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LAPORAN JAGA JUMAT, 23 OKTOBER 2015

M/Pr/50th

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Anamnesis

Keluhan utama N!e"i #a$a #e"ut %anan &a'ah

 Telaah (al ini $ialami )s 1 ha"i *MR*+ N!e"i$i"asa%an te"usmene"us $an sema%in n!e"i -i%a&e".e"a%+ A'aln!a n!e"i $i"asa%an #a$a ulu hati

%emu$ian n!e"i &e"#in$ah %e #e"ut %anan &a'ah+/emam , mual , muntah , #enu"unan nasuma%an , #e"ut %em&un. ,BAB , BAKn)"mal+Ri'a!at si%lus hai$ n)"mal+

RPT ti$a% $i-um#ai

RPO ti$a% -elas

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Status Present

*ens)"ium 4M

 T/ 13060 mm(.

(R 70 819RR 20 819

 Tem# 3:,6;4

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*tatus Gene"alisata Ke#ala

  Mata 4)n-+Pal#+<n Anemis , R4 ,*%le"a <%te"i%

  (i$un. Ti$a% $i-um#ai %elainan  Mulut  Ti$a% $i-um#ai %elainan

Lehe" Ti$a% $i-um#ai %elainan  Th)"a%s Ti$a% $i-um#ai %elainan

A&$)men  Inspeksi : Simetris, Distensi(-)  Palpasi : Soepel,Nyeri (+) i M!"urney Point,

#o$sin% si%n(+)  Perkusi : &impani  'uskultasi : Peristaltik (+)Normal

E%st"emitas atas Ti$a% $i-um#ai %elainan E%st"emitas &a'ah Ti$a% $i-um#ai %elainan Genitalia Te"#asan. %atete", UO =500>> 'a"na

%unin.

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/RE

- Pe"ineum &iasa, T*A %etat, Mu%)sa li>in, N!e"i$ia"ah -am 11 ? 12, Am#ula "e>ti &e"isi e>es

-

(an$s>))n e>es,$a"ah,len$i"

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@)t) Klinis

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@)t) Th)"a8 PA

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(asil La&)"at)"ium

(& (>t B4 PLT 12,1 3,1 12+C:0 31C000

Na K 4l 1C2 C,C 11

U"4" 1 0,:

KG/ 1C0

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/ia.n)sa Ke"-a

A##en$isitis a%ut

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 Tatala%sana

- <D@/ %"istal)i$- <n-+ Anti&i)ti%

- Nill #e" m)uth

- <nse"si Katete" U"in

Ren>ana

A##en$e>t)m!

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@)t) /u"anteO#

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@)t) Ja"in.an A#en$i%s

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@)t) Ja"in.an A#en$i%s

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@)t) P)stO#

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 TER<MAKA*<(