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LAPORAN JAGA11 APRIL 2016
Jokevin Prasetyadhi
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KASUS 1
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IDN!I!AS
" Na#a$ An% K
" Usia$ 1& tah'n
"(R$ 00)6*)+6)16
" Ana#nesa di,ak'kan se-ara a'to . a,,oana#nesa di IGD
RSUS%
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ANA(NSIS
" Ke,'han 'ta#a$ Nyeri di /i/ir /aah sete,ah KLL seak 2
a# S(RS%
" Ke,'han ta#/ahan$ Sik' kiri s',it ditek'k seak 2 a#
S(RS%
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ANA(NSIS
RPS$
Aa, keadian ketika asien #en3endarai seeda #otor
tana he,#4 saat in3in #enya,i #o/i, ti/a)ti/a dita/rak
o,eh seeda #otor dari arah dean% Ke#'dian asien
terhe#as dan aah terseret di asa,4 dan sik' kiri
#e#/ent'r asa,% Ke,'ar darah dari ,'/an3 hid'n3 kiri
se,a#a 5 #enit%
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ANA(NSIS
RPS$
Pasien /e,'# #endaat eraatan aa'n se/e,'#
datan3 ke RS% Pen'r'nan kesadaran )74 #'a, )74 #'ntah
)74 sakit kea,a )74 'sin3 )74 a#nesia )74 darah dari
te,in3a )7%
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PRI(AR8 SUR98
" A$ Airay -,ear
" :$ RR ; 2< =>#enit4 naas sontan4 er3erakan dada
si#etris
" ?$ N; 112 =>#enit4 k'at4 re3',ar% !D; 1@0
" D$ G?S; 15
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S?ONDAR8 SUR98
" A,er3i$ )7
" (edikasi$ )7
"
Past i,,ness4 s'r3ery$ )7" L$ 1
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P(RIKSAAN BISIK
Keadaan U#'# $ !a#ak sakit rin3an
Kesadaran $ ?o#os #entis4 G?S 15 #enit4 k'at4 re3',ar%
" La' Pernaasan $ 2< =>#enit%
" S'h' $ &6%2 E?
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S!A!US GNRALIS
" Kea,a$ nor#osea,
" (ata$ isokor4 #>#% R?L . R?!L >4 KA)>)4 SI )>)
"
!C!$ sekret )74 si#etris" Leher$ e#/esaran KG: )7
" Par'$ 9es >4 rh )>)4 h )>)4 si#etris4 sonor
" Jant'n3$ S1S2 re3',er4 #'r )4 3a,,o )
" A/do#en$ datar4 s'e,4 :U 74 N! )7
" kstre#itas$ akra, han3at4 ?R! F2 detik%
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S!A!US LOKALIS
Re3io ,a/i'# inerior$
" 9L & = 1 = 1 -#
"
!ei ,'ka $ tidak rata" Dasar ,'ka $ s'/#'kosa
" Perdarahan akti $ )7
" Nyeri tekan $ 7
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S!A!US LOKALIS
Re3io #enta,is$
" 9 2 = 1%5 -#
"
!ei ,'ka $ tidak rata" Dasar ,'ka $ s'/k'tan
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S!A!US LOKALIS
Re3io -'/ita,is kiri$
" 9 1%5 = 1%5 -#
"
!ei ,'ka $ tidak rata" Dasar ,'ka $ s'/k'tan
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S!A!US LOKALIS
?'/ita, sinistra$
" Look$ 9 74 ede#a )74
erite# )74 deor#itas )7
" Bee,$ s'h' nor#a,4 -reit's )74
nyeri tekan 74 sas#e 74
dis,okasi )7" (ove$ RO( ,eksi ekstensi$
+0)1&0E4 ronasi 74 s'inasi
7
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S!A!US LOKALISRe3io dors'# edis kiri$
" 9 #',tie, 1 = 1 -#
" !ei ,'ka $ tidak rata
" Dasar ,'ka $ s'/k'tan
Re3io #a,e,o's ,atera, kiri$
" 9 1 = 2%5 -#
" !ei ,'ka $ tidak rata
" Dasar ,'ka $ s'/k'tan
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LA:ORA!ORIU(Result Reference Range
Full Blood Count
Ce#o3,o/in 1&%6 11%@0)15%50
Ce#ato-rit
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LA:ORA!ORIU(Result Reference Range
Biochemistry
SGO! AS!7 1+ 5)&<
SGP! AL!7 10 0)55
Ure'# 1+ F50
?reatinine 0%5& 0%5)1%1
eGBR 1*@ ;60
:,ood Rando# G,'-ose 11@ F200
lectrolyte
Na 1&+ 1&@)1
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RA8 !ORAKS
Kesan$
?or dan ',#o tidak
ta#ak ke,ainan
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RA8 L:OH
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DIAGNOSIS
" 9',n's ,a-erat'# ,a/i'# inerior
" 9',n's e=-oriat'# #',tie, ada ekstre#itas
" ,/o srain sinistra 3rade I
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!RAPI
Non)#edika#entosa$
" :ersihkan ,'ka den3an Na?, 0%*
" Ar# s,in3 'k'ran S
(edika#entosa$
" A!S 1500 IU I(
" !! 0%5 #, I(
" Ranitidine 50 #3 I9
" Ketoro,a- &0 #3 I9
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!RI(A KASIC
