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7/17/2019 mr ulkus
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LAPORAN JAGA PDW
Tgl 29Juli 2015PPDS Jaga:dr. Adwin Adnandr. Aziz
dr. Karldr. Rid!aluldr. Nadi"#a!Dr. $r%anDr. Andri GunawanDr. Wa!#uni
Dr. &'ndra
Ti( Jaga $GD:1. &ar)una2. $n*an
+aulinar,. -u* +adng. Ki/i R.5. Riz/i +auli
Ti( Jaga PDP:1. a/!rul G.2. -i*ra P.,. Lura N.. Ri*a S.5. $"nanil &.. Ad' P.. K!aliza +.
3. R'ni A.
Ti( Jaga PDP:1. 4z(il Ari%a2. i*ara .,. Riz/ia. Rzalia 6.5. uni*a. D'"i
Ra*na"ari
7/17/2019 mr ulkus
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Na(aPa"i'n
: N#. N
4(ur : 1 *a!un
Ala(a* : La( a*'u/ N. R+ : 979,75
P'(8ia#aa
n
: PJS
$d'n*i*a"
7/17/2019 mr ulkus
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Ana(n'"i"
K'lu!an 4*a(a : D'(a( "')a/ 2 !ariS+RS
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Riwa#a* P'n#a/i* S'/arang
Pa"i'n da*ang d'ngan /'lu!an d'(a( "')a/ 2 !ari S+RSd'(a( dira"a/an *'ru" ('n'ru" dan /adang di"'r*ai ('ngigil.Pa"i'n )uga ('ng'lu!/an n#'ri "'ndi dan "a/i* /';ala *'ru"('n'ru" "';'r*i di*'/an. Pa"i'n )uga ('ngala(i (ual (un*a!"'"'/ali (un*a! 8'ri"i (a/anan dan (inu(an #ang di/("u("i
riwa#a* (un*a! !i*a( *ida/ ada. Riwa#a* 8a*u/ <=> 8'rda!a/ <7>"'"a/ <=> dan n#'ri dada "'8'lu(n#a *ida/ ada. r'/u'n"i AK"'8'lu(n#a 17, /ali?!ari warna /uning @lu(' 1007200 ?AKna(un 2 !ari *'ra/!ir ini ;a"i'n "'ring AK ;ada (ala( !arid'ngan %r'/u'n"i !ingga /ali. N#'ri "aa* AK <7> AK 8'r;a"ir<7>. A dala( 8a*a" nr(al diar' <7> A !i*a( *ida/ ada.
Pa"i'n ('(ili/i lu/a ;ada /a/i /anan dan /irin#a. Lu/a ;ada /a/i/anan "uda! ada "')a/ 2 *a!un #ang lalu a/i8a* *'r/'na duri.S'dang/an lu/a ;ada /a/i "'8'la! /iri "')a/ 2 8ulan #ang lalua/i8a* *'r/'na ;a/u. Lu/a 8'rnana! <=> dan n#'ri <=>. Pa"i'n )uga('ng'lu!/an "uli* 8'r)alan a/i8a* lu/a ;ada /'dua /a/in#a
*'r"'8u*. Pandangan /a8ur <7> /'8a" <7> /'"'(u*an <7>.
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Riwa#a* P'n#a/i* Da!ulu :
Dia8'*'" ('lli*u" "')a/ 1, *a!un #ang lalu/n*rl ru*in di ;li 'nd/rin RS4D6A "')a/ 2
*a!un #ang lalu. Riwa#a* /'l'(a!an angg*a g'ra/ a*a" /anan
"')a/ , 8ulan #ang lalu
&i;'r*'n"i <7>
Riwa#a* P'nggunaan O8a* :
$n"ulin n@ra;id 20720720 dan l'@'(ir 07070720 iu
Ga8a;'n*in
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Riwayat Penyakit Keluarga : &';a*i*i" &i;'r*'n"i D+ <=> a"(a al'rgi
"a/i* )an*ung *ida/ ada
Riwayat Sosial Ekonomi dan Kebiasaan : P'/'r)aan "'rang i8u ru(a! *angga
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P'('ri/"aan i"i/
K'adaan u(u( : *a(;a/ "a/i* "'dang
K'"adaran : (;" ('n*i"
TD 120?0 ((&g ND 3 B?('ni* r'gul'r i"i u/u; /ua*ang/a*
RR 2 B?('ni* T: ,3 C-
: 52 /g T: 155 ( $+T: 21 /g?(2 <nr(w'ig!*>
Kuli* : Saw (a*ang *urgr /'(8ali ';a*
K';ala : D'%r(i*a" <7>
Ra(8u* : !i*a( *ida/ (uda! dia8u*
+a*a : /n)ung*i@a ;al;'8ra in%'rir ;ua* <=?=>
"/l'ra i/*'ri/ 7?7
