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P P D S J A G A

D R . S H I D D I Q , D R . I L M I

C O A S S J A GA

FA U Z A N F , S A B I L L A S

LAPORAN JAGA

BANGSALSELASA, 1 MARET 2016

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REKAPITULASI PASIEN BARU

•  Tn. S  Dy!n"# ".$ %$&! '' !n"#()n*&+)&-* '' ""(&, DM /*!" II, CKD /

• Ny. S H*!)+*"(*& !&'& DM /*!" II

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I. IDENTITAS

N&(& 3 Ny . S

U*& 3 45 /&%#n

 J"n* "+&(*n 3 P"-"(!#&n

A&(& 3 I+&(

S/&/#3 S#'&% M"n*&%

P""-&&n 3 I# -#(&% /&n&

A+&(&/ 3 J&&-/& P#&/

MRS 3 1 M&-"/ 2016

N) RM 3 250754

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II. DATA DASAR

Anamnesis

8A#/)&n&(n"* '&n A++)&n&(n"* /&n&+2 M&-"/ 2016 !##+ 01.009IB:

Keluhan Utama

!"n#-#n&n "&'&-&n "& 1 HSMRS

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RI9A;AT PEN;AKIT SEKARANG

20 Tahun SMRS3 P&*"n '* '*&n)* '*&"/" ("+*/#. P&*"n)n/-)+ -#/*n " ')/"- '&n '*"-* )&/ ("/:, ny"-* '&'& 8>:. L&+# "+#&-& !&*"n +&n#n

("(&?& !&*"n " IGD, '* $" GDS @0 (='+ ("n#n&&n On" /)#$%.L&+# '* IGD '*"-*&n D"/-)" 50 @ &$)n, +&+# "&n ("n%*+&n '&n

!&*"n +"(& '&n (#+&* &'&-. C" GDS 1@ (='+

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RI9A;AT PEN;AKIT SEKARANG

Di Bangsal pukul 01.00 3 !&*"n (&*% ("-&&+"(&, !#*n 8:, !"&+>!"&+ '*"+#-#% &'&n,

"("/&- 8:. BAK 8: n)-(&+, BAB 8: n)-(&+.K"-*n&/ '*n*n 8>:, (#&+ 8>:, (#n/&% 8>:, ny"-* '&'&

8>:, "& 8>:.

R*?&y&/ (&&n !&*"n /+ 1 (&-"/ 2016.

!&* 804.00:3 ## '*&"/&)+.

0.00 3 #&%

S*&n 812.00: 3 n&*, +, &y#-, #

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Riwayat Penyakit Dahulu

K"+#%&n "-#!& 1 /%n ;++ '*"-/&* %"()-)*'

HT, &n/#n, *n&+, &(&, &+"-* '*&n&+

Riwayat Penyakit Keluaga

DM, HT, A(&, &+"-*, &n/#n, *n&+, '*&n&+

Riwayat Peng!"atan

M"/

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Pemeiksaan %isik 

• T&(!& S&*/ S"'&nK"&'&&n #(#(

• C)(!) ("n/*K"&'&-&n

• 110= 0 ((H T"&n&n D&-&%

• 107 = ("n*/F-"#"n* N&'*

• 1 = ("n*/F-"#"n* N&

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• N)-()$%"!&+, /*'& '*/"(#&n "+&*n&nK"!&+&

• C)n#n/*& &n"(* 8=:, +"-&*/"-*8>=>:M&/&

•  T*'& '*/"(#&n "+&*n&n, %*!"-"(* 8>:

 THT

•  JP 7>2 $(H2O, /*'& /"-'&!&/!"("&-&n KGBL"%"-

• M#)& **- +"(&, /*'& &'& +"*,

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• In!"* 3 *$/# $)-'* /"-+*%&/• P&+!&* 3 *$/# $)-'* /"-&& /*'& #&/

&n&/• P"-#* 3 &/& &n/#n '&+&( &/&

n)-(&+• A##+/&* 3 *-&(& /"-&/#-, 1>2 n)-(&+

(#-(#- 8>:, &++)! 8>:

 J&n/#n

• In!"* 3 n)-()$%"/• P&+!&* 3

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• In!"* 3 '&/&-, (&& 8>:• A##+/&* 3 **n ## 8:

n)-(&+• P&+!&* 3 #!"+, ny"-* /"&n 8>:.• P"-#* 3 /*(!&n* '* "+#-#%

+&!&n &')("n

A')("n

• A-&+ %&n&/, "'"( 8>:, CRT 2'"/*, "#&/&n )/)/ 7 7

•   7 7E/-"(*/&

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P"("-*&&n P"n#n&n 814.@:

