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MORNING REPORT
28 Desember 2015Oleh :
Robertus Brian Junarli (1102005054)
I Made Restu Widiana (1102005074)
I Komang Gede riana !di"utra (110200510#)
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Identitas Pasien
Nama : PM
Jenis Kelamin : Lai!lai
"sia : 5# ta$%n
&'ama : (ind%
N) RM : 150*28+0
&lamat : Jl, -i%n' .anara n), I & Gian/ar
Peeraan : Pensi%nan PN
tat%s Pernia$an : Menia$
Tan''al MR : 2 Desember 2015 314,15 .IT&
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&namnesis
Keluhan Utama : N/eri dada
Onset : 6 + $ari MR7 memberat 15 am MR
Lokasi : Dada iri dan anan asien7 menalar e len'an anan
Kualitas : N/eri seerti tertindi$7 15 menit setia seran'an ada $ari ertamdan ed%a7 di $ari eti'a el%$an dirasaan meneta
Kuantitas : N/eri $ilan' timb%l
Gejala penyerta : 9erdebar 3!7 erin'at din'in 37 PND 3!7 DOE3!7 )rt$)n3!7 anas badan 3!7 9at% 3!7 m%al 3!7 m%nta$ 3!
Faktor memperberat : 9erati;itas
Faktor memperingan : di 2 $ari ertama el%$an membai den'an istira$at7
$ari e!+ el%$an tida membai den'an istira$at
Kronologi : Pasien mer%aan r%%an dari R"D ani
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&namnesis
Ri
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Pemerisaan @isi
Tanda Vital
Keadaan Umum : ait edan' Score Nyeri V!S" : 2A10
Kesadaran : -)m)s mentis 3E4B5M*
Tekanan #arah : 120A80 mm('
Suhu : +*750 -
Nadi : 5CAmenit
$$ : 20 CAmenit
Saturasi Oksigen : 100 ada O2 nasal >ann%la 2 lm
%erat %adan : 1 '
Tinggi %adan : 1*8 >m
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Pemerisaan "m%m
Kepala
N)rm)>e$ali
&ata
K)n%n'ti;a anemis !A!7 slera iter%s !A!7 )dem alebra !A!7 %il is))r A
Leher
JBP: PR 6 0 >m (2O7 embesaran elenar !A!7 t$/r)id !A!
Thora'
imetris
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Pemerisaan "m%m
(antung
)* +nspeksi : It%s )rdis n)rmal7 %lsasi di aeC
2, ,alpasi: It%s )rdis n)rmal7 t$rill 3!
+, ,erkusi
9atas atas : I- II
9atas ba
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Pemerisaan "m%m
,ulmo :
%ara na?as ;esi%ler 3A7 r)n$i 3!!!A!!!7 dan
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Pemerisaan Pen%nan'
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Pemerisaan Pen%nan'
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Pemerisaan Pen%nan'
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INTERPRET&I EKG
Irama sin%s (R *0CAmenit7
&Cis L&D
P n)rmal
PR inter;al 071* deti
FR 0712 deti
RA di B1 1 mm
T!T >$an'e : T ele;asi di B2!B*7 I7 aBL l%red di B5!B*7 I7 aB@7 B1!B+ R
Kesan NR TEMI anteri)r estensi? -R999
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@OTO T(OR&H
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INTERPRET&I RONTGEN T(OR&H
@)t) T$)raC &P :
-)r : besar dan bent% esan n)rmal7 tama alsi?iai a)rti> n)b P%lm) : tama )ns)lidasi di aeC ar% iri, Tama enebalan $il%s anan
in%s le%ra anan dan iri taam
Dia$ra'ma anan iri n)rmal
T%lan'!t%lan' : tida tama elainan
Kesan :
%se r)ses sesi?i 3m)$)n )relasi linis dan lab)rat)ri%m
Penebalan $il%s anan
&)rt)s>ler)sis
aran : @)t) T) L)rd)ti>
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Dara$ Len'a 321A12A2015
,arameter $esult +nterpretation Normal Value
.9- )/*0 1 4,1!11
NE" 0*/2) 1 2,5!,5
LM 2,4 1,0!4,0
MONO 1,40 1 0,1!1,2
EO 0,141 1 0,0!0,5
9&O 0,0#4 0,0!0,1
R9- 5,1 4,50!5,#0
(G9 14,2 1+,50!1,50
(-T 4*,8 41,0!5+,0
M-B 81,# 80,0!100,0
M-( 24,8 L 2*,0!+4,0
M-(- +0,2 L +1,0!+*,0
RD. 14,+ 11,*!14,8
PLT 20# 150!440
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Kimia Klini 321A12A2015
,arameter 3 result Normal 4alue $emarks
GOT 244, 11!++ 1
GPT 48,8 11!50
9 &>a #* 0!140
9"N 8 8!2+
-reatinin 0,88 0,!1,2
-KM9 Massa 40 0!5 1
Tr))nin T #*4 50ne'ati;e7 50!100l)
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(emat)l)'i 321A12A2015
,arameter $esult Normal 4alue $emarks
PPT 10, N)rmal
erbedaanden'an )ntr)l 2 deti
INR 0,##
K)ntr)l PPT 12,1
,arameter $esult Normal 4alue $emarks
K)ntr)l &PPT ++,#
&PTT ++,* N)rmal erbedaanden'an )ntr)l deti
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Dia'n)sis
$ TEMI anteri)r eCtensi? 3Kili 1$ Late )nset
$ TIMI +A14
$ -R999
$ Tana ?ibrin)liti
$ (iertensi ter)ntr)l
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Penatalasanaan
MR
IB@D Na-l 07# 8 tm O2 4 lm
&set)sal 1 C 80 m'
-l)id)'rel 1 C 5 m'
-at)ril + C *,25 m'
Diaeam + C 5 m'
En)Caarin 2 C 07* >> i;
LaCadin + C 1 >t$
im;astatin 1 C 20 m'
IDN + C 5 m'
K)nser;ati?
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Terima Kasi$