Fds Lapjag Igd II

7/25/2019 Fds Lapjag Igd II

1/23

LAPORAN JAGA IGD26-27 Desember 2015

15.00 - 06.00 WIB

Oleh:

Fa!llah D"sra #!$"rma%

&'%s!le%:

$r. (!l)a #!%$ar"* #+.PD

KEPANITERAAN KLINIK ILMU PENYAKIT DALAM

RSUD Dr. M. Yunus BENGKULU

2015


2/23

&A#,# 1

I$e%"as Pas"e%:

Nama : %. &

,s"a : 52 ah!%

Alama : Be%/!l!Aama : Islam

Pe/eraa% : Pea%"

#a!s +er/a"%a% : (e%"/ah


3/23

ANA(N#I#

3 Keluhan Utaa :

#a/" +er! )a% membera sea/ 12 am #(R#

3 RPS

12 am #(R#* +as"e% me%el!h sa/" +er! )a% sema/"%membera. #a/" +er! er!ama $"rasa/a% $" ba"a% +er! /a%a%.

Pas"e% !a me%el!h erasa m!al ea+" "$a/ sam+a" m!%ah.

Pas"e% me%a/! sa/" +er! leb"h $"rasa/a% saa seelah

me%a%/a beba% )a% bera. Demam 4-* BAB %'rmal* BA&

%'rmal* m!al $a% m!%ah 4. R"a)a m"%!m 'ba-'baa% 4-.

Pas"e% bel!m +er%ah ber'ba !%!/ me%'ba" /el!ha% erseb!.

b!la% #(R#* +as"e% +er%ah me%alam" /el!ha% )a% ser!+a*

seelah be/era me%a%/a be%$a-be%$a bera. Pas"e%

me%a/! s!$ah +er%ah me%'ba" +e%)a/"%)a erseb!.


4/23

3 RPD : 8"+ere%s" 4-* /e%9"% ma%"s 4-.

3 RP& : /el!ha% $a% sa/" )a% sama $"sa%/al

3 R"a)a s's"al : Pas"e% be/era sebaa" b!r!h

ba%!%a% $e%a% sa!s e/'%'m" )a% se$a%*

$a% sa%"as" l"%/!%a% )a% ba"/.


5/23

P(RIAAN FI#I&

3 &, : sa/" se$a%3 &esa$ara% : 'm+'s me%"s

3 a%$a ;"al : D0 mm8

N< ?0@=m%

R< 2 @=m% #< 6*5

3 &e+ala :

- '%!%";a Pal+ebra +!9a -=-

- #/lera I/er"/ -=-

3 Leher :

+embesara% &GB 4-* +embesara% /ele%ar "r'"$4-


6/23

3 h'ra@

Par!

I: sa"s $"%am"s s"mer"s /a


7/23

3 Ja%!% :

I : "/!s /'r$"s "$a/ erl"haP : "/!s /'r$"s "$a/ eraba

P : baas /a%a% a%!% l"%ea +araser%al"s $e@ra

I# E

baas /"r" a%!% l"%ea m"$/la;"/!la s"%"sraI# E

baas aas a%!% I# II

A : BJ1 $a% BJ2 re!ler 4 %'rmal* all'+ 4-* m!rm!r 4-


8/23

3 Ab$'me%:

I : $aar

A : B, 4 %'rmalP : %)er" e/a% re"' l!mbal $a% "l"a/a /a%a%4

he+ar $a% l"e% "$a/ eraba

bal'eme% 4-=-

%)er" /e'/ EA 4-=-P : "m+a%" $"sem!a re"' ab$'me%

3 /srem"as :

a/ral ha%a

+""% e$ema 4-=-


9/23

8A#IL P(RIAAN LABORAORI,(

3 8b : 1*2 =$L

3 8 : >

3 r'mb: 255.000 sel=mmA

3 Le! : >.200 mmA


10/23

DIAGNO#I#

D"a%'s"s /era :

3 /'l"/ ab$'me% e.9 s!s+. B#&

D"a%'s"s ba%$"% :

