Resume Yuliana
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8/18/2019 Resume Yuliana
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RUMAH SAKIT UMUM DOK II JAYAPURA SMF SARAF
IKHTISAR Nama : Ny. Yuliana Inur No. DM : 20 17 51
WAKTU PUAN! Umur : "# $a%un Su& : RR Sara' K(la) III Wani$a
Alama$ : Polima* II+ P(n,i,i*an : -+ Ma)u* Ruma% Sa*i$ : 2# D()(m&(r 201+ M(nin//al : 2 anuari 201.
Rin/*a)an Wa*$u Ma)u*+ P(ralanan P(nya*i$ Hin//a K(luar
1. Anamnesis (Heteroanamnesis)
Keluan Utama !
(ma% an//o$a /(ra* )(&(la% *anan
RPD !
Pa)i(n ,i&a3a ,(n/an *(lu%an *(l(ma%an an//o$a /(ra* a$a) ,an &a3a% )(&(la% *anan ,imana $an/an
*anan ,a4a$ ,ian/*a$ namun )(/(ra a$u% *(m&ali ,an *a*i *anan %anya ,a4a$ ,i/()(r yan/ ,ira)a*an
)(a* 1 %ari )(&(lum ma)u* ruma% )a*i$. Pa)i(n u/a m(n/(lu% $an/an ,an *a*i 4a)i(n yan/ )(&(la%
*anan )(4(r$i *()(mu$an+ 4a)i(n u/a mulai &i6ara 4(lo+ ,an mulu$ 4a)i(n m(n6on/ *( )(&(la% *iri.
Saa$ ,i&a3a *( ruma% )a*i$+ 4a)i(n ma)i% )a,ar+ *(lu%an )a*i$ *(4ala ,ira)a*an ol(% 4a)i(n+ *(an/
$i,a* a,a+ 4u)in/ &(r4u$ar $i,a* a,a+ $(lin/a &(r,(n/in/ $i,a* a,a+ mun$a% $i,a* a,a+ /(la4 $i&a-$i&a$i,a* a,a+ 4(n/li%a$an 4a)i(n ,ia*ui m(man/ )u,a% mulai *a&ur )(a* lama+ namun a,a *(lu%an mual
)(%in//a 4a)i(n $i,a* &i)a ma*an. T(*anan ,ara% 4a)i(n )aa$ ,i &a3a *( U!D 15080 mmH/.
RPS !
Ri3aya$ %i4(r$(n)i ,ia*ui namun $i,a* ,i*($a%ui )(6ara 4a)$i )(a* *a4an+ $i,a* $(r*on$rol ,an $(*anan
,ara% $(r$in//i 10 ,ia)$ol( $i,a* ,i*($a%ui+ ri3aya$ ,ia&($() m(lli$u)+ *ol()$(rol+ 4(nya*i$ an$un/+
4(nya*i$ /inal ,i)an/*al+ ri3aya$ 4(n//unaan al*o%ol ,an m(ro*o* u/a ,i)an/*al ri3aya$
4(n//unaan *on$ra)(4)i $i,a* ,i*($a%ui.
