MR Dr Sukartini

8/17/2019 MR Dr Sukartini

1/27


2/27

Re%u&e #'(at#e't

Nama Usia Diagnosis

A'.) 2 ta$u' e&a&"e'*ue

A'.A + ta$u' e&a&"e'*ue

A'.M 2 ta$u' e-a'*e&a&&(lek%


3/27

1. Na&a / A'. )

Je'#% ela' / Pere&(ua'

U&ur / 2 ta$u'


4/27

• Keluhan Utama / e&a&

• Riwayat Penyakit Sekarang :

e&a& $ar# ke3. e&a& 'a#k turu' "e'*a'(e&er#a' at (e'uru' (a'a%. Me'*#*au ,

&e'**#*#l . Pa%#e' %e&(at &e'*ala ke-a'* 1

ket#ka "e&a&. e-a'* ter-a"# %ela&a 51+ &e'#t.

et#ka ke-a'* %eluru$ tuu$ &e'e'tak'e'tak.

Pa%#e' "#a7a ke Pu%ke%&a% ter"ekat "a' "#er#

at le7at a'u%. )eelu&'a (a%#e' &e'*ala

atuk er"a$ak 5 3 $ar# %eelu& MR).Mual ,&u'ta$ ,%a' , *u%# er"ara$ . BAB "a'

BA "ala& ata% 'r&al. Na8%u &aka' &e'uru'.

)eelu&'a (a%#e' %e&(at "#ra7at "# Pu%ke%&a%

%ete&(at


5/27

Riwayat Penyakit Dahulu :

T#"ak a"a kelu$a' %eru(a %eelu&'a

Riwayat Penyakit Keluarga :

T#"ak a"a keluar*a a'* &el#k#

kelu$a' a'* %a&a "e'*a' (a%#e'


6/27

Pe&er#k%aa' !#%#k

• ea"aa' U&u& / ta&(ak %ak#t r#'*a'

• e%a"ara' / 9&(%&e't#%

• :#tal )#*'/

Na"# / 140;&e'#t

!rek. 'a(a% / 2


7/27

• Kepala/leher / A'e% ;, #kteru% ;, &ata

=7'* , uu'uu' =eku'* ,(er'a(a%a'=u(#'* $#"u'* , %#a'%#% , &uk%a ##r a%a$

>, l#&8a"e'(at#

• ThoraxPul& /

I'%(ek%# / Be'tuk "a' (er*eraka' %#&etr#%, retrak%#

I9)

Pal(a%# / !retu% raa %ul#t "#e?alua%#

Perku%# / )'r "# %e&ua la(a'*a' (aru

Au%kulta%# / :e%#kuler, R$'k# ;, 7$ee@#'* ;


8/27

9r /

I'%(ek%# / I=tu% =r"#% t#"ak ta&(ak

Pal(a%# / I=tu% =r"#% t#"ak teraaPerku%# / Bata% -a'tu'*

a'a' / I9) III r#*$t (ara%ter'al l#'e

#r# / I9) : le8t "=la?#=ular l#'e

Au%kulta%# / )1)2 tu'**al re*uler, *all( ,&ur&ur


9/27

• !"omen

I'%(ek%#/ Ta&(ak "atar

Pal(a%# / )e, 'er# teka' , $e(at&e*al# ,%(le'&e*al# , &a%%a tur*r kul#t a#k.

Perku%# / T#&(a'#

Au%kulta%# / B#%#'* u%u% > ke%a' 'r&al

• #kstrimitas

Akral $a'*at, e"e&a ;


10/27

•

Pemeriksaan Penun$ang: Leuk%#t / 4400 ;&&3

e&*l#' / C,2 *r;"l

e&atkr#t / 20,1 D

Tr&%#t / 10E.000 ;&&3


11/27

IAGNO)I)

%&D D'

DiagnosisKer$a

e&a&e'*ue

e&a&"e'*ue


12/27

PFNATALA)ANAAN

%&D D'

I:! RL 12 t(& I:! RL 16 t(& &akr

Para=eta&l %r.3 1 =t$ Para=eta&l %r 3

=t$#a@e(a& ta 2 2 &* #a@e(a& %u(( 10 &*

-#ka ke-a'*


13/27

2. A'. A;+ ta$u'; Pere&(ua'

U / e&a&

RP) / e&a& $ar# ke4. e&a& 'a#k turu' "e'*a'

(e&er#a' at (e'uru' (a'a%, &e'**#*#l , ke-a'*

. Pa%#e' -u*a &e'*ala atuk er"a$ak %e-ak 2 $ar#%eelu& MR). Pa%#e' a"a %e%ak %e-ak 4 $ar# Pa%#e'

t#"ak a"a &ual , &u'ta$ , BAB "a' BA "ala&

ata% 'r&al

RP / Pa%#e' t#"ak (er'a$ &e'*ala ke-a'*

%eelu&'a

RP / eluar*a (a%#e' t#"ak a"a kelu$a' %eru(a


14/27

Pemeriksaan (isik :

e%a"ara' / =&(% &e't#%

Ta'"a :#tal / N / C6;# T/ 36,3H 9

RR/ 24 ;#e(ala;Le$er / A'e% ; , Ikter#k ;, (er'a(a%a' =u(#'*

$#"u'* , %#a'%#% , &ulut &e'=u=u

(e&e%ara' GB , !ar#'* $#(ere%

T$rak%/

Pul& / I'%(ek%# / Per*eraka' %#&etr#%, retrak%#%u=%tal , R$'k# >;>,

7$e@#'* ;