 &enisPemeiksaan

Hasil 'ilai Ru(ukan

H" 11.) 1@ 14 ='+

H/ @7 50 72

E-*/-)*/ @,4 5.@ 6.0 #/&=L

L"#)*/ 420 5,400 10,400 =L

 T-)()*/ 247.000 170,000>500,000 = L

MC 0 40 6

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U-"#( @@ 20 70 (='L

K-"&/*n*n 0. 0.7 1.7 (='L

*luk!sa +aah

,sewaktu-

/ 150 (='L

N&/-*#( 1@ 1@7 15 (()+=L

K&+*#( 5, @,7 7,0 (()+= L

Kl!i+a 10) 7 107 (()+= L

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III. RINGKASAN

• Ny S, 45 /&%#n. D&/&n " IGD '"n&n "+#%&n!"n#-#n&n "&'&-&n +&+# "&n "$&-& ("n'&'&%*n& ("n**/ +*'&% "& &( 5 )-". S""+#(ny&!&*"n &'&-. K"-*n&/ '*n*n 8>:. '* $" GDS @0 (='+("n#n&&n On" /)#$%. L&+# '* IGD '*"-*&nD"/-)" 50 @ &$)n, +&+# "&n ("n%*+&n '&n!&*"n +"(& '&n (#+&* &'&-. C" GDS 1@ (='+.

• K"+#%&n &&/ *n* +"(&, "-*n&/ '*n*n 8>:, ny"-*!"-#/ 8>:, !#*n 8:, !"&+>!"&+ '*"+#-#% &'&n,"("/&- 8:. BAK 8: n)-(&+, BAB 8: n)-(&+.K"-*n&/ '*n*n 8>:, (#&+ 8>:, (#n/&% 8>:, ny"-* '&'&8>:, "& 8>:.

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III. RINGKASAN

• R*?&y&/ (&&n &*

• R*?&y&/ '&%#+# 3 K"+#%&n "-#!& 1 /%n ;++ '*"-/&*%"()-)*'

• R*?&y&/ K"+#&-& 3 >R*?&y&/ !"n)&/&n 3 A$&-)" 11, In#+*n 14 #

!&*

• P&'& !"("-*&&n *,• K"&'&&n #(#( 3 &*/ "'&n

• K"&'&-&n CM

•  TD 110=0, n&'* 107, #%# @6,7, RR 1.

• BB50 TB177 $(

  BMI 16, 678#n'"-?"*%/:

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III. RINGKASAN

• M&/& 3 CA 8=:

• A')("n 3 #!"+, NT 8>:, BU 8: n)-(&+,

• E/-"(*/& 3 &-&+ %&n&/, "'"( 8>:, CRT 2 '/

P"("-*&&n L&3

• An"(*& NN, %*!)+*"(*&, %*!"-+)-*'&

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I. DAFTAR MASALAH

1. H*!)+*"(*& !&'& DM /*!" II

2. An"(*& NN

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. PENGKAJIAN

1: H*!)+*"(*& !&'& DM /*!" II

•)An&(n"* 3 D&/&n " IGD '"n&n "+#%&n !"n#-#n&n"&'&-&n +&+# "&n "$&-& ("n'&'& %*n& ("n**/+*'&% "& &( 5 )-". S""+#(ny& !&*"n &'&-. K"-*n&/

'*n*n 8>:. '* $" GDS @0 (='+ ("n#n&&n On" /)#$%.L&+# '* IGD '*"-*&n D"/-)" 50 @ &$)n, +&+# "&n("n%*+&n '&n !&*"n +"(& '&n (#+&* &'&-.

•)K"+#%&n &&/ *n* +"(&, "-*n&/ '*n*n 8>:, !#*n 8:,"("/&- 8:. BAK 8: n)-(&+, BAB 8: n)-(&+. K"-*n&/'*n*n 8>:, (#&+ 8>:, (#n/&% 8>:, ny"-* '&'& 8>:, "& 8>:.

P. F** 3 TD 110=0, n&'* 107, #%# @6,7, RR 1.

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. PENGKAJIAN

a" *DS / mg+l

R"n$&n& D*&n)/* 3 GDP, GD2PP, HA1C,

R"n$&n& M)n*/)-*n 3 GDS = 2 &(, O"-&* TT

R"n$&n& T"-&!* 3

IFD D"/-)" 10 20 /!(  %&*  $" GDS  

 *& n)-(&+ &n/* IFD RL 20 /!(O&/ #n/# DM '* /)!

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. PENGKAJIAN

2: An"(*& NN

•  An&(n"* 3 +"(& 8:,

• P. F**3 TD 110=0, n&'* 107, #%# @6,7, RR 1.,

M&/& 3 CA 8=:

P L&3 H 11,, MC 0, MCH @1, MCHC @7

• R"n$&n& D*&n)/* 3 >

• R"n$&n& T"-&!*3 )&/* !"ny"& #/&(&  DM

 

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PROGNOSIS

• Q#) &' */&(3 '#*& &' )n&(

• Q#) &' F#n$/*)n&(3 '#*& &' )n&(

• Q#) &' S&n&/*)n&(3 '#*& &' (&+&(