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MORNING CONFERENCE
18 januari 2016
MH/ LK/ 21 th
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ANAMNESA
Keluhan ta!a" #er$elan$an tan$an %anan &ulit
'i$era%%an
(elaah" Hal ini 'iala!i O& ) 2 ja! &e*elu! !a&u%
ru!ah &a%it+ A,aln-a O& !en$en'arai &e#e'a !.t.r'an
!en$a%u 'i &ere!#et .leh !.*il &ehin$$a OS
terjatuh 'an tan$an O& !enahan *erat *a'an OS+
Ri,a-at #in$&an !ual !untah
R3( " (i'a% jela&
R3O" (i'a% jela&
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3ri!ar- Sur4e-
Air,a- " Clear
5reathin$ " .ntan RR 20/ i
Cir7ulati.n " a%ral han$at ( 120/80 !!H$
HR 86/i
i&a*ilit- " GCS 19E#.&ure "Se7.n'ar- &ur4e-
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Se7.n'ar- Sur4e-
Ke#ala " 'ala! *ata& n.r!al
Leher " 'ala! *ata& n.r!al
(h.ra " 'ala! *ata& n.r!alA*'.!en " 'ala! *ata&
n.r!al
Etre!ita& ata& " &tatu& l.%ali&ata
Etre!ita& *a,ah " 'ala! *ata& n.r!alGenitalia " la%ila%i
'ala! *ata& n.r!al
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Statu& l.%ali&ata
• E%&tre!ita& ata& 'etra"
L..% " &,ellin$ : 'e;.r!ita& : #eru*ahan
,arna %ulit
Feel "7re#itati.n 3ain : N
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La*.rat.riu!
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F.t. Klini&
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Foto Thorak PA erect
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Foto Wrist Joint AP/Lat
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Foto Manus AP/Obliq
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ia$n.&i& Kerja " Cl.&e' ;ra%tur R 'i&tal
ra'iu&
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(in'a%an 'i IG
• IVFD kristaloid 2 !tt/I
• In"# $etorolac
•
In"# %anitidin
%encana
Pe&asan!an lon! ar& cast
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Foto 'ost 'e&asan!an LA(
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FOTO PO)T $O*T%OL
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(ERIMA KASIH
