MORNING REPORT YZ.ppt
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Transcript of MORNING REPORT YZ.ppt
![Page 1: MORNING REPORT YZ.ppt](https://reader035.fdokumen.com/reader035/viewer/2022062316/577c810a1a28abe054ab3db9/html5/thumbnails/1.jpg)
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IDENTITAS PxNama : An. Aura Asha Shaquila (p)Usia : 5 tahunAlamat : Ds. Tanjung Harjo Kec. Kapas
BojonegoroStatus : -Tanggal MRS : 08 Juni 2015
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IDENTITAS ORANG TUA PxAyahNama : Tn SumarlikUmur : 29 tahunPekerjaan : WiraswastaPendidikan : SMAIbu Nama : Evma SUmur : 29 tahunPekerjaan : IRTPendidikan : SMK
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KELUHAN UTAMADEMAM
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Demam sejak 5 hari SMRS. Demam naik turun karena diberi obat penurun panas. Menggigil -- , Mengigau -- , mimisan -- , gusi berdarah -- , berak hitam/darah -- , nyeri saat kencing -- , nyeri telan -- .
Nyeri perut sebelah kanan sejak 1 jam SMRS. Nyeri dirasa seperti ditusuk-tusuk.
Lemas dirasakan 1 hari SMRSMuncul bintik merah sejak 2 jam SMRS.Pusing -- , mimisan -- , mual -- , muntah -- , batuk -- ,
pilek -- , kejang -- .
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Makan dan minum biasa 3x sehari.BAB terakhir 1 jam SMRS, Kuning, padat.BAK terakhir 5 jam SMRS, Jernih.
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RIWAYAT PENYAKIT DAHULUPasien tidak pernah sakit seperti ini.
Pasien tidak pernah masuk rumah sakit sebelumnya
Riwayat kejang -- , sesak -- , asma -- , batuk lama -- .
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RIWAYAT PENYAKIT KELUARGAKeluarga tidak pernah sakit seperti ini Riwayat kejang -- , sesak -- , asma -- , batuk
lama -- .
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RIWAYAT PENGOBATANMinum obat penurun panas dari 2 hari yll
dari perawat.
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RIWAYAT PERSALINAN.Anak pertama, lahir normal, cukup bulan, dibantu bidan. BB Lahir 3100g. Langsung menangis saat lahir. Ibu tidak pernah sakit saat kehamilan.
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RIWAYAT IMUNISASIHepatitis B +Polio +BCG +DPT +Campak +
KESIMPULAN : Lengkap
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PEMERIKSAAN FISIKKeadaan umumKesan sakit: SedangKesadaran : Alert
Usia : 5 tahunTB : 112 cmBB : 18 kg
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VITAL SIGNTD : 110/70 mmHg.Nadi : 108x/menit (reguler)Suhu : 36 °C (axiller)RR : 36x/menit (reguler)
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Kepala/leher : a -- / i -- / c -- / d -- Mata : Pupil isokor ki = ka Conjunctiva palbebra inf pucat --Oedema palpepbra --Cowong -- Telinga: Bentuk normalSekret --/--
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Hidung:Pernafasan cuping hidung -- Epistaksis --Cairan bening --Deviasi septum nasi --Mulut : Sianosis --Labium Oris kering --Lidah tifoid --Pembesaran tonsil --Faring hiperemi --
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Leher : Simetris Pembesaran KGB --Pembesaran Kelenjar tyroid --
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Thorak : Paru : Inspeksi : SimetrisPalpasi : SimetrisPerkusi : Sonor / SonorAuskultasi : Vesikuler / Vesikuler
Rhonki --Wheezing --
Jantung : S1 S2 Tunggal Reguler
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Abdomen :Inspeksi : Distended --Auskultasi : Bising usus ++ NormalPalpasi :
Hepar/Lien tidak ada pembesaranGinjal tidak ada pembesaranMassa --Nyeri tekan
Perkusi : Metoerismus --
++ -- --++ -- ---- -- --
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Ekstremitas Akral Hangat Hangat
Dingin Dingin
CRT < 2 detik
Oedema --
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PROBLEM LISTDemamNyeri PerutLemasMuncul Bintik Merah
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ASSESMENTObservasi Febris hari ke 5DD : - DF- DHF
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PLANNINGPlanning Diagnosa
- Darah Lengkap- Remple Leed Test- Test Widal (Serial)- SGOT SGPT
Planning terapi- Infus Asering 1400 ml/24 jam- Paracetamol 180 mg/ kali (3dd pulv 1) p.r.n