lapjag michelle2

8/17/2019 lapjag michelle2

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LAPORAN JAGA Jumat 08/04/16

Michelle H

07120110086



Identita Paien

• Nama ! "n# A

• $elamin ! La%i la%i

•

"&l Lahi' ! 08/11/1(() *22 tahun+• Alamat! Pe'um mutia'a, "an&e'an&

• A&ama ! Ilam

• N-# MR ! 00.70.28.



Anamnei

$eluhan tama!Ne'i e'ut %anan 3aah 2 ha'i 5MR5

Riaat $! Ne'i e'ut %anan 3aah 2 ha'i 5MR5,

ne'i aalna di'aa%an di dae'ah uluhati%emudian 3e'indah %e %anan 3aah# Ne'idi'aa%an te'u mene'u, %ala 8/10,

ema%in a'ah i%a 3e'&e'a%, tida% ada an&meme'in&an# Mual , muntah ., Ate'a%hi' 2 ha'i 5MR5,n-'mal# Na9u ma%anmenu'un#



$eluhan Lain!

Paien men&a%u men&alami demam 1 ha'i 5MR5,te'u mene'u, tetai uhu tida% diu%u'#

Riaat 3e'-3at !

Paien telah 3e'-3at %e %lini% 24 am de%at 'umah 1 ha'i5MR5, tetai aien tida% in&at di3e'i%an -3at aa#

Riaat ena%it dahulu!

:M . , hie'teni .

Riaat -e'ai ! tida% e'nah di-e'ai e3elumna

Riaat %elua'&a !

"ida% ada an& i&ni;%an



Peme'i%aan <ii%

• $eada'an! c-m- menti *G=51>+

• "e%anan da'ah! 120/80 mmH&

•

Nadi! (7 ?/menit• 5uhu! )6#8 celciu

• 5atu'ai O2! ((@

• RR ! 20 ?/menit



$eala dan Lehe' !

• $eala ! "ida% ada de9-'mita

. Mata ! $-nun&tia ucat *./.+,5cle'a i%te'i% *./.+, Puil 3ulat i-%-')mm/)mm

•

Hidun&! 5e%'et *−

+, :a'ah *.+• "elin&a ! 5e%'et *−+, :a'ah *.+



• Mulut ! d3n• Lehe' ! "ida% te'a3a em3ea'an $G dan ti'-id

"h-'a%Ine%i !• Pe'&e'a%an na9a imet'i, 3entu% dada 'ata, 'et'a%i

inte'%-ta *.+, -'th-nea *.+Palai !• Ne'i te%an *.+, e%ani dada 3ai%• Pe'%ui ! Ne'i %et-% *.+, 5-n-' */+Au%ultai !• Pa'u ! uni na9a ei%ule' */+,

'-n%hi *./.+, heeBin& *./.+• Jantun& ! uni antun& I,II 'e&ula', mu'mu' *.+,

&all- *.+



A3d-men

Ine%i ! data', tida% ada diteni, ea *.+

Au%ultai ! iin& uu *+, 5uel

Pe'%ui ! Ne'i %et-% *.+, Acite *.+

Palai ! Ne'i te%an *.+, "ida% te'a3aem3ea'an hea' dan lien#



5tatu l-%ali

• A3d-men

Ine%i! data', tida% ada diteni, maa., 3e%a - .

Au%ultai! iin& uu *+Pe'%ui! "imani, acite .

Palai!

Ne'i te%an ada'e&i- iliaca %anan,ne'i lea Mc u'ne , -a, -3tu'at-' ,

de9an mu%ula' .



LAORA"ORIMResult Reference Range

Full Blood Count

Hem-&l-3in 16#88 11#70.1>#>0

Hemat-c'it >2#0> )>#00.47#00

C'th'-cte >#80 )#80.>#20

Dhite 3l--d cell >#)> )#60.11#00

Dierential Count

a-hil 1 0.1

C-in-hil 0 1.)

and Neut'-hil ) 2.6

5e&ment Neut'-hil 44 >0.70

Lmh-cte 44 2>.40

M-n-cte 8 2.8

Platelet c-unt 188#00 1>0#00.440#00

C5R > 0.20

P" 11#10 (#4 E 11#)

AP"" )8#10 )1.47



Result Reference Range

Biochemistry

5GO" *A5"+ 2> >.)4

5GP" *AL"+ 27 0.>>

'eum 14#0 F71='eatinine 0#8) 0#>.1#1

l--d Rand-mGluc-e

122 F200

Electrolyte

Na 1)4 1)7.14>

$ )#7 )#6.>#0

=l (7 (8.107



ALARA:O 5=ORC

5MP"OM5• Mi&'at-' 'i&ht iliac 9-a ain 1• An-'e?ia 1• Naue/-mitin& 1

5IGN5• "ende'ne in 'i&ht iliac 9-a 2• Re3-und tende'ne in 'i&ht iliac 9-a 1• Cleated teme'atu'e 1

La3-'at-' ;ndin&• Leuc-ct-i 2• 5hi9t t- the le9t -9 neut'-hil 1

• "-tal 10

• 1.4 . unli%el

• >.6 P-i3le

• 7.8 P'-3a3le

•

(.10 Hi&hlP'-3a3le

5mt-m )

5i&n 4La3 2

"-tal 9



K.Ra "h-'a?



&A3d-men



• "ida% tama% t'u%tu' tu3ule' 3untu/a3e/ cai'an3e3a ada 'e&i- Mc u'ne

• Pem3ea'an %elena' &etah 3enin& meente'ialmultile

• O'&an.-'&an int'aa3d-minal lainna dalam 3atan-'mal



:ia&n-i

• Aendiiti a%ut



"e'ai

an& udah di3e'i%an!. =e9t'ia?-ne 2 &' I

. Met'-nidaB-le >00 m& I

. Ome'aB-le 40 m& I

. P'ime'an 10 m& I

"e'ai -e'ati9!

Aende%t-mi cit-



La-'an Oe'ai

• Paien tidu' te'lentan& den&an inal anatei

• A antieti% laan&an -e'ai

• Inii 3i%ini

• Mucle littin&

• Pe'it-neum di3u%a, identi;%ai caecum

• Aendi% leta% antecaecal

• Aende%t-mi d-u3le li&ai

• $-nt'-l enda'ahan

• Jahit lai demi lai

• Oe'ai eleai



Int'u%i -t -

• I<: RL 28 tm

• =e9t'ia?-ne 2 &' I

•

Met'-nidaB-le ) ? >00 m& I• $ete'-lac ) ? )0 m& I

lapjag michelle2

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