". Pemeri#saan Fisi# (saat ti$a %i U&D)
K()a,aran : Somnol(n 9!S : ;mn$+ S& : 8+5o
Status InternaK(4alal(%(r : Konun/$i?a an(mi) 9--=+ )6l(ra i*$(ri* 9--=+ 4(m&()aran K!@ 9-=+ oral 6an,i,ia)i) 9-=T%ora*) : Paru : Sim($ri)+ r($ra*)i 9-=+ i*u$ /(ra* na4a)+ )uara na4a) ?()i*ul(r+ r%on*i 9--=+
3%((in/ 9--=
an$un/ : @unyi an$un/ I-II r(/ular+ murmur 9-=+ /allo4 9-=A&,om(n : Da$ar+ )u4(l+ @U 9B=+ %(4arli(n 9$i,a* $(ra&a$i,a* $(ra&a=;*)$r(mi$a) : A*ral %an/a$+ u,(m 9-=
Status 'euroloisRan/)an/ M(nin/(al : Ka*u *u,u* 9-=+ la)(/u(*(rni/ 9$a* $(r&a$a)$a* $(r&a$a)=+ @ru,in)*i I+II 9--=Sara' C$a* : Ma$a : 4u4il &ula$ i)o*or+ CDS : mm+ r('l(> 6a%aya 9BB=+ /(ra* &ola ma$a : ,(n/an
ran/)an/ ny(ri ,i,a4a$*an *()an &ola ma$a *anan ,an *iri &(r/(ra* &ai* *( )(/alaara%.Waa% : ,(n/an ran/)an/ ny(ri ,i,a4a$*an *()an mulu$ m(n6on/ *( )(&(la% *iri
Mo$ori* : D(n/an ran/)an/ ny(ri ,i,a4a$*an *()an %(mi4ar()( ,(>$ra ,(n/an *(*ua$an
5
2 5
,imana (*)$r(mi$a) )u4(rior ,an in'(rior ,(>$ra l(&i% $(r$in//al ,i&an,in/*an yan/ *iriS(n)i&ili$a) : Su*ar ,inilai
4(nurunan *()a,aran= B 92> ny(ri *(4ala= B 92 > mun$a%= B 90+1 > $(*anan ,ara% ,ia)$oli*=
B 9 > a$(roma= E 12 F 92+5 > 1= B 92 > 1= B 92 > 0= B 90+1 > 80= B 9 > 0= E 12
F 0+5 (Merau#an)
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8/18/2019 Resume Yuliana
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AS&M
P(nurunan *()a,aran 9B=+ ny(ri *(4ala 9B=+ &a&in)*y 9-= → Stro#e Per%araan
*. Pemeri#saan Penun+an
Pemeri#saan Hematoloi
Jenis Pemeri#saanHasil
'ilai Ru+u#an",-1"-"1 ,-1-"1*
H& 11+5 /,l #+2 /,l P : 1+0 E 18+0 W : 12+0 E 1"+0(u*o)i$ 8.800mm 12+1"0mm 5.000 E 10.000mm
H(ma$o*ri$ +# G 2#+2G P : 2-52G W : "-8G
Trom&o)i$ 121.000mm 82.000mm 100-00 ri&umm
;D - 15-158 P : #-0 W : #-20
Para)i$ Malaria N(/a$i' - B : 1-10 4ara)i$100 l4BB : 11-100 4ara)i$100 l4
BBB : 1-10 4ara)i$ l4BBBB : 10 4ara)i$ l4
Pemeri#saan Kimia Klini#
Jenis Pemeri#saanHasil
'ilai Ru+u#an
-1"-"1 ,-1-"1*!DS #7 m/G #7 m/G 200 m/G
Ur(um 5 m/G 27 m/G 20-50 m/G
Kr(a$inin 1+1 m/G 0+7 m/G P : 0+8-1+5 m/G W : 0+5-1+ m/G
A)am Ura$ 2+# m/G 1+5 m/G P : +5-7+7 m/ G W : 2+5-5+5 m/G
Al&umin - 2+ /, +-+8 /,
S!CT 78 U 2 U * : 0-50 U Pr :0-5 U
S!PT U 0 U * : 0-50 U Pr :0-5 U
Kol()$(rol To$al - 117 m/G 200 m/G
Tri/li)(ri,a - 8# m/G 1"0 m/G
Kol()$(rol HD - 10 m/G "5 m/G
Kol()$(rol D - 8# m/G 150 m/G
Na$rium - 155 mmol 10-1 mmol
Kalium - 2+" mmol +"-5+ mmol
Klori,a - 127 m/, #5+7-105+# m/,
/. Follo0 UTanal 2atatan Tin%a#an Keteranan
2-+"01201 S : l(ma% an//o$a /(ra* )(&(la%
*anan+ $i,a* mau ma*an
C : $i,a* ,ila*u*an 4(m(ri*)aan
Tan//al 01201:
Mo$ori*
5
> 5
Dia/no)a K(ra : Hi4(r$(n)i /ra,( II B
lo3 in$a*( B ,y)4(4)ia (6 'un/)ionalB )u)4. H(mi4ar()a ,(>$ra (6 )u)4.