3 &'lel""as"s


11/23

RAPI

N'%Carma/'l'"s :

"rah bar"%

Farma/'l'"s

IEFD RL =m%

&e'r'la9 am+ @1 4IE

B!s9'+a% am+ @1 4IE


12/23

PLANNING

1. e/ ,r"% le%/a+

2. R'%e%

. &'%s!l ba"a% be$ah


13/23

&A#,# 2

I$e%"as Pas"e%:

Nama : %. #

,s"a : 50 ah!%

Alama : /eb!% beler* Be%/!l!Aama : Islam

Pe/eraa% : PN#

#a!s +er/a"%a% : (e%"/ah


14/23

ANA(N#I#

3 &,:

Demam sea/ 1 har" #(R#

3 RP# :

1 har" #(R#* +as"e% me%el!h/a% $emam* $emam

$"rasa/a% er!ama +a$a malam har"* me%""l 4-*

/er"%a 4-* b"%"/-b"%/ merah4-. Pas"e% !a m!al $a%m!%ah* m!%ah ber"s" a"r $a% ma/a%a%. %)er" !l! ha"

4* #a/" /e+ala 4-* %aCs! ma/a% me%!r!% 4* BAB 4

@ sehar"* /'%s"se%s" lembe/* $arah $a% le%$"r 4-. BA&

4* %)er" saa BA& 4-. Ba!/ +"le/ 4-


15/23

3 RPD :

"$a/ +er%ah me%alam" /el!ha% ser!+a sebel!m%)a.

3 RP& :R"a)a /el!ara )a% me%$er"a +e%)a/" )a% sama

$"sa%/al.


16/23

P(RIAAN FI#I&

3 &, : sa/" se$a%

3 &esa$ara% : 'm+'s me%"s3 a%$a ;"al : D


17/23

3 h'ra@

Par!

I: sa"s $a% $"%am"s s"mer"s. rera/s" sela "a $a% s!+ra/la;"/!la 4-

+e%!%aa% '' ba%! %aCas 4-

P: semCrem"!s De@ra #"%"sra s"mer"s.

e/s+a%s" $"%$"% $a$a $e@ra s"%"sra s"mer"s.P: s'%'r $"sem!a la+a% +ar!.

A: ;es"/!ler 4 %'rmal.

hee"% -=-. R'%/" -=-


18/23

3 Ja%!% :

I : "/!s /'r$"s "$a/ erl"ha

P: "/!s /'r$"s eraba $" l"%ea m"$/la;"/!la s"%"sra I# E.

hr"ll 4-

P: baas /a%a% a%!% l"%ea ser%al"s $e@ra* baas /"r"

a%!% l"%ea m"$/la;"/!la s"%"sra I# E $a% baas aas

a%!% I# II

A: 8R: 6@=m%* re!ler. #1 $a% #2 4N* all'+ 4-* m!rm!r4-


19/23

3 Ab$'me%:

I: $aar

A:B, 4 me%"%/aP: %)er" e/a% 4 re"' e+"asr"!m

P: "m+a%" $"sem!a re"' ab$

3 /srem"asa/ral ha%a

!r'r /!l" 4N


20/23

DIAGNO#I#

3 D"a%'s"s /era :

Obs. Febr"s e.9 s!s+. Demam )+h'"$

3 D"a%'s"s ba%$"% :

- (alar"a- Demam De%!e


21/23

RAPI

N'%Carma/'l'"s

3 "rah bar"%

3 D"e lamb!% II

Farma/'l'"s3 I%C!s RL =me%"

3 Dr"+ O%$a%ser'% 1 am+!l

3 P @ 500 m

3 De@a%a s)r!+ @ 1

3 J"/a has"l W"$al 4* 9hl'ram+he%"9'l ab @500 m

4sam+a" 7 har" bebas $emam


22/23

PLANNING

3 Darah r!"%: hem'l'b"%* hema'/r"* r'mb's"* le!/'s"

3 Per"/sa "$al

3 !be/s 4"$a/ erse$"a

3 DDR


23/23

RI(A &A#I8

Fds Lapjag Igd II

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