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7/23/2019 CKD-MR 16 OKT http://slidepdf.com/reader/full/ckd-mr-16-okt 1/25 MORNING REPORT 16 OKTOBER 2013
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7/23/2019 CKD-MR 16 OKT
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MORNING REPORT16 OKTOBER 2013
7/23/2019 CKD-MR 16 OKT
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IDENTITAS PASIENNama : Ny. T (RM : )Umur : 54 a!u"
A#m: N$am%&r r 14'04 a* a"+u"$,r-"$-" a"&m
BB : 40 $
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KE/UAN UTAMANyr- %ru
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SEKARAN
Nyr- %ru 2 m-"$$u SMRS. Nyr- a+am
"yr- - %ru a"a" aa* m,u* %u"$$u"$
"yr- +u$a -ra*aa" - %ru ,aa!
"yr- ,ram,a! *aa uu
"yr- !-#a"$ -m,u#Mu"a!+ 4 a#- -*- maa"a". T-a% a#- mu"a!
1507240 88BAB (7) 3 !ar- "u (9). BAK 2 (N)
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,aa" #ma* 1 ,u#a"Nyr- %a#a (9) 1 ,#" mm,a- $ &*a&"
172 +am "yr- m,a#-."a;*u maa" m"uru" 1 m-"$$u SMRS.Pu*-"$ (9) ,r%uar -a aa" ,r-r-Pa*-" m"$#u! $aa# - u,u! *+a 1 ,#".
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RIAAT PENAAKITDAU/UMRS < mam -;&-DM (7)T (9) *+a ,ra%a #ama=
RIAAT PENAKITKE/UARA
Dmam -;&-
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PEMERIKSAAAN >ISIK
Kaaa" umum : ,a-K*aara" : 8&m%&* m"-*?-a# S-$"
Ta"a" Dara! : 160'120 mm$
Su!u a*-#r : 36.4 @
Na- : 2 'm"-
RR : 23 'm"-
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Kepala :
Maa : 8&&"$ (7) a"m-* (9) -8ru* (7) maa mra! (7)
-u"$ : D-*%"u (7) %-*a*-* (7) *r (7)
T#-"$a : %rara!a" (7)
>&&r urm- (9)
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Leher :Pm,*ara" KB (7)
Pm,*ara" -r&- (7)
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Thorax :
D-"-"$ aa : ,"u "&rma#
Paru :
I"*%*- : %r$raa" -"-"$ aa *-mr-*9'9
Pa#%a*- : ;rm-u* ra,a *-mr-* 9'9
Pru*- : *&"&r 9'9
Au*u#a*- : ?*-u#r 9'9 !C-"$ 7'7 R&"8!- 7'7
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a"u"$ :I"%*- : -a am%a -8u* 8&r-*
Pa#%a*- : -a ra,a -8u* 8&r-*
Pru*- : ,aa* +a"u"$ -r- M/ *-"-*ra -8* ?,aa* +a"u"$ a"a" PS/ ra
Au*u#a*-: S1 S2 Tu"$$a#
$a##&% (7) murmur (7)
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Abdomen :
I"*%*- : %ru *&
Au*u#a*-: BU (9) N
Pa#%a*- : %ar'#-"'r" -a ra,a
"yr- a" %-$a*r-um (9)!-%&&mr-um a"a" (9)
Pru*- : -m%a"-
a" * '* (9)
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Ekstremitas :
Ara# !a"$a 9 9 Oma 7 79 9 7 7
u#- r-"$ 9 9
9 9
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Pmr-*aa"/a,&ra&r-um
Nama
Pemeriksaan
Hasil Nilai Normal
B F.4 / : 13.071F $G H P :
11.4715.1 $G
/u&*- 5.300 4.500 11.000
/a+u E"a% Dara! 2572J / : 0715 H P : 0720
(mm'+am)-u"$ "-* 1'0'0'5J'31'1
0
172'071'374'40750'207
40'47J
P? 23 / : 40750G H P : 3F74FG
