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Identitas Pasien

▪

Nama : Tn. Nasib▪ Usia : 58 ta!n

▪ "gama : Is#am

▪ "#amat : $ondo%oso

▪ Tangga# MR& : 10-04-2016

▪ Tangga# Pemeri'saan : 10-04-2016

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"namnesis

▪

(U: &esa'▪ RP& : Pasien merasa sesa' se)a' 1 mingg! *ang #a

memb!r!' saat bera'ti,itas+ terasa ngangsor 'etiber)a#an 10 meter+ a'ir-a'ir ini pasien tid!rmengg!na'an 2 banta#+ bat!' / se)a' 10 ari *#a#!+ daa' / 'e'!ningan

▪ RP : Pasien post MR& 'arena stro'e 1 ta!n *angT -/+ M -/

▪ RP : -/

▪ "#ergi : -/

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Pemeri'saan 3isi'

▪ ita# &ign:▪ T : 160100 mmg

▪ Nadi : 87m '!at+ reg!#er

▪ &!! : 6+49

▪ RR : 07m

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Pemeri'saan 3isi'

▪

KEPALA : Norma#+ simetris▪ MATA : ;o%ong -/+ 'on)!ngti,a p!;at -/+ i'ter!s

▪ THT : te#inga : se'ret -/+ id!ng : napas ;!pingid!ng -/+ tenggoro'an:

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Pemeri'saan 3isi'

▪

THORAX : Norma#+ &imetris+ retra'si -/ I;t!s ;ordis ▪ COR

▪ Inspe'si : -/

▪ Pa#pasi: i;t!s ;ordis tida' teraba

▪ "!s'!#tasi : &1 ? &2 norma# dan reg!#er+ ga##op -/+ m!rm!r -

▪ PULMO

▪ Inspe'si : -/

▪ Pa#pasi: gera'an dada simetris+

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Pemeri'saan Pen!n)ang

DL Hasil Satuan Rujukan

LED 1 Jam - Mm P: 0-10@: 0-20

HB 11+2 gA P: 14-18

@: 12-15

Leuksit 1.B00 mm 4.000-10.000

Se!men 80 A 50-0Lim"sit 14 A 20-40

Mnsit 6 A 2-8

Hematk#it 6 A P: 40-0

@: -48

T#m$sit 44.000 mm 150.000-

400.000

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Pemeri'saan Pen!n)ang

%ula

Da#a&

Hasil

Se'aktu 162

L(T Hasil Satu

an

Rujuka

nS%OT B8 MgrA P:

@: 1

S%PT 14 UI P: 42@: 2

R(T Hasil Satuan Rujukan

K#eatinin 1+12 MgrA P: 0+6-1+1

@: 0+5-0+B

U#ea 48 UI 10-50

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Pemeri'saan Pen!n)ang

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iagnosis $anding

▪

eart 3ai#!re▪ PP( 

▪ "sma

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iagnosis (er)a

▪

iagnosis Primer : eart 3ai#!re 3/▪ iagnosis &e'!nder : &!sp. Pne!monia

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P#anning

▪

iagnosis : -/▪ Terapi:

▪ I3 R= 500;;24 )am tpm/

▪ In). e

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Cd!'asi

▪

Meng!rangi a'tiDtas *ang berat▪ Membatasi )!m#a 'ons!msi air min!m

▪ Meng!rangi 'ons!msi garam

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Monitoring

▪

 >!m#a ;airan *ang mas!' dan *ang di'e#!ar'an▪ (e#!an

▪ C(E

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