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  • Calculus of Kidney-Print

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    Calculus of Kidney-print

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    13 views2 pages

    Calculus of Kidney-Print

    Uploaded by

    Es Batu

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    of 2

    PENGKAJIAN AWAL MEDIS RAWAT INAP

    Nama Pasien : SUWARNI No RM : 594683


    Tgl Lahir/Umur : 12 Juli 1967 / 56 Ruang : YUDHISTIRA - Kelas I

    Tiba di ruang rawat inap:


    Tanggal : 2024/02/19
    Jam : 18:00

    Pengkajian:
    Tanggal : 2024/02/19
    Jam : 20:00

    Anamnesis
    : -

    Keluhan Utama
    Keluhan Utama : Nyeri pinggang kanan
    Riwayat Penyakit Sekarang : Dj stent kanan dan batu ren kanan
    Riwayat Penyakit Dahulu : HN sedang D post URS D
    Riwayat Penyakit Keluarga : Tidak ada

    Pemeriksaan Fisik
    Keluhan Umum : Ku cukup
    Gcs 456
    Status Neurologis : -

    Tanda Vital
    Tensi (mmHg)
    Sistol : 130
    Diastol : 80
    N (x/mnt) : 87
    S (c) : 36,6
    RR (x/mnt) : 20
    Kepala : Normal
    Leher : Normal
    Thorax : Normal
    Abdomen : Normal
    Extremitas : Normal

    Pemeriksaan Penunjang (Hasil)


    : Dj stent D + Batu ren D
    Asesmen
    Diagnosa Awal : Batu ren D + DJ stent insitu D
    Masalah Kesehatan : Nyeri pinggang kanan

    Planning
    : Pro PCNL D besok selasa 20/2/24

    Sasaran
    : -

    DPJP : dr. Fakhri Surahmad, Sp.U

    DP/16/RM/2022/REV.02
    RM16

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