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LAPORAN JAGA DOKTERMUDA BAGIAN PENYAKIT
DALAMKamis, 10 desember 2015
IGD
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PAIEN 1
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IDENTI!IKAI
" Nama # D$a% ri P&s'i(asari
" Je)is Ke*ami) # Perem'&a)
" Usia # 22 (a%&)
" A*ama( # Pa*emba)+
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ANAMNEI
KELUAN UTAMA #
BAB -AIR EJAK ±4 HARI SMR
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RI.AYAT PERJALANAN PENYAK
" / %ari MR, 'e)deri(a me)+e*&% BAB air, re3&e)si 4am'as77 air, 8ar)a 3&)i)+, ba)$a3)$a 9 +e*as air mi)era:;, *e)dir ;, )a)a% :;, 8ar)a se'er(i &ia) beras :;< M&m&a*:;, demam :=; (ida3 (er*a*& (i)++i< Pe)derri(a masi% ma&Pe)deri(a *a*& ber>ba( 3e'&s3esmas, 3e*&%a) (ida3 bePe)deri(a *a*& ber>ba( 3e RM<
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RI.AYAT PENYAKIT DAULU
" Ri8a$a( BAB air sebe*&m)$a :;
" Ri8a$a( +as(ri(is :;
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PEMERIKAAN !IIK
" Keadaa) &m&m # Tam'a3 sa3i( ri)+a)
" Kesadara) # ->m'>s me)(is
" Te3a)a) Dara% # 120?0 mm+
" Nadi # @ 3a*ime)i(
" Per)aasa) # 20 3a*ime)i(
" &%& # 4@, -
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KEADAAN PEI!IK
" Ma(a # K>)C&)+(ia 'a*'ebra '&a( :;, s3*era i3(eri3 :;
" M&*&( # M&3>sa m&*&( 3eri)+ :=;
" Le%er # JP :52; m20, Pembesara) KGB :;
" T%>ra6 # Da*am ba(as )>rma*
" Abd>me) #
F I)s'e3si # Da(ar
F Pa*'asi # Lemas, -&bi(a) 3&*i( 'er&( 3emba*i *amba(<
F Per3&si # Tim'a)i
F A&s3&*(asi # Bisi)+ &s&s :=; me)i)+3a(
" E3s(remi(as # A3ra* %a)+a(, edema 're(ibia :;
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DIAGNOI EMENTARA
Gastroenteritis akut dengan dehidrasedang
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Dia+)>sis Ba)di)+
" GEA dise)(ri>rm
" GEA 3>*eri>rm
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REN-ANA PEMERIKAAN
" Dara% r&(i)
" Kimia dara%
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PROGNOI
" Ad i(am # B>)am
" Ad i(am # B>)am
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PENATALAKANAAN
" N>) !arma3>*>+i #
F Istirahat
F Diet Nasi biasa
F Edukasi
" !arma3>*>+i #
F IVFD RL gtt xxx/menit F Inj. Omeprazoe !x"# mg
F Inj. Ondansentron $mg
F %otrimoxazoe &x'(# mg )O
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PAIEN 2
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IDENTI!IKAI
" Nama # As)i bi) Na)+&*is
" Je)is Ke*ami) # La3i*a3i
" Usia # 50 (a%&)
" A*ama( # M&ara E)im
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ANAMNEI
KELUAN UTAMA #
NYERI DADA KIRI EJAK ±4 JA
SMRS
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RI.AYAT PERJALANAN PENYAK
" / Cam MR, >s me)+e*&% )$eri dada 3iri< N$eri dada dse'er(i di(i)di% be)da bera(< N$eri me)Ca*ar 3e *e)+a) 3iri, b'&)++&)+ da) ra%a)+< M&a* :=;, m&)(a% :;, 3eri)+a( di)+i) da) BAK se'er(i biasa< Os 3em&dia) ber>ba( 3e R B&)da Prame)da'a( (era'i as'i*e( da) >ba( a)(i )$eri $a)+ di(em'e*,sedi3i( ber3&ra)+< Os 3em&dia) dir&C&3 3e RM Pa*emba)+
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RI.AYAT PENYAKIT DAULU
" Ri8a$a( i'er(e)si :;
" Ri8a$a( DM :;
" Ri8a$a( mer>3>3 :;
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RI.AYAT PENYAKIT KELUARGA
" Ri8a$a( 3e*&ar+a me)i)++a* 3are)a sa3i( Ca)(&)+ :;
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PEMERIKAAN !IIK
" Keadaa) &m&m # Tam'a3 sa3i( seda)+
" Kesadara) # ->m'>s me)(is
" Te3a)a) Dara% # 1400 mm+
" Nadi # 11 3a*ime)i(
" Per)aasa) # 1? 3a*ime)i(
" &%& # 4@,0 -
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KEADAAN PEI!IK
" Ma(a # K>)C&)+(ia 'a*'ebra '&a( :;, s3*era i3(eri3 :;
" Le%er # JP :52; m20, Pembesara) KGB :;
" T%>ra6 #
F %or * I(&s >rdis (ida3 (er*i%a( da) (ida3 (eraba, bada*am ba(as )>rma*< R 11 3a*ime)i(, m&rm&r :;, +
" Abd>me) # Da(ar, *emas, (im'a)i, bisi)+ &s&s :=; )>rma*
" E3s(remi(as # A3ra* %a)+a(, edema 're(ibia :;
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PEMERIKAAN PENUNJANG
" Pemeri3saa) Dara% #
F +,, * !"& mg/dL
" EKG # T E*easi 'ada *ead aL, 1,2,4,,5
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DIAGNOI EMENTARA
STEMI Anterior luas
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REN-ANA PEMERIKAAN
" Dara% r&(i)
" Kimia dara%
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PENATALAKANAAN
" N>) !arma3>*>+i #
F Istirahat
F Diet jantung III
F Edukasi
" !arma3>*>+i #
F Inj. -orn !.& ampuF spiet !x!(# mg
F %opidogre !x0## mg
F %obazam !x!# mg
F Lansoprazoe !x 0# mg
F 1eparin 2rixtra3 !x&45 66