Pal(a%# / Geraka' "a"a %#&etr#% )

Perku%# / )'r

Au%kulta%# / :e%#kuler9r / I'%(ek%# / Iktu% =r"#% t#"ak terl#$at

Pal(a%# / I=tu% kr"#% teraa (a"a #=% +

Perku%# / Bata% -a'tu'* "ala& ata% 'r&al

Au%kulta%#/ )1, )2 tu'**al re*uler, Gall( ,

Mur&ur


15/27

A"&e' / I'%(ek%# / atar Pal(a%#/ )e, $e(at&e*al# , tur*r kul#t a#k

Perku%#/ T#&(a'#

Au%kulta%# / Bu > ke%a' 'r&al

Fk%treta% / Akral $a'*at, e"e&a

Ru&(le Lee" / >

Pe&.Pe'u'-a'* /

/ C,1=t / 2


16/27

%&D D'

DiagnosisKer$a

e&a&e'*ue ""!

! *ra"e I


17/27

PFNATALA)ANAAN

%&D D'

I:! RL 1+ t(& I:! RL 1+ t(& &akr

Para=eta&l %r.3 1

=t$

Para=eta&l %r 3

=t$Ba'ak 'u& Ba'ak 'u&


18/27

3. A'.M; 2,1 t$ ; Per&u(a'

elu$a' Uta&a / e-a'*

R#7aat Pe'ak#t )ekara'* /

e-a'* "#ala %ea'ak 6E "e'*a' "ura%#+ &e'#t, ke-a'* ter-a"# 4 $ar#)MR) .et#kake-a'* %eluru$ tuu$ (a%#e' &e'e'tak'e'tak "a' &ata'a &e&elalak ke ata%.Pa%#e' -u*a &e'*ala "e&a& $ar# ke4,&e'**#*#l . Batuk , &ual , &u'ta$ ,BA 'r&al, BAB 'r&al


19/27

Riwayat Penyakit Dahulu :

T#"ak a"a kelu$a' %eru(a %eelu&'a

Riwayat Penyakit Keluarga :

T#"ak a"a keluar*a a'* &el#k#

kelu$a' a'* %a&a "e'*a' (a%#e'


20/27

Ter%e'u& / + ula'

M#r#'* / 6 ula'

Te'*kura( / 6 ula'Mera'*kak / elu& #%a

Ber"#r# / elu& #%a

Ber-ala' / elu& #%aB#=ara 2 %uku kata / elu& #%a


21/27

Pe&er#k%aa' !#%#k

• ea"aa' U&u& / ta&(ak %ak#t r#'*a'

• e%a"ara' / 9&(%&e't#%

• :#tal )#*'/

Na"# / 124;&e'#t

!rek. 'a(a% / 24;&e'#t

)u$u / 36,+ 0 9


22/27

• Kepala/leher / A'e% ;, #kteru% ;, &ata

=7'* , uu'uu' =eku'* ,(er'a(a%a'=u(#'* $#"u'* , %#a'%#% , &uk%a ##r a%a$

>, l#&8a"e'(at#

• ThoraxPul& /

I'%(ek%# / Be'tuk "a' (er*eraka' %#&etr#%, retrak%#

I9)

Pal(a%# / !retu% raa %ul#t "#e?alua%#

Perku%# / )'r "# %e&ua la(a'*a' (aru

Au%kulta%# / :e%#kuler, R$'k# ;, 7$ee@#'* ;


23/27

9r /

I'%(ek%# / I=tu% =r"#% t#"ak ta&(ak

Pal(a%# / I=tu% =r"#% t#"ak teraaPerku%# / Bata% -a'tu'*

a'a' / I9) III r#*$t (ara%ter'al l#'e

#r# / I9) : le8t "=la?#=ular l#'e

Au%kulta%# / )1)2 tu'**al re*uler, *all( ,&ur&ur


24/27

• !"omen

I'%(ek%#/ Ta&(ak "atar

Pal(a%# / )e, 'er# teka' , $e(at&e*al# ,%(le'&e*al# , &a%%a tur*r kul#t a#k.

Perku%# / T#&(a'#

Au%kulta%# / B#%#'* u%u% > ke%a' 'r&al

• #kstrimitas

Akral $a'*at, e"e&a ;


25/27

•

Pemeriksaan Penun$ang: Leuk%#t ;&&3

e&*l#' / *r;"l

e&atkr#t /

Tr&%#t / ;&&3


26/27

IAGNO)I)

%&D D'

DiagnosisKer$a

e-a'* e&a&&(lek%

e-a'*"e&a&

k&(lek% Glal

e?el(&e'tal elae"


27/27

PFNATALA)ANAAN

%&D D'

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