S$o*( in'ar*
- I *orn(a 9=
Dia/no)a K(ra : S$o*( in'ar* )y)$(m*aro$i) *iri
Dia/no)a Tam&a%an : $in(a *or4ori)
- I
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- M(mor(> >1 $a&
- a4$o4ril >12+5
m/
- A)am 'ola$ 2>1
$a&
- Pro 4a)an/ N!T
10-11+1+15-
1801201
S : @a$u* 9B=
C: K()a,aran : 6om4o) m(n$i) 9!S :
;12 /r
- In. @raina6$
2>500 m/
- S(ma> >" /$$
NDS
- In. Alinamin
2>1 am4
- M(mor(> >1 $a&
- Amlo,i4in 1>10
m/
- A)am 'ola$ 2>1$a&
- I$ra*onaol( 1>1
$a&
- ($iriin 1>1 $a&
- K($o*onaol(
6r(am 1>)(%ari
T(ra4i $am&a%an $an//al
1101201:
- A)4il($ 1>1 $a&
T(ra4i $am&a%an $an//al
101201:
- Human al&umin
20G
- Am&ro*)ol >1 $a&
- Pro 6(* )4u$um
@TA
- Pro o$o T%ora*)
Tan//al 701201:
Ha)il )4u$um @TA n(/a$i' 9-=
20-2201201 S : $i,a* )a,ar+ &a$u* 9B=
C: K()a,aran : So4or 9!S : ;1mn$+ R : 20 >mn$+ S& : 7o
Status Interna
K(4alal(%(r : a --+ Si --
T%ora*) : )im($ri)+ r($ra*)i 9-=+ i*u$/(ra* na'a)+ Sn ?()i*ul(r BB+ r%o
9--=+ 3%( 9--=+ @ I-II r(/ular
A&,om(n: ,a$ar+ )u4(l+ @U 9B=
;*)$r(mi$a) : a*ral %an/a$+ u,(m
(*)$r(mi$a) )u4(rior ,an in'(rior 9BB=
!(ni$alia : ,(*u&i$u) ,i ,a(ra% /lu$(u)
ma*)imu) ,(>$ra ($ )ini)$ra
Status 'eurolois
Ran/)an/ M(nin/(al : Ka*u *u,u*
9B=+ la)(/u(*(rni/ 9$a* $(r&a$a)$a*
$(r&a$a)=+ @ru,in)*i I+II 9--=
Sara' C$a* : Ma$a : 4u4il &ula$ i)o*or+ CDS : 1 mm+ r('l(> 6a%aya 9=+
r('l(> *orn(a 9BB=+ !@M : $i,a* a,a/(ra*an &ola ma$a
Waa% : mulu$ m(n6on/ *( )(&(la%*iri
Mo$ori* : $i,a* ,a4a$ ,i(?alua)i*ar(na 4a)i(n $i,a* )a,ar
12 /r
- In. @raina6$
2>500 m/- S(ma> >" /$$
NDS
- In. Alinamin
2>1 am4
- M(mor(> >1 $a&
- Amlo,i4in 1>10
m/
- A)am 'ola$ 2>1
$a&
- I$ra*onaol( 1>1
$a&
- ($iriin 1>1 $a&
- K($o*onaol(6r(am 1>)(%ari
- ;>$a6( >1 am4
- Pro 6(* (l(*$roli$
Tan//al 2201201
N(uro$am )$o4
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Dia/no)a Tam&a%an : $in(a *or4ori)
3. Dianosa A#ir
- S$ro*( (6 in'ar* a$(ro$rom&o$i* DD )$ro*( 4(r,ara%an )i)$(m *aro$i) )ini)$ra
- Tin(a Kor4ori)
4. Terai
- I1 $a&
- I$ra*onaol( 1>1 $a&
- ($iriin 1>1 $a&5K($o*onaol( 6r(am 1>)(%ari
- ;>$a6( >1 am4
6. Pronosis
Luo a, ?i$am : malam
Luo a, 'un6$ionam : malam
Luo a, )ana$ionam : malam
o-A)) P(m(/an/ Pa)i(n
;l?ira A. An$o%+ S.K(,
Do*$(r S4()iali)
,r. Halomoan Sara/i+ S4.S