PEMERINTAH KABUPATEN PASER

DINAS KESEHATAN
PUSKESMAS BATU KAJANG
Jl. Negara Kuaro Batu Kajang Kec. Batu Sopang Kab. Paser Kaltim 76252 Telp. (0543) 5230021

BLANGKO UGD
Nama : No. Reg : / RI-UGD / / 2015
Umur : Th / Bl / hr Jam Masuk : WITA
Jenis Kelamin : L / P Tgl Masuk :
Pekerjaan : Tgl Keluar :
KK : Alamat :

Keluhan Utama :
Anamnesa :

Tanda Vital : GCS :

Tekanan Darah : / mmhg RR : x/ menit
Nadi : x/menit Temp : °C

Pemeriksaan Fisik Khusus :

Pemeriksaan Lab :

Diagnosa :

Pengobatan / Tindakan :

Petugas ,

…………………………………..
 emergency unit form
Name : Mr S No. Reg : / RI-UGD / / 2015
Age : 60 years hours of entry : 07.45 am
gender : male date of entry : 13 October 2020
profession : farmer adress : Batu Kajang village
status : widower

main complaint : headache

anamnesa
: Mr. S got up in the morning at 05.00 for prayer, after that drank a cup of black coffee,
suddenly felt dizzy and vomited and his ears ringed, had time to rest for 1 hour at home
until he was taken to the emergency unit, Mr. S had a history of high blood pressure
disease for the past 5 years and routinely take 12.5 mg of captopril type pressure
medicine once a day

Vital sign GCS : 15

blood pressure : 190/120 mmhg RR : 26 x/ minute
pulse : 102 x/minute Temp : 36.9 °C

lab examination : cholesterol 346 mg/dl

When blood sugar 105 mg/dl
Uric Acid 6 mg/dl

diagnosis : Hypertensi

treatment / action : oxygen 4-5 liters / minute

sublingual nipedipine 10mg 07.50 am

officer,

James Brown