POMR BAG/SMF ILMU BEDAH RSU HAJI SURABAYA FAKULTAS KEDOKTERAN UNIVERSITAS MUHAMMADIYAH MALANG 2016 Nama Um!" S!'! A)ama P,&P,&-..-.' .'a& a& P,',"aa&
: Ny Ny P : #$ Ta%!& : Ja(a : I*+am : SMA SMA : IRT
S!mma"y Daa Ba*, Keluhan Utama : Ny,". ,"! 'a&a& 'a&a& 5a(a% RPS : P7 m,&),+!% &y,". ,"! 'a&a& 5a(a% *,a' 2 5!+a& .&. A(a+&ya A(a+&ya &y,". -. !+! %a. ',m!-.a& .&-a% ', ,"! 'a&a& 5a(a% -a& m,&,a P7 *,".&) m,&)a m,&)a5a. 5a.'a& 'a& *a'.& *a'.&ya ya a. a. *,a' *,a' 2 m.&)) m.&))! ! .&. .&. a*.,& a*.,& m,"a* m,"a*a'a a'a& & *a'. *a'. 5,"am5a% a"a% M!a+ 89; m!&a% 89; &a*! &a*! ma'a& ma'a& *,-.'. *,-.'. m,&!"!& m,&!"!& BAB -a& BAK &"ma+ Pa*.,& *!-a% .-a' %a.- 'a",&a m,ma'a. m,ma'a. '5 # 5!+a&a& 5!+a&a& T.-a' *,-a&) ',!.%a& RPD : 9 HT -.*a&) -.*a&)'a+ 'a+ 9 DM -.*a& -.*a&)'a )'a++ RPK : RPsos. • K,5.a K,5.a*aa *aa& & O+a% O+a% "a)a "a)a :P,&-, :P,&-,". ".aa a"a&) 5,"+a% 5,"+a% "a)a • K&* K&*!m !m*. *. ma'a ma'a&a &a& & *ay *ay!" -a& -a& 5!a%95!a%a& 5!a%95!a%a& • P7 ma'a& .-a' ,"a!"
3+!, 4 3!,
P,",m!a& #< a%!& 9 Ny,". ,"! '!a-"a& 'a&a& 5a(a% 9
9
9 9 9
9 9
P,". ,".& &-a%a& a%a& &y," &y,".. -. !+! !+! %a. ',m!-.a& .&-a% ', ,"! 'a&a& 5a(a% &y,". ,'a& m= 5!"&,y 8> *a* a* *.)& *.)&8> 8> ",5!& %,&m,&a %,&m,&a 8> "?*.&) ,* 8> Ha*.+ La5 : L,'*. : $$20 *,+/mm#
P"5+,m L.* Ny,". ,"! '!a-"a& 'a&a& 5a(a%
I&..a+ D.a)&*.* A,&-.=..* '"&.* ,*a*,"5a*. a'!
P+a&&.&) D.a)&*.*
P+a&&.&) T%,"ay MRS A,&-.'m.
I&!* RL20 ,,* /m,&. A&.5..' ".+a'*.*: 3,".a7&, 27I )" P" a,&-.'m.
M &.".&) V.a+ *.)& K ,+!%a& ,+!%a& a*.,&
E-!'a*.
KIE P,&,+a*a& ',a-a P7 -a& ',+!a")a m,&),&a. -.a)&*a -a& K,m!&)'.& a& ,&y,5a5 ,"a-.&ya ,&ya'. B,".'a& !)a ,&,+a*a& m,&),&a. ,"a. *,"a .&-a'a& ya&) a'a& -.+a'!'a&
M,&,+a*
1
PEMERIKSAAN FISIK K,a-aa& !m!m : Tama' *a'. Kesadaran : 3m* M,&.* G3S :@6 BB ,&-,".a : @ ') : 6# ') TB ,&-,".a : 1$ =m
'a& ',a-a ',+!a")a 7 m,&),&a. ',m!&) '.&a& ya&) a'a& ,"a-. 8'm+.'a*.
-a& ")&*.* ,&ya'.
Vital Sign T,'a&a& Da"a% : 120/$0 mmH) : 110/$0 mmH) Na-. : $2 7/m,&.; S!%! : #6;C 3 : #6;$3 RR : 20 7/m&
KEPALA A/I/3/D : 9/9/9/9 LEER P,m5,*a"a& KBG 89; *"!ma 89; ,&.&)'aa& JVP 89 !"RA# B,&!': N"m=%,* K!+. : S.-," &,?. 89; 3++a,"a+ 89 A7.++a: P,m5,*a"a& KGB 89 $ Pulmo Inspeksi : G,"a' &aa* *.m,".* Palpasi : G,"a' &aa* *.m,".* Perkusi : S&" Auskultasi: ?,*.'!+,"; S!a"a &aa* am5a%a& : R&=%. 9/9; %,.&) 9/9 $ %or
2
Inspeksi : I=!* ="-.* .-a' ama' P!+*a*. ",="-.a+ .-a' ama' Palpasi : I=!* ="-.* ,"a5a -. M3L *.&.*"a *,.&)). I3S V Perkusi : Baa* a&!&) 'a&a& a-a a"a*,"&a+ +.&, -,7"a I3S V Baa* a&!&) '.". -. M3L *.&.*"a *,.&)). I3S V Auskultasi : S1 S 2 !&))a+; m!"9m!" 89; )a++ 89
A&D"MEN Inspeksi : B,&!' +a; *.m,".*; ,"-aa ; 3a! m,-!*a 89; *".a, 89 Palpasi : *!,+; Ny,". ,'a& ,"! 'a&a& 5a(a% 8>; ma**a 89 e'ar .-a' ,"a5a Lien : .-a' ,"a5a Ren : .-a' ,"a5a Perkusi : timpani B.*.&) !*!* &"ma+ Pm7 '%!*!* : 9 &y,". ,'a& m= 5!"&,y 8> 9 *a* *.)&8> 9 ",5!& %,&m,&a 8> 9 "?*.&) ,* 8>
EKS!REMI!AS a'"a+ %a&)a ,'*",m.a*
8>
-.
',,ma
O,-,ma 89 -. ',,ma ,'*",m.a* =ya&*.*
89 -. ',,ma ,'*",m.a*
#
,"y,ma a+ma".* 9/9 3RT 2 -,.'
asil La( : ( : )*+, g-dl Leosit : ,.,/0 sel-mm* %! : 1)+/ 2 !rom(osit : /33.000 sel-mm* S4"! : /0 UL S4P! : )1 UL &Sn : ,5 /6'' : ,7 &UN :)) %reatinin serum : 0+8
@
