Anda di halaman 1dari 12

ER MORNING REPORT

FRIDAY, MARCH 8th 2019

Senior : Rosydiah R, dr., ORL-HNS


ER : SUK
Ward : ARY / SUR / RRR / CIT
Total Patients : 2

1. Ch. Zakini, 2 y.o


Ass : R . nasal cavity FB of “bead”
Tx : Extracted  discharged

2. Mr. M. Sahi , 32 y.o (consulted from opthalmology dept.)


Ass : R. Orbita tumor + weak condition + epistaxis
Tx : no epistaxis
WARD MORNING REPORT
FRIDAY, MARCH 8th 2019

Total patients : 22
1st class : 6
2nd class : 2
3rd class : 14

OPD and operation schedule will be reported by


doctor in charge on Sunday Night
Observed Patients : 2
1. Mrs. Emilia Wawo Djo, 59 y.o (Spv: Dr. Muhtarum Yusuf, dr., ORL-HNS (C), FICS)

S: decrease of consciousness
O: General state :look weak, GCS : 325
BP : 100/70 mmHg Temp: 39,7 °C
HR : 145 x/minute SpO2 : 92 % with NRM 10 lpm
RR : 22 x/minute Urine Output = 500 cc/12 hours
No stridor, no retraction
Local states:
- Ears: within normal limit
- Nose: mass at R/L nasopharynx. Secret +/+. Palatum molle
phenomenon (-)
- Throat: bombans at palatum molle. Isthmus faucium + 40%
- Neck: multiple mass at R. Colli level II-IV, solid, fixed, Ø 3x3x2 cm
multiple mass at L. Colli level II-III, solid, fixed, Ø 2x2x1 cm

A: Susp. Nasopharyngeal Carcinoma + Impending UAO + Septic Shock +


Pansitopenia
P : - Blood culture, urine culture, urine analysis, CBC evaluation
I : - O2 NRM 10 lpm
- Loading PZ 1500 cc/ 2 hours
- Maintenance IVFD D5 ½ NS 21 drops/minute Internal
Medicine
- Ranitidine inj. 50 mg / 12 hours IV
Dept.
- Ceftriaxone inj. 1 g / 12 hours IV
- Norepinephrin 50 nanogram/kg/minute (microdrip)
- Leucogen inj. 1 ampul /24 hours SC
- Metamizole inj. 1 g / 8 hours IV Lab result 8/3/2019
- Alinamin F inj. 1 ampul/12 hours IV  Neuro Dept. Hb : 10,1 BGA
RBC : 4,37 PH : 7,43
Mx : Vital sign, complaint, UAO signs
HCT : 31,8 pCO2 : 33
WBC : 0,33 pO2 : 88
PLT : 84 BEecf : -2,4
Neutrofil : 0,11