Tr&m,&*- 2F6.000 150.0007350.000'/
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Nama
PemeriksaanHasil Nilai Normal
M? J6 J074
M 2J 26732
M 32 32736
B-#- T 0.43 L1 m$'#
B-#- D 0.J1 0.2 m$'#
SOT 11.3 0731 /
SPT .0 0732 '/
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Nama
Pemeriksaan
Hasil Nilai Normal
BUN 6F2 4.J 23 m$'#
Srum 8ra-"-" 5.32 0.5 1.2 m$'#
Ur-8 a8- J. 2.475.F m$'#
A#,um-" 7 3.575.2 $'#
#&,u#-" 7 173 $'#DA 102 126 m$'#
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Nama
Pemeriksaan
Hasil Nilai Normal
P! 6.0 57J
Bra "-* 1.010 100371030
%r&-" F5'u# (99) "$a-;
#u&*- 100 'u# (99) "$a-;
B-#-ru,-" 7 "$a-;
Er-r&*- 10'u# (9) "$a-;
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edimen !rine Hasil Nilai Normal
/u&*- 25730 073 '#%,
r-r&*- 10715 071 '#%,
*-#-"r 7 "$a-;
%-# 274 91
r-*a# N$a-; N$a-;
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ELEKTROLIT Hasil Nilai Normal
Na 140 1367145 mm&#'/K 5.1 35751 mm&#'/
a .J J17104 m$'#
# 104 4F7111 mm&#'/
Rumu* "o"kro#t$%o!lt :
0.J5 10.3
INITIAL PRO&LEM
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INITIAL PRO&LEMINITIAL
AEMENTINITIAL
PLANNINGTPL PPL
Nyr- !-%&&"r-um Dm,u* %u"$$u"$
"yr- *u%ra %u,-*Mu"a!Nyr- a"%-$a*r-um
Nyr- a"
!-%&&"r-um D
Baa" #ma*K&"+u"-a a"m-*B : F.6
Nyr- %a#a TD : 160'120 mm$
aa# - u,u!>&&r urm- (9)
Ku#- r-"$ a"m-aMua# mu"a!
-*%%*-a
&#-8a,&m"
a"m-a
T
S-"r&m
urm-8
KD ?
-%r"*-
O,*. &#-8a,&m"
A"m-a
PD :BO> US ABD
%!&*%a
PT :D- TKRPRPr& : 40 $r'!rKa#&r- : 100'!ar-
Ka#-um -,aa*-I";. R"*am-" 24088'24+m
Tra";u*- PR 1,a$'!ar- *m%a- B I"+. Om%raCŒm$I"+. K&r&#a8 21
I"+ a #u8&"a* 21
a%&%r-# a,325m$
Pm& :
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INITIAL PRO&LEMINITIAL
AEMEN
T
INITIAL
PLANNING
TPL PPL
Ur-8 a8- : J.
>#a" * (9)
,u" : 6F.2
S : 5.32
>R : 10.3
Pr&-" : F5 m$'# (99)
/u&*- : 100'u# (99)
Er-r&*- : 10'u# (9)
S : / : 25730
E : 10715
!-%rur-8m-a
aC&m-a
R"a# -*&rr
Pr&-"ur-
maur-
KD ?
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M"$a%a=BO> u"u m#-!a a%aa! aa &,*ru*- ar"a ,au
aau *%&"-#--* r,ra % "yr- %-"$$a"$US a, : $-"+a# m"$8-# : KD. -"+a# mm,*ar
:!-r&,;r&*-* : r+a- ar"a *um,aa" *!$ $-"+a#
&r#&a 8a-ra".
P!&*%a : ,r-aa" $ 8a#*-um. -a ;&*;a -"$$-a#-um aa" ,a"ya - -a &#! %!&*%a &*&%!&r&*-*.,r-a" aO3 50073000 m$ u m"am,a! a*u%a"
a " &r*- !-%&a#m-.-"ar- maa"a" -"$$- %!&*%&r : a8a"$ * r-m
+u.
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I"+ 8a $#u&"a : m"uru"a" !-%ra#m-!-%ra#m- ar-m-a -a a#-um *a"$a -"$$- (KF) : -"*u#-"7
r&*" -1 u"- -"*u#-" -a% 5 $r $#u&*a.M-*a# -"; D10G (1 * 50088)
500 88 50 $r. I"*u#-" -,r-a" : 10 u"-
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P"$aura" ,a#a"8 8a-ra"I"%u (&u%u7500 88)
Pm,r-a" 8a-ra" $ -";'m-"um !ru* ,a#"8$ &u%u
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TERIMAKAIH
