEGIATAN URAIAN

P'ien diteri( diIGD

Di"akukan Primar# sur$e#

Air7y 5A < e*'rethin! 5 < '"ontn 24=/(enit:ir%tion 5: < ndi 100=/(enit re!%r

i'i %%" 9D >0/?0((#!Di'*ity < G:S 18534;8M6

3="o'%re < -6,2 :

(e(*%t "er(intn *ortori%( dn @ry 9or' PA, 3KG

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ID3N9I9AS PASI3N

N( < 9n.

(%r < -6 th%n

No. RM < 6?.26.24

A(t < &n. A'hn

K( I;

Stt%' < *e%(

Menih

Pe(*yrn < JKN

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ANAMN3SIS

Ke"u%an Utama: men&ret

9eh<

# ini di(i o' 'e& - *%n ini, (enret *er'it hIn! ti(*%,

tet"i d( 1 *%n ini (enret (en&di ter%' (ener%' den!n

re%en'i 48=/hri, ir B ("'. Lendir 5, drh 5

M% 5+, (%nth 5, nyeri "er%t 5, "en%r%nn n'% (n 5+.

*t% 5+, *erdh 5+, dh *er7rn "%tih, h ini di(i o' 2

*%n ini, ri7yt *t% drh 5, 'e' n"' 5, ri7yt "e(in

OA9 5+ d( 1 (in!!% ini, n(%n o*t dihentin d( 2 hri ini

ri7yt de(( 5+, di(i o' 2 *%n ini, de(( *er'it hin!

ti(*% dn t%r%n den!n o*t "en%r%n "n', ri7yt erin!t

(( 5+

"en%r%nn di&%("i e*ih %rn! 20 ! d( - *%n ini.

ri7yt A hit( 5+, di(i o' 2 *%n yn! %, tet"i 't ini

'%dh tid !i.

ri7yt 'e' *e*' di'n!, ttoo tid di&%("i, ri7yt

"e(in nro* &eni' '%nti di'n!.

ri7yt DM di'n!, #9 di'n!, AK 5+ N,

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ANAMN3SIS

RP9 <

RPO < OA9

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!AKTU/JAM

KEGIATAN URAIAN

Se&on'ar# Sur$e#Pe(eri'n $i'i:M, Ndi 100=/(enit, re!%er, %t t/) %%", RR24=/(enit, 9D 110/?0((#!, te(" -6,80:

K%it < d( *t' nor(, t%r!or *i

Ke" < tid d deor(it'R(*%t < hit(, tid (%dh di*%tMt < on&%n!ti) ""e*r "%t 5/, 'eriteri 5/, e%n! 59ein! < d( *t' nor(#id%n! < d( *t' nor(M%%t < or %er 5, idh erin! 5Leher < J;P R2 ( #2O, tid ter* KG

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!AKTU KEGIATAN URAIAN

Da'a < 'i(etri', 'tti', din(i'.Jantun < In'"e'i < it%' ordi' tid teriht

P"'i < it%' ordi' ter* di I:S ; LM:S Per%'i < *t' &nt%n! iri 1 ( ter LM:S I:S;;I A%'%t'i < *%nyi &nt%n! 1 dn 2 re!%er, (%r(%r dn!o" tid dParu<in'"e'i < 'i(etri' nn dn iri

""'i < 'te( re(it%' nn '( den!n iri, e'n (en!er' "er%'i < 'onor (en!er' "d ed% "n!n "r% %'%t'i < SP< *roni 'e%r%h "n!n "r% S9< roni *'h di 'e%r%h "n!n "r%A('omen< in'"e'i < 'i(etri'

""'i < 'oe"e, he"r, ien C ren tid ter*"er%'i < 'hitin! d%ne'' 5, ti("ni %'%t'i< "eri'tti (enin!tEkstremitas <S%"erior < ede( /Inerior< ede( /

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$O9O9ORAKS

)oto t%ora* PA Ere&t

9re di (edi

Ked% '%d%t o'to

"hreni%' ni",

tert%t%" &rin!n *re't

9id t(" initrt di

ed% "n!n "r%.

