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Re%u&e #'(at#e't
Nama Usia Diagnosis
A'.) 2 ta$u' e&a&"e'*ue
A'.A + ta$u' e&a&"e'*ue
A'.M 2 ta$u' e-a'*e&a&&(lek%
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1. Na&a / A'. )
Je'#% ela' / Pere&(ua'
U&ur / 2 ta$u'
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• Keluhan Utama / e&a&
• Riwayat Penyakit Sekarang :
e&a& $ar# ke3. e&a& 'a#k turu' "e'*a'(e&er#a' at (e'uru' (a'a%. Me'*#*au ,
&e'**#*#l . Pa%#e' %e&(at &e'*ala ke-a'* 1
ket#ka "e&a&. e-a'* ter-a"# %ela&a 51+ &e'#t.
et#ka ke-a'* %eluru$ tuu$ &e'e'tak'e'tak.
Pa%#e' "#a7a ke Pu%ke%&a% ter"ekat "a' "#er#
at le7at a'u%. )eelu&'a (a%#e' &e'*ala
atuk er"a$ak 5 3 $ar# %eelu& MR).Mual ,&u'ta$ ,%a' , *u%# er"ara$ . BAB "a'
BA "ala& ata% 'r&al. Na8%u &aka' &e'uru'.
)eelu&'a (a%#e' %e&(at "#ra7at "# Pu%ke%&a%
%ete&(at
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Riwayat Penyakit Dahulu :
T#"ak a"a kelu$a' %eru(a %eelu&'a
Riwayat Penyakit Keluarga :
T#"ak a"a keluar*a a'* &el#k#
kelu$a' a'* %a&a "e'*a' (a%#e'
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Pe&er#k%aa' !#%#k
• ea"aa' U&u& / ta&(ak %ak#t r#'*a'
• e%a"ara' / 9&(%&e't#%
• :#tal )#*'/
Na"# / 140;&e'#t
!rek. 'a(a% / 2
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• Kepala/leher / A'e% ;, #kteru% ;, &ata
=7'* , uu'uu' =eku'* ,(er'a(a%a'=u(#'* $#"u'* , %#a'%#% , &uk%a ##r a%a$
>, l#&8a"e'(at#
• ThoraxPul& /
I'%(ek%# / Be'tuk "a' (er*eraka' %#&etr#%, retrak%#
I9)
Pal(a%# / !retu% raa %ul#t "#e?alua%#
Perku%# / )'r "# %e&ua la(a'*a' (aru
Au%kulta%# / :e%#kuler, R$'k# ;, 7$ee@#'* ;
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9r /
I'%(ek%# / I=tu% =r"#% t#"ak ta&(ak
Pal(a%# / I=tu% =r"#% t#"ak teraaPerku%# / Bata% -a'tu'*
a'a' / I9) III r#*$t (ara%ter'al l#'e
#r# / I9) : le8t "=la?#=ular l#'e
Au%kulta%# / )1)2 tu'**al re*uler, *all( ,&ur&ur
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• !"omen
I'%(ek%#/ Ta&(ak "atar
Pal(a%# / )e, 'er# teka' , $e(at&e*al# ,%(le'&e*al# , &a%%a tur*r kul#t a#k.
Perku%# / T#&(a'#
Au%kulta%# / B#%#'* u%u% > ke%a' 'r&al
• #kstrimitas
Akral $a'*at, e"e&a ;
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•
Pemeriksaan Penun$ang: Leuk%#t / 4400 ;&&3
e&*l#' / C,2 *r;"l
e&atkr#t / 20,1 D
Tr&%#t / 10E.000 ;&&3
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IAGNO)I)
%&D D'
DiagnosisKer$a
e&a&e'*ue
e&a&"e'*ue
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PFNATALA)ANAAN
%&D D'
I:! RL 12 t(& I:! RL 16 t(& &akr
Para=eta&l %r.3 1 =t$ Para=eta&l %r 3
=t$#a@e(a& ta 2 2 &* #a@e(a& %u(( 10 &*
-#ka ke-a'*
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2. A'. A;+ ta$u'; Pere&(ua'
U / e&a&
RP) / e&a& $ar# ke4. e&a& 'a#k turu' "e'*a'
(e&er#a' at (e'uru' (a'a%, &e'**#*#l , ke-a'*
. Pa%#e' -u*a &e'*ala atuk er"a$ak %e-ak 2 $ar#%eelu& MR). Pa%#e' a"a %e%ak %e-ak 4 $ar# Pa%#e'
t#"ak a"a &ual , &u'ta$ , BAB "a' BA "ala&
ata% 'r&al
RP / Pa%#e' t#"ak (er'a$ &e'*ala ke-a'*
%eelu&'a
RP / eluar*a (a%#e' t#"ak a"a kelu$a' %eru(a
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Pemeriksaan (isik :
e%a"ara' / =&(% &e't#%
Ta'"a :#tal / N / C6;# T/ 36,3H 9
RR/ 24 ;#e(ala;Le$er / A'e% ; , Ikter#k ;, (er'a(a%a' =u(#'*
$#"u'* , %#a'%#% , &ulut &e'=u=u
(e&e%ara' GB , !ar#'* $#(ere%
T$rak%/
Pul& / I'%(ek%# / Per*eraka' %#&etr#%, retrak%#%u=%tal , R$'k# >;>,
7$e@#'* ;
Pal(a%# / Geraka' "a"a %#&etr#% )
Perku%# / )'r
Au%kulta%# / :e%#kuler9r / I'%(ek%# / Iktu% =r"#% t#"ak terl#$at
Pal(a%# / I=tu% kr"#% teraa (a"a #=% +
Perku%# / Bata% -a'tu'* "ala& ata% 'r&al
Au%kulta%#/ )1, )2 tu'**al re*uler, Gall( ,
Mur&ur
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A"&e' / I'%(ek%# / atar Pal(a%#/ )e, $e(at&e*al# , tur*r kul#t a#k
Perku%#/ T#&(a'#
Au%kulta%# / Bu > ke%a' 'r&al
Fk%treta% / Akral $a'*at, e"e&a
Ru&(le Lee" / >
Pe&.Pe'u'-a'* /
/ C,1=t / 2
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%&D D'
DiagnosisKer$a
e&a&e'*ue ""!
