Lapjag Michelle 4

7/25/2019 Lapjag Michelle 4

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LAPORAN JAGAKamis 28/04/16

Michelle H

07120110086


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Idenias Pasien

Nama ! "n# $

Kelamin ! La%i la%i

"&l Lahi' ! 1(/11/1))1 *24 ah+n, N-# MR ! 00.70.61.

"an&&al mas+% A ! 2) A'il 2016

0#00


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Anamnesis

Kel+han 3ama!

Ne'i sel+'+h e'+ 10 5am MR

Riaa ena%i se%a'an&! Ne'i sel+'+h e'+ 10 5am MR e'+s

mene'+s ida% men5ala'ida% ada an&meme'in&an s%ala ne'i 8/10# Kem9+n&: m+al : m+nah : ;10 %ali isima%ananda'ah .


4/25

Riaa ena%i dah+l+!

>M . hie'ensi .

Riaa -e'asi !

Laa'a-mi e%sl-'asi a/i in?a&inasi h 2008 di RMeh-dis Medan

Laa'a-mi e%sl-'asi a/i in?a&inasi h 2011 di RMedi%a =>

Riaa %el+a'&a !

"ida% ada an& si&ni@%an


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Peme'i%saan isi%

Kesada'an! c-m-s menis *GB1,

"e%anan da'ah! )0/60 mmH&

Nadi! 14( C/meni +h+! (6#1 celci+s

a+'asi O2! )8D

RR ! (0 C/meni


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Keala dan Lehe' !

Keala ! "ida% ada deE-'mias

. Maa ! K-n5+n&i?a +ca *./., cle'a

i%e'i% *./., P+il 9+la is-%-' (mm/(mm

Hid+n& ! e%'e *, >a'ah *.,

"elin&a ! e%'e *, >a'ah *.,

=i9i' ! ama% lesi hie'i&menasi +%+'an:. 02 cm e'se9a' di la9ia inEe'i-'

G+si ! ida% ama% hie'i&menasi


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Lehe' ! "ida% e'a9a em9esa'an KG=dan i'-id

"h-'a%s

Inse%si !Pe'&e'a%an naEas sime'is 9en+% dada 'aa'e'a%si ine'%-sa *., -'h-nea *.,Palasi !Ne'i e%an *., e%sansi dada 9ai%Pe'%+si ! Ne'i %e-% *., -n-' *:/:,A+s%+lasi !Pa'+ ! =+ni naEas ?esi%+le' *:/:,

'-n%hi *./., heeFin& *./.,Jan+n& ! =+ni 5an+n& III 'e&+la' m+'m+'*., &all- *.,%s'emias ! edema . ida% ama%

hie'i&menasi


8/25

a+s l-%alis

A9d-men

Inse%si! disensi : massa . 9e%as - :*la e%sl-'asi,

A+s%+lasi! =isin& +s+s *:, men+'+nPe'%+si! "imani ascies .

Palasi!

Ne'i e%an sel+'+hlaan& a9d-mendeEans m+s%+la' : massa .


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LA=ORA"ORI3MResult Reference Range

Full Blood Count

Hem-&l-9in 14#) 11#70.1#0

Hema-c'i 1#10 (#00.47#00

'h'-ce 7#(7 (#80.#20

hie 9l--d cell #71 (#60.11#00

Dierential Count

=as-hil 1 0.1

-sin-hil 0 1.(

=and Ne+'-hil 2 2.6

e&men Ne+'-hil 67 0.70

Lmh-ce 22 2.40

M-n-ce 8 2.8

Plaele c-+n 617#00 10#00.440#00

R 0.20

P" 12#20 )#4 11#(

AP"" 4)#40 (1.47


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Result Reference Range

Biochemistry

GO" *A", 1 .(4

GP" *AL", 16 0.

3'e+m ()#0 71B'eainine 1#04 0#.1#1

=l--d Rand-mGl+c-se

)(#( 200

Electrolyte

Na 141 1(7.14

K (#8 (#6.#0

Bl )8 )8.107


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.Ra "h-'a%s *2)/04/16,

"ama% l+sensi s+9diaE'a&ma %ananminimal .; +se% ne+m-e'i-ne+m


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KG

P'-9a9le "


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3s&A9d-men

2)/04/16


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Asies masiE .; s+se% e'i-niis

Lesi hie'e%-i% den&an mminimal -se'i-'acc-+sic shad- in'a ?esica Eellea .;

s+se% %-leliiasis O'&an.-'&an in'aa9d-men lainna dalam

9aas n-'mal


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B" scan a9d-men *02/0/16,


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20/25

Gam9a'an +da'a 9e9as ada a9d-menane'i-' .; s+se% e'E-'asi

Ile+m men&alami dilaasi ada

a9d-men en&ah den&an dindin&mene9al dise'ai m+liel lesihie'dens didalamana +%+'an :/.

1#(7.2( cm.; s+se% ileiis den&anm+liel -li di dalamna

Asies masiE dan eE+si le+'a 9ilae'al


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=NO ( -sisi


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>ia&n-sis

>ia&n-sis %e'5a!+s# Pe+F Je&he's nd'-me

h-c% sesis

" ind+ced 9 ain

>ia&n-sis 9andin& !

A9d-minal ain e#c dd/ in?a&inasi dd/ac+e mesene'ial h'-m9-sis


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"e'ai O2 (lm l+id!

Ase'in& 200ml : &el-E+sin 00ml lan5+Amin-


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Plan

Laa'--mi e%sl-'asi 9ac% + IB3%-ns+l = *K,=> %-nse'?aiE R/%-l-n-s%-i

Raa 9e'sama ca'di- dan ine'na

Pana+ "" dan m-ni-' 9alancecai'an

Lapjag Michelle 4

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