JENIS PEMERIKSAAN HASIL SATUAN NILAI RUJUKAN METODE

HEMATOLOGI
DARAH RUTIN :
Hemoglobin 15.0 gr/dl 11.5 16.5 Cyanmet
Leukosit 9.0 10^3/uL 4.0 10.0 Elek Impedence
Trombosit 194 10^3/uL 150 500 Elek Impedence
Hematokrit 47.2 % 35.0 49.0 Kalkulasi
Waktu protrombin (PT) 11.8 Detik 11.3 14.7 -
PTT 30.4 Detik 27.4 39.3 -
KIMIA KLINIK
Glukosa Sewaktu 101 mg/dL 75 115 GHOD PAP
Ureum 22 mg/dL 10 15 GLDH
Creatinin 0.53 mg/dL 0.50 1.10 Jaffe
SGOT H 44 U/L 12 37 IFCC
SGPT H 57 U/L 12 41 IFCC
SEROLOGI
HBsAg Negatif Negatif Chromatography
Physical Examination

Done at 07.00 am, May 17th 2017 in Bugenvil room of dr. Soewondo Hospital

General condition : slightly ill

Awareness : composmentis, GCS 15
Vital signs
Blood pressure : mmHg
Heart rate : 80 x /minute, regular
Temperature : 36,50C
Breathing : 22 x/minute

Physical Assessment

General Appearance : clean in appearance, well groomed, and cooperative

Skin : brown, skin turgor normal
Head : mesocephal form, injuries (-)
Eyes : isokor pupil (d: 3 mm/ 3 mm), light reflex (+/+), palpebra conjungtival pallor (-/-),
sclera jaundice (-/-)
Ears : discharge (-/-)
Nose : septal deviation (-), discharge (-/-)
Mouth : normal, cyanosis (-)
Neck : symmetrical, deviation of the trachea (-), enlarge lymph nodes clear (-), anenlarge
thyroid gland (-)
Chest : normochest, symmetrical
Abdomen : lesion (-), tenderness (-) in the upper and right abdomen
Extremities : left upper extremities : deformity at os. Humerus sinistra (-), edema present,
pain
Motor
Dextra Sinistra
Upper: 5 Upper: 2
Lower: 5 Lower: 5

Sensory
Dextra Sinistra
Upper: N Upper: N
Lower: N Lower: N

Localized Status of upper extremities in os. Humerus sinistra:

Look:
- Skin colour : normal
- Edema : (+) at left upperarm and forearm
- Pale and wrinkled : (-)
- Wound : (-)
- Deformity : (+)
Feel:
- Skin temperature : normal
 - Tenderness : (-)
- Crepitation : (-)
- Artery pulsation : (+)
Movement:
Pasif