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7/17/2019 mr ulkus

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LAPORAN JAGA PDW

Tgl 29Juli 2015PPDS Jaga:dr. Adwin Adnandr. Aziz

dr. Karldr. Rid!aluldr. Nadi"#a!Dr. $r%anDr. Andri GunawanDr. Wa!#uni

Dr. &'ndra

Ti( Jaga $GD:1. &ar)una2. $n*an

+aulinar,. -u* +adng. Ki/i R.5. Riz/i +auli

Ti( Jaga PDP:1. a/!rul G.2. -i*ra P.,. Lura N.. Ri*a S.5. $"nanil &.. Ad' P.. K!aliza +.

3. R'ni A.

Ti( Jaga PDP:1. 4z(il Ari%a2. i*ara .,. Riz/ia. Rzalia 6.5. uni*a. D'"i

Ra*na"ari

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Na(aPa"i'n

: N#. N

4(ur : 1 *a!un

Ala(a* : La( a*'u/ N. R+ : 979,75

P'(8ia#aa

n

: PJS

$d'n*i*a"

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Ana(n'"i"

K'lu!an 4*a(a : D'(a( "')a/ 2 !ariS+RS

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Riwa#a* P'n#a/i* S'/arang

Pa"i'n da*ang d'ngan /'lu!an d'(a( "')a/ 2 !ari S+RSd'(a( dira"a/an *'ru" ('n'ru" dan /adang di"'r*ai ('ngigil.Pa"i'n )uga ('ng'lu!/an n#'ri "'ndi dan "a/i* /';ala *'ru"('n'ru" "';'r*i di*'/an. Pa"i'n )uga ('ngala(i (ual (un*a!"'"'/ali (un*a! 8'ri"i (a/anan dan (inu(an #ang di/("u("i

riwa#a* (un*a! !i*a( *ida/ ada. Riwa#a* 8a*u/ <=> 8'rda!a/ <7>"'"a/ <=> dan n#'ri dada "'8'lu(n#a *ida/ ada. r'/u'n"i AK"'8'lu(n#a 17, /ali?!ari warna /uning @lu(' 1007200 ?AKna(un 2 !ari *'ra/!ir ini ;a"i'n "'ring AK ;ada (ala( !arid'ngan %r'/u'n"i !ingga /ali. N#'ri "aa* AK <7> AK 8'r;a"ir<7>. A dala( 8a*a" nr(al diar' <7> A !i*a( *ida/ ada.

Pa"i'n ('(ili/i lu/a ;ada /a/i /anan dan /irin#a. Lu/a ;ada /a/i/anan "uda! ada "')a/ 2 *a!un #ang lalu a/i8a* *'r/'na duri.S'dang/an lu/a ;ada /a/i "'8'la! /iri "')a/ 2 8ulan #ang lalua/i8a* *'r/'na ;a/u. Lu/a 8'rnana! <=> dan n#'ri <=>. Pa"i'n )uga('ng'lu!/an "uli* 8'r)alan a/i8a* lu/a ;ada /'dua /a/in#a

*'r"'8u*. Pandangan /a8ur <7> /'8a" <7> /'"'(u*an <7>.

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Riwa#a* P'n#a/i* Da!ulu :

Dia8'*'" ('lli*u" "')a/ 1, *a!un #ang lalu/n*rl ru*in di ;li 'nd/rin RS4D6A "')a/ 2

*a!un #ang lalu. Riwa#a* /'l'(a!an angg*a g'ra/ a*a" /anan

"')a/ , 8ulan #ang lalu

&i;'r*'n"i <7>

Riwa#a* P'nggunaan O8a* :

$n"ulin n@ra;id 20720720 dan l'@'(ir 07070720 iu

Ga8a;'n*in

7/17/2019 mr ulkus


Riwayat Penyakit Keluarga : &';a*i*i" &i;'r*'n"i D+ <=> a"(a al'rgi

"a/i* )an*ung *ida/ ada

Riwayat Sosial Ekonomi dan Kebiasaan : P'/'r)aan "'rang i8u ru(a! *angga

7/17/2019 mr ulkus


P'('ri/"aan i"i/

K'adaan u(u( : *a(;a/ "a/i* "'dang

K'"adaran : (;" ('n*i"

TD 120?0 ((&g ND 3 B?('ni* r'gul'r i"i u/u; /ua*ang/a*

RR 2 B?('ni* T: ,3 C-

: 52 /g T: 155 ( $+T: 21 /g?(2 <nr(w'ig!*>

Kuli* : Saw (a*ang *urgr /'(8ali ';a*

K';ala : D'%r(i*a" <7>

Ra(8u* : !i*a( *ida/ (uda! dia8u*

+a*a : /n)ung*i@a ;al;'8ra in%'rir ;ua* <=?=>

"/l'ra i/*'ri/ 7?7

T?&?+ : dala( 8a*a" nr(al

L'!'r : JP R72 (&2O ;'(8'"aran KG <7>

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P'('ri/"aan i"i/

Jan*ung:

