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FAKULTAS KEDOKTERAN UNIVERSITAS MALAHAYATI
SMF ILMU BEDAH RS PERTAMINA BINTANG AMIN
BANDAR LAMPUNG
IDENTITAS PASIEN
Nama : Nn. C Jeni Ke!amin : Pe"em#$an
Um$" : 1% &a'$n Ban(a : )NI
Pe*e"+aan : Pe!a+a" A(ama : I!am
A!ama& : Ra+a,aa N-. RM : /0%%
I. ANAMNESIS
Diam,i! 2a"i : A$&-anamnei 2an a!!-anamnei Tan((a! : 13/3410
Jam :
1%.1/ )IB
1. Ke!$'an U&ama
Paien 2a&an( *e IGD RSPBA 2en(an *e!$'an 5a+a' 2an &$'$'
&e",a*a"
4 meni& 6an( !a!$
4. Ke!$'an Tam,a'an
)a+a'7 !en(an7 2a2a 2an #e"$& &e"aa #ana7 #e2i' 2an
*a*$. Sea* 89
;. Ri5a6a& Pen6a*i& Se*a"an(
O ,e"ama *e!$a"(an6a 2a&an( *e IGD RSPBA 2i,a5a -!e'
5a"(a
e&em#a& e&e!a'
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Ke+a2ian *e,a*a"an &e"+a2i 2i "$ma'n6a 2an men(enai e!$"$'
an((-&a
*e!$a"(a 6ai&$ a6a'7 i,$7 2an a2i*.
0. Ri5a6a& A!e"(i
Paien &i2a* memi!i*i "i5a6a& a!e"(i &e"'a2a#
$a&$ -,a& ma$#$n
ma*anan.
. Ri5a6a& O#e"ai
Ri5a6a& -#e"ai 2ian(*a!.
II. STATUS PRESENT
A. STATUS UMUM
Kea2aan $m$m : a*i& e2an(Kea2a"an : C-m#- Men&i
8V?E/M0
B. PEMERIKSAAN FISIK
Primary Survey:
A: Ai"5a6 ,e,a
B: Be"na#a #-n&an7 >"e*$eni na#a 41@3meni&7 "e($!e"7
*e2a!aman
=$*$#
C: A*"a! 2in(in7 >"e*$eni na2i /@3meni&
D: GCS 1/ 8E?V0M/
Secondary Survey:
Ke#a!a : Ram,$& &e",a*a" e,a(ian
)a+a' : 5a+a' &e",a*a" 2en(an 2e"a+a& !$*a ,a*a"
I9II
Ma&a : a!i &e",a*a"7 ,$!$ ma&a &e",a*a"7
*-n+$n(&ia &i2a* #$=a&7
=!e"a &i2a* i*&e"i*
Hi2$n( : 'i2$n( &e",a*a"7 ,$!$ 'i2$n( e,a(ian
&e",a*a"
M$!$& : !a,i$m in>e"i-" &e",a*a" 2en(an 2e"a+a&
!$*a ,a*a" I9II
Te!in(a : &e",a*a" 2en(an 2e"a+a& !$*a ,a*a" I9II
Le'e" : !e'e" ,a(ian 2e#an &e",a*a" 2en(an 2e"a+a& !$*a
,a*a" I9II
T'-"a@ : &'-"a@ an&e"i-" &e",a*a" 2en(an 2e"a+a&
!$*a ,a*a" II
Jan&$n( : BJ I II n-"ma!7 m$"m$" 897 (a!!-# 89
Pa"$ :ei*$!e"7 "-n*i 9397 5'eein( 939
A,2-men : a,2-men 2a"i $m,i!i*a! *e &'-"a@ an&e"i-"
&e",a*a"
2en(an 2e"a+a& !$*a ,a*a" II
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E*&"emi&a a&a : *e2$a !en(an &e",a*a" 2en(an
2e"a+a& !$*a ,a*a" II7
&e!a#a* 2an #$n(($n( &an(an &e",a*a" 2en(an
2e"a+a& !$*a ,a*a" I
e*&"emi&a ,a5a' : DBN
(eni&a! 2an an$ : DBN
Status Lokalis (daerahlukabakar):
Ke#a!a 2an Le'e" :
E*&"emi&a a&a *anan : 1%
E*&"emi&a a&a *i"i : 1%
Da2a :
Pe"$& :
P$n(($n( :
Pin((an( :
E*&"emi&a ,a5a' *anan :
E*&"emi&a ,a5a' *i"i :
Geni&a!ia :
T-&a! L$*a Ba*a" : 0;
III. PEMERIKSAAN PENUNJANG
LABORATORIUM
A. Laboratorium:
Be!$m 2i!a*$*an
IV.DIAGNOSIS KERJA
S$#.T"a$ma In'a!ai !$*a ,a*a" ,e"a& 82e"a+a& I9II 2en(an
!$a 0;
V. PENATALAKSANAAN
1. Pa&i*an ai"5a6 !a#an(7 !a*$*an -,e"ai.
4. Re$i&ai =ai"an :
R$m$ Ba@&e"
?== @ 2e"a+a& !$*a ,a*a" @ K( BB ?== @ 0; @ /?*(
1;.0% == RL
Ha"i #e"&ama :
/ $n&$* % +am #e"&ama 0.%? == RL @ 4 1;0.%
%@0 ?%
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4%;7/ m ?74/ &&32e&i* 8($6$"
/ $n$* 10 +am ,e"i*$&n6a 0.%? == RL @ 4 1;0.% 10@0 0
1?17/ m 47;04/ &&32&*
Ha"i *e2$a :
Se&en(a' +$m!a' =ai"an #e"&ama :
0.%? == RL @ 4 1;0.%
4?@0 1??
?7/ m 17// &&32e&i*
'a"i *e&i(a :
e&en(a' +$m!a' =ai"an *e2$a :
;.?4 == RL @ 4 0%.? ?74?m 7%/ &&32e&i*
4?@0 1??
;. Pe"a5a&an !$*a :
9 ,e"i'*an !$*a 2en(an NACL
9 2e,"i2emen&
9 2ein>e*i 2en(an S-! Sa!-n 874/ 3 47/ ("3!i&e"
9 -!e*an *"im an&i,i-&i* Si!e" S$!>a2iain
9 &$&$# !$*a 2en(an &$!!e
9 ,$n(*$ !$*a 2en(an e",an
?. Ana!(ei*
/. An&i,i-&i*
0. An&i &e&an$
. An&ai2
%. Paan( Ca&e&e" $"in $n&$* meman&a$ =ai"an
-$$&
. K-n$! S#.B
1. PROGNOSIS
$- A2 Vi&am : B-nam
$- A2 F$n=&i-nam : B-nam
$- A2 Sana&i-nam : B-nam