:9R r'io 80 E

Ke'n< 9 "r%

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SG ADOM3N

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SG ADOM3N

Kesan : %ati +

a""("a''er+ in,a"+

s-"een 'a"am (atas

norma"

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3KG

Ir( < Sin%' rit(e

FRS rte 100=/(enit

Ge. P 5+

PR int. 0,16 'e

Nor(o=i'

FRS d%r. 0,06 'e

S99 hn!e' 5, 9 t 5

Ke'n < 'in%' tirdi

!AKTU/JAM KEGIATAN URAIAN

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!AKTU/JAM KEGIATAN URAIAN

.A RSUP0AM#*/L/9r < 11+2 / 11+334 / 5678444M:;/M:#/M:#:< 34 / 99+ / -2,8Dite< ENe%/Li(/Mon/3o'/' < 6,-/,?/4,4/0,10/0,80

N < 18re%( < -2:retinin < 1,2

Ntri%( < 195 O'(orit' < 2--Ki%( < 2,-Korid < 100

KGD d rndo( < 6 (!/d A*%(in < 1+5R'io P9/P99/99 < 8,>0 / 1,?0 / 1,-1

AGDA < "# ?,4- / ":O2 28 / "O2 1-- / #:O- 16,6 /9:O2 1?,4 / 3 6,1 / St.O2 >>E

Anti #I; < non reti

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NO MASA.A0 PENGKAJIAN INSTRUKSI TARGET DANMONITORING

1 Dire roniDehidr'i

rin!n'edn!

An(ne'eMenret 'e& -

*%n ini, re%en'i 48=/hri, ir B ("'.M% 5+, "en%r%nnn'% (n5+."en%r%nn *ert*dn 5+,ri7yt 9"r% 5+,

9D >0/?0 ((h! A*do(en < "eri'tti(enin!t

D"t di"iirn<:oiti' 9:oiti' %erti

: oon

Renndi!no'ti<

ee' r%tin Drh '(r Koono'o"i

Renn ter"i < 9irh *rin!

I;$D N 0,> Eor 1 ''en&%tny -0 !tt/ine7 dit* t* 2t* "ert('en%tny 1t*/(enret

Kini'*ortori%(

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2 9 "r%den!n

'e%nderine'i

*t% 5+, *erdh5+, dh *er7rn

"%tih, - *%n"e(in OA9 5+

Pen%r%nn *ert*dn 5+ erin!t(( 5+ de((di(i e*ih %rn!

2 *%n ini tidter% tin!!i. O''e*e%(ny '%dh(n OA9 'e(1 (in!!% n(%ndihentin d( 2

(in!!% ini.'e*e%(ny o' '%dh(end"t in&etri=one di RS%r

.

Renndi!no'ti<

K%t%r '"%t%(/'t,9A DS -=

Renn ther"i <in&. :eot=i(e 1!r(/&(OA9 din&%tn.

A(*ro=o -= :I

Kini'L*ortori%(

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NO MASA.A0 PENGKAJIAN INSTRUKSI TARGETDANMONITORING

- "o'tPSMA

Pe(er'n i'i

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4 #i"o*%(in M% 5+ (%nth 5+'e& 1 (in!!% ini.

Pen%r%nn n'%(n 5+

L* < A*%(in < 1,8

Renn ter"i <Diet tin!!i "rotein

'%*tit%'i *%(in1 '/hriRenndi!no'ti<:e *%(in "o't'%*tit%'i

L*ortori%(

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8 #i"ontre(i#i"oo'(or

M% 5+,Menret 5+,re 48=/hri

9id 'eer (n5+Sen'< :ML* <N < 128

D"t di"iirn#i"ontre(i

hi"oo'(orhi"o)oe(i

Renn ter"i < I;$D N: 0,>E

20 !tt/IK"'% !r( -=1Renndi!no'ti<3etroit %n!

L*ortori%(

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TERIMA

KASIH

Documents

Morpot 14042016