! *ra"e I
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PFNATALA)ANAAN
%&D D'
I:! RL 1+ t(& I:! RL 1+ t(& &akr
Para=eta&l %r.3 1
=t$
Para=eta&l %r 3
=t$Ba'ak 'u& Ba'ak 'u&
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3. A'.M; 2,1 t$ ; Per&u(a'
elu$a' Uta&a / e-a'*
R#7aat Pe'ak#t )ekara'* /
e-a'* "#ala %ea'ak 6E "e'*a' "ura%#+ &e'#t, ke-a'* ter-a"# 4 $ar#)MR) .et#kake-a'* %eluru$ tuu$ (a%#e' &e'e'tak'e'tak "a' &ata'a &e&elalak ke ata%.Pa%#e' -u*a &e'*ala "e&a& $ar# ke4,&e'**#*#l . Batuk , &ual , &u'ta$ ,BA 'r&al, BAB 'r&al
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Riwayat Penyakit Dahulu :
T#"ak a"a kelu$a' %eru(a %eelu&'a
Riwayat Penyakit Keluarga :
T#"ak a"a keluar*a a'* &el#k#
kelu$a' a'* %a&a "e'*a' (a%#e'
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Ter%e'u& / + ula'
M#r#'* / 6 ula'
Te'*kura( / 6 ula'Mera'*kak / elu& #%a
Ber"#r# / elu& #%a
Ber-ala' / elu& #%aB#=ara 2 %uku kata / elu& #%a
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Pe&er#k%aa' !#%#k
• ea"aa' U&u& / ta&(ak %ak#t r#'*a'
• e%a"ara' / 9&(%&e't#%
• :#tal )#*'/
Na"# / 124;&e'#t
!rek. 'a(a% / 24;&e'#t
)u$u / 36,+ 0 9
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• Kepala/leher / A'e% ;, #kteru% ;, &ata
=7'* , uu'uu' =eku'* ,(er'a(a%a'=u(#'* $#"u'* , %#a'%#% , &uk%a ##r a%a$
>, l#&8a"e'(at#
• ThoraxPul& /
I'%(ek%# / Be'tuk "a' (er*eraka' %#&etr#%, retrak%#
I9)
Pal(a%# / !retu% raa %ul#t "#e?alua%#
Perku%# / )'r "# %e&ua la(a'*a' (aru
Au%kulta%# / :e%#kuler, R$'k# ;, 7$ee@#'* ;
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9r /
I'%(ek%# / I=tu% =r"#% t#"ak ta&(ak
Pal(a%# / I=tu% =r"#% t#"ak teraaPerku%# / Bata% -a'tu'*
a'a' / I9) III r#*$t (ara%ter'al l#'e
#r# / I9) : le8t "=la?#=ular l#'e
Au%kulta%# / )1)2 tu'**al re*uler, *all( ,&ur&ur
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• !"omen
I'%(ek%#/ Ta&(ak "atar
Pal(a%# / )e, 'er# teka' , $e(at&e*al# ,%(le'&e*al# , &a%%a tur*r kul#t a#k.
Perku%# / T#&(a'#
Au%kulta%# / B#%#'* u%u% > ke%a' 'r&al
• #kstrimitas
Akral $a'*at, e"e&a ;
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•
Pemeriksaan Penun$ang: Leuk%#t ;&&3
e&*l#' / *r;"l
e&atkr#t /
Tr&%#t / ;&&3
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IAGNO)I)
%&D D'
DiagnosisKer$a
e-a'* e&a&&(lek%
e-a'*"e&a&
k&(lek% Glal
e?el(&e'tal elae"
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PFNATALA)ANAAN
%&D D'