$ : i/*u" /rdi" *ida/ *'rli!a*

P: i/*u" /rdi" *'ra8a di 1 )ari ('dial $-S 5 lin'a (id la@iula

P: a*a" : 8a*a" a*a" )an*ung ;ada i" , (idla@iula "ini"*ra

Ka: 8a*a" )an*ung /anan ;ada $-S 5 Lin'a Para"*'rnal d'B*ra Ki : 8a*a" )an*ung /iri ;ada $S 5 lin'a (id la@iula "ini"*ra

A: un#i )an*ung $7$$ r'gul'r gall; <7> 8i"ing "i"*li/ <7>

Paru7;aru:$ : G'ra/an dada "i('*ri" ;ada "*a*i" dan dina(i"

P: %r'(i*u" ('ning/a* /'dua la;angan ;aru

P: "nr ('('nd'/ ;ada 1?, la;angan ;aru 8awa! "ini"*ra

A : '"i/ular rn/!i 8a"a! di 1?, 8awa! la;angan ;aru 8awa! "ini"*ra

<=?=> w!''zing <7?7>

7/17/2019 mr ulkus


P'('ri/"aan i"i/

A8d('n:

$ : di"*'n"i <7>

P : "';'l &a*i?li'n? !';ar *a/ *'ra8a

P : *i(;ani <=> "!i%*ing duln'"" <7>A : i"ing u"u" <=> /'"an nr(al

F/"*'r(i*a":

lu/a ;ada '/*r'(i*a" 8awa! r'gin ;'di"d'B*ra "ini"*ra.

;ua* <7> 'd'(a <7> (*ri/ <5757575>. A$d'B*ra 120?125 09 A$ "ini"*ra 125?120 10

7/17/2019 mr ulkus


P'('ri/"aan P'nun)ang

Laboratorium (30-7-20!"

&8 : 3, g?dl

&* : 25 H

Fri*r"i* : ,,00.000?((,

L'u/"i* : 1.00 ?((,

Tr(8"i* : ,03.000?((,

Na : 1,0((l?L

K : , ((l?L

-l : 93 ((l?L

KGDS : 22 (g?dL

diI*'l : 0?0?5?1?3

LA $PD <,0??2015>

iliru8in : n'ga*i%

Pr*'inuria : =2

4r8iling'n : n'ga*i%

R'du/"i : =1

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FKG

7/17/2019 mr ulkus


Da%*ar +a"ala! :

1. S';"i" ' dd

1. 4l/u" dia8'*i/u( a?r P'di"

,. -AP

2. 4l/u" Dia8'*i/u(?r ;'di" d'/"*ra "ini"*ra,. D+ *i;' 2 nr(w'ig!*

7/17/2019 mr ulkus


#asala$ Pengka%ian Ren&ana'iagnosis

Ren&anaatalaksana

) Se*sis e&dd +lkusdiabetikum

a,r Pedis

2) +lkusdiabetikuma,r *edisdetra

sinistra

"? d'(a( 2 !ari #ang lalulu/a ;ada /'dua /a/i

? l'u/"i* 1.00 ?((

S? : *'rda;a* lu/a di /a/i/anan dan /iri ;a"i'n.

lu/a #ang "uli* "'(8u!

La8 : GDS : 22 (g?dl

-- r'a/*i%;r*'in

-Pral"i*nin

- /ul*ur ;u"-STA

-Dara! Ru*in- Rn*g'n;'di"

era*i.armakologis- / &e.triaone /

gr,2 %am- Para&etamoldri* , 2 %am

era*i non.armakologis :

7Tira! 8aring7rawa* lu/a? !ari

era*i.armakologis :$@ l'@BaBin 500(g?2 )a(

Edukasi• +'n)'la"/an

/';ada ;a"i'nr'nana;'('ri/"aan

"'lan)u*n#a• +'n)'la"/an ;ada

#asala$ Pengka%ian Ren&ana Ren&ana atalaksana

7/17/2019 mr ulkus


#asala$ Pengka%ian Ren&ana'iagnosis

Ren&ana atalaksana

2. D+ *i;' 2nr(w'ig!*

S? 7 ;a"i'n ('ng'lu!/an "'ring AK;ada (ala( !ari

7 Riwa#a* /'luarga D+ <=> 7 +'(ili/i riwa#a* D+ "')a/ 1,

*a!un #ang lalu

O? ;'('ri/"aan "i/ : : 52 /g T:155 ( $+T: 21 /g?(2 <nr(w'ig!*>

KGDS : 22 (g?dl

-P'ri/"a KGDS2 PP- *!ra/"-undu"/;i-4rinali"a

-&8A1-

era*i non.armakologis:'iet '# 700 kkal

1arrmakologi :

S l'@'(ir 07070711S n'@ra;id 77

#onitoring7 KGDS

Edukasi7('n)aga ;la (a/an

7Ola!raga "'ara *'ra*ur

7/17/2019 mr ulkus


TFR$+A KAS$&

mr ulkus

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