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Copy CPPT

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Dokter

Catatan

Jenis Bayar

Usia

No.Rekam Medik

Nama Pasien

TTL

Agama

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Formulir CPPT

Tanggal

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Profesi

Nama Pengisi Data

S [SUBJECTIVE]

O [OBJECTIVE]

<p>USG ABdomen</p>

<p>- USG yang lainnya sesuai dengan pemeriksaan</p>

<p>-Kelainan yang ditemukan :</p>

<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:"Calibri","sans-serif""><strong><u><span style="font-size:12.0pt">Kandung empedu</span></u></strong><span style="font-size:12.0pt"> : </span></span></span></p>

<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:"Calibri","sans-serif""><span style="font-size:12.0pt">Besar normal, <em>dinding </em></span><em><span style="font-size:12.0pt">tampak menebal iregular. </span></em><span style="font-size:12.0pt">Duktus biliaris intr</span><span style="font-size:12.0pt">a </span><span style="font-size:12.0pt">hepatal t</span><span style="font-size:12.0pt">id</span><span style="font-size:12.0pt">ak melebar<em>, </em></span><em> </em><span style="font-size:12.0pt">tidak </span><span style="font-size:12.0pt">tampak </span><span style="font-size:12.0pt">lesi </span><span style="font-size:12.0pt">hiperekhoik </span><span style="font-size:12.0pt">dengan</span><em><span style="font-size:12.0pt"> acoustic shadow</span></em><em><span style="font-size:12.0pt"> intraluminal. Tampak sludge intraluminal.</span></em></span></span></p>

<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:"Calibri","sans-serif""><strong><u><span style="font-size:12.0pt">Ginjal kiri</span></u></strong><strong> </strong><span style="font-size:12.0pt">:</span></span></span></p>

<p style="text-align:justify"><span style="font-size:12.0pt"><span style="font-family:"Calibri","sans-serif"">Ukuran normal</span></span><span style="font-size:12.0pt"><span style="font-family:"Calibri","sans-serif"">, kontur normal, parenkim normal, inte</span></span><span style="font-size:12.0pt"><span style="font-family:"Calibri","sans-serif"">n</span></span><span style="font-size:12.0pt"><span style="font-family:"Calibri","sans-serif"">sitas gema</span></span><span style="font-size:12.0pt"><span style="font-family:"Calibri","sans-serif""> masih normal</span></span><span style="font-size:12.0pt"><span style="font-family:"Calibri","sans-serif"">. Batas tekstur parenkim dengan central echocomplek </span></span><span style="font-size:12.0pt"><span style="font-family:"Calibri","sans-serif"">masih jelas</span></span><span style="font-size:12.0pt"><span style="font-family:"Calibri","sans-serif"">. <em>T</em></span></span><em><span style="font-size:12.0pt"><span style="font-family:"Calibri","sans-serif"">am</span></span><span style="font-size:12.0pt"><span style="font-family:"Calibri","sans-serif"">pak</span></span><span style="font-size:12.0pt"><span style="font-family:"Calibri","sans-serif""> lesi</span></span><span style="font-size:12.0pt"><span style="font-family:"Calibri","sans-serif""> hiperekhoik</span></span> <span style="font-size:12.0pt"><span style="font-family:"Calibri","sans-serif"">dengan acoustic shadow</span></span><span style="font-size:12.0pt"><span style="font-family:"Calibri","sans-serif""> di pole atas dengan diameter lk 0,8 cm</span></span><span style="font-size:12.0pt"><span style="font-family:"Calibri","sans-serif"">.</span></span></em><span style="font-size:12.0pt"><span style="font-family:"Calibri","sans-serif""> <em> </em></span></span><span style="font-size:12.0pt"><span style="font-family:"Calibri","sans-serif"">Sistem pelvokalises tidak melebar. Ureter tidak terdeteksi.</span></span></p>

A [ANALISIS]

<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:"Calibri","sans-serif""><strong><em><u><span style="font-size:12.0pt">Kesan </span></u></em></strong><u><span style="font-size:12.0pt">: </span></u></span></span></p>

<ul>
	<li style="text-align:justify"><span style="font-size:11pt"><span style="font-family:"Calibri","sans-serif""><strong><em><span style="font-size:12.0pt">Cholecystitis dengan sludge gallbladder</span></em></strong></span></span></li>
	<li style="text-align:justify"><span style="font-size:11pt"><span style="font-family:"Calibri","sans-serif""><strong><em><span style="font-size:12.0pt">Nefrolithiasis sinistra</span></em></strong></span></span></li>
	<li style="text-align:justify"><span style="font-size:11pt"><span style="font-family:"Calibri","sans-serif""><strong><em><span style="font-size:12.0pt">USG </span></em></strong><strong><em><span style="font-size:12.0pt">hepar, spleen, pankreas, ginjal kanan dan vesika urinaria</span></em></strong><strong><em><span style="font-size:12.0pt"> saat ini tak tampak kelainan</span></em></strong><strong><em><span style="font-size:12.0pt">.</span></em></strong></span></span></li>
</ul>

P [PLANNING]

I [INSTRUKSI]