T?&?+ : dala( 8a*a" nr(al
L'!'r : JP R72 (&2O ;'(8'"aran KG <7>
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P'('ri/"aan i"i/
Jan*ung:
$ : i/*u" /rdi" *ida/ *'rli!a*
P: i/*u" /rdi" *'ra8a di 1 )ari ('dial $-S 5 lin'a (id la@iula
P: a*a" : 8a*a" a*a" )an*ung ;ada i" , (idla@iula "ini"*ra
Ka: 8a*a" )an*ung /anan ;ada $-S 5 Lin'a Para"*'rnal d'B*ra Ki : 8a*a" )an*ung /iri ;ada $S 5 lin'a (id la@iula "ini"*ra
A: un#i )an*ung $7$$ r'gul'r gall; <7> 8i"ing "i"*li/ <7>
Paru7;aru:$ : G'ra/an dada "i('*ri" ;ada "*a*i" dan dina(i"
P: %r'(i*u" ('ning/a* /'dua la;angan ;aru
P: "nr ('('nd'/ ;ada 1?, la;angan ;aru 8awa! "ini"*ra
A : '"i/ular rn/!i 8a"a! di 1?, 8awa! la;angan ;aru 8awa! "ini"*ra
<=?=> w!''zing <7?7>
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P'('ri/"aan i"i/
A8d('n:
$ : di"*'n"i <7>
P : "';'l &a*i?li'n? !';ar *a/ *'ra8a
P : *i(;ani <=> "!i%*ing duln'"" <7>A : i"ing u"u" <=> /'"an nr(al
F/"*'r(i*a":
lu/a ;ada '/*r'(i*a" 8awa! r'gin ;'di"d'B*ra "ini"*ra.
;ua* <7> 'd'(a <7> (*ri/ <5757575>. A$d'B*ra 120?125 09 A$ "ini"*ra 125?120 10
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P'('ri/"aan P'nun)ang
Laboratorium (30-7-20!"
&8 : 3, g?dl
&* : 25 H
Fri*r"i* : ,,00.000?((,
L'u/"i* : 1.00 ?((,
Tr(8"i* : ,03.000?((,
Na : 1,0((l?L
K : , ((l?L
-l : 93 ((l?L
KGDS : 22 (g?dL
diI*'l : 0?0?5?1?3
LA $PD <,0??2015>
iliru8in : n'ga*i%
Pr*'inuria : =2
4r8iling'n : n'ga*i%
R'du/"i : =1
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Da%*ar +a"ala! :
1. S';"i" ' dd
1. 4l/u" dia8'*i/u( a?r P'di"
,. -AP
2. 4l/u" Dia8'*i/u(?r ;'di" d'/"*ra "ini"*ra,. D+ *i;' 2 nr(w'ig!*
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#asala$ Pengka%ian Ren&ana'iagnosis
Ren&anaatalaksana
) Se*sis e&dd +lkusdiabetikum
a,r Pedis
2) +lkusdiabetikuma,r *edisdetra
sinistra
"? d'(a( 2 !ari #ang lalulu/a ;ada /'dua /a/i
? l'u/"i* 1.00 ?((
S? : *'rda;a* lu/a di /a/i/anan dan /iri ;a"i'n.
lu/a #ang "uli* "'(8u!
La8 : GDS : 22 (g?dl
-- r'a/*i%;r*'in
-Pral"i*nin
- /ul*ur ;u"-STA
-Dara! Ru*in- Rn*g'n;'di"
era*i.armakologis- / &e.triaone /
gr,2 %am- Para&etamoldri* , 2 %am
era*i non.armakologis :
7Tira! 8aring7rawa* lu/a? !ari
era*i.armakologis :$@ l'@BaBin 500(g?2 )a(
Edukasi• +'n)'la"/an
/';ada ;a"i'nr'nana;'('ri/"aan
"'lan)u*n#a• +'n)'la"/an ;ada
#asala$ Pengka%ian Ren&ana Ren&ana atalaksana
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#asala$ Pengka%ian Ren&ana'iagnosis
Ren&ana atalaksana
2. D+ *i;' 2nr(w'ig!*
S? 7 ;a"i'n ('ng'lu!/an "'ring AK;ada (ala( !ari
7 Riwa#a* /'luarga D+ <=> 7 +'(ili/i riwa#a* D+ "')a/ 1,
*a!un #ang lalu
O? ;'('ri/"aan "i/ : : 52 /g T:155 ( $+T: 21 /g?(2 <nr(w'ig!*>
KGDS : 22 (g?dl
-P'ri/"a KGDS2 PP- *!ra/"-undu"/;i-4rinali"a
-&8A1-
era*i non.armakologis:'iet '# 700 kkal
1arrmakologi :
S l'@'(ir 07070711S n'@ra;id 77
#onitoring7 KGDS
Edukasi7('n)aga ;la (a/an
7Ola!raga "'ara *'ra*ur