Laporan Jaga Malam 2
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Transcript of Laporan Jaga Malam 2
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Laporan Jaga Malam
Tanggal 04 - 07 - 2015
Tn. Sumarno / 49 thn
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• Keluhan utama:• Os datang dengan batuk darah 4 SMRS. ( ±7x
dalam 4 hari)• Batuk terakhir ± 1 gayung air mandi• Warna darah merah bercampur putih
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• Keluhan tambahan:• Pusing(+)• Sesak(+)• Deman(+)• BAK (tidaka ada kelainan)• BAB ( hitam) – 1 hari SMRS• Pasien sedang minum obat paru(1 kuning,2
putih,1 merah) – os tidak ingat nama obat
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• Riwayat • Tahun 2012 pernah minum obat paru 6 bulan. • Tidak pernah memeriksakan diri setelah
minum obat• DM,HT,Jantung (tidak pernah diperiksa)• Keluarga:DM(ayah)
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• Keadaan umum : TSS• Kesadaran : CM• TD : 110/70• N :92 x/menit• RR :26 x/menit• Suhu : 37
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• Mata : CA +/+, SI -/-• Mulut : mulut kering• Leher : KBG(-)• Thoraks :
Pulmo: SnV +/+, Rhonki +/+, Wheezing -/-Cor: BJ I = II reguler, Murmur(-),Gallop(-)
• Abdomen : Supel + Flat,BU (+) normal, NT(-) abdomen bawah,NT(-) epigastrium,
NL(-), timpani• Ekstremitas : Akral dingin di 4 ekstremitas,
tidak ada edem, CRT < 2s • Kulit : Ikterik (-) , PPE (-)
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Pemerikasaan Laboratorium
• Leukosit : 14,8 ( )• Eritrosit : 2,67 ( )• Hb : 6,9
( )• HT :
22( )• Trombosit:511 ( )• MCV : 81• MCH : 26• MCHC : 32
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• Obs hemaptoe ee TB paru• Obs melena• Suspect TB Paru (BTA ??)• Suspect TB Paru lesi luas kasus kambuh• DD Pneumoni
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• O2 3 lpm• IVFD RL/ 8 jam• Vit K 50• Vit C 50• Transamin 50