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MORNING

REPORT
RSUD KEPANJEN

SELASA sore
26-4-2016
DOKTER JAGA :
1. dr. Antarestawati
2. dr. Andreas
Jumlah Total Pasien
Rawat Jalan

:1

Rawat Inap

: 14

APS
Meninggal

:2
:1

: 18

SMF IPD
Nama

Diagnosa

Tn. Warimin/55 th

OF H-2 + nausea vomiting

Tn. Mahendra / 30 th

Septic shock ec septic arthritis

SMF IKA
Nama

Diagnosa

An. Ratu amanda / 10th

OF H-7 + epistaxis

By. Nayla / 8 bulan

OF H-1 + hematoschezia

SMF Jantung
Nama

Diagnosa

Tn. Ndani/59 th

AF RVR hemodinamik instabil

Ny. Sumiati/ 58 th

Obs. Dyspneu ec HF

SMF paru
Nama

Diagnosa

Tn. Tilin/65 th

Susp bronchitis

Tn. Subandi/ 54 th

Obs dyspneu ec susp


bronchitis kronis

Ny. Sunariyah /31 th

Obs dyspneu

SMF Bedah Saraf


Nama

Diagnosa

Ny. Kasmini/ 60 th

CKR + HT st2

Tn. Sunardi/30 th

CKR + susp. Internal bleeding


+ fraktur iliac wing D

SMF Saraf
Nama

Diagnosa

Tn. Sarikan/75 th

Afasia motoris + hemiplegi D


ec CVA infark

Tn. Gini/78 th

Afasia sensoris ec susp CVA


infark dd bleeding

SMF bedah
Nama

Diagnosa

Nn. Gladys/19 th

Contusio musculorum reg


femoralis D + v.Laceratum
labium inferior

Nn. Yuswandari/19 th

Dog bite

SMF OBG
Nama

Diagnosa

Leni Vidiawati/ 26 th

GII 36-37 mgg solusio plasenta

Lailatul Hasanah/ 22th

G1 uk 28-29 mgg + OF H-4

Ny. Winarti

GIIP2002Ab000 41-42 mgg +


HT

1. Tn. S/30 th/CKR+fr iliac


wing D+susp internal bleeding

ANAMNESA
Keluhan Utama.
Post KLL
Riwayat Penyakit Sekarang.
Pasien trauma,jatuh dari motor setelah menabrak anak kecil,
tidak pakai helm, px terbentur di kepala dan pinggul. Pingsan
(+), tidak ingat kejadian sebelum KLL, muntah (-)

Primary survey
A : clear, C spine stable
B : spontan simetris RR 26x
C : TD 120/80, N 84x
D : GCS 456, pupil isokor

PEMERIKSAAN FISIK
TD = 120/80

N = 84

Keadaan Umum :GCS 456

RR = 26 x/menit Tax : 36 C
Saturasi O2 99%

Kepala

Anemic Icteric
Pupil isokor,
V. Laceratum reg parietal D 1x3cm

Leher

JVP R + 0 cmH2O 30

Thorax:

Cor:

Pembesaran KGB (-)

Invisible and palpable at ICS V MCL Sinistra


RHM SL Dextra
LHM ictus
S1 S2 single, murmur (-), gallop (-)

Lung: Simetris, Vesikular, Wheezing (-/-), Rhonki (-/-)


Abdomen

Soufle, BS (+) Liver span 8 cm, traubes space thympani

Extermitas

Deformitas hip joint D

DIAGNOSIS
1.CKR
2.CF iliac wing D

Terapi :
oCT scan kepala
oFoto thorax BOF, Hip Joint
oO2 2-4 lpm via nasal canul
oIVFD NS 0.9% 20 tpm
oInj. Ketorolac 3x1 ampul
oInj. Ranitidin 2x1 ampul
oCek lab DL serial
o Konsul dr Mujiono,SpOT:
Bedrest
Pasien raber
Konsul dr Amukti, SpB :
Jika hemodinamik tidak stabil, abdominal tapping
USG abdomen CITO besok
Inj. Kalnex 3x500 mg

Konsul dr Yahya,SpBS: menunggu hasil CT scan

LABORATORY FINDING
Result

Normal Value

Leucocyte

12570

/l

Hemoglobine

8.9

gr/dl

11.0 16.5

PCV

26.3

35 50

Trombocyte

202.000

/L

150.000 390.000

PT

11.7 K=10.2

9.7-13.1

aPTT

26.7 K=26.0

22.0-30.0

RBS

195

mg/dl

< 200

Ureum

40

mg/dL

10-50

Creatinine

0.86

mg/dL

0.7 1.5

SGOT

38

U/L

11 41

SGPT

20

U/L

10 41

Na

mmol / L

136 145

mmol / L

3.5 5.0

Cl

mmol / L

98 106

HbSAg

(-)

3.500 10.000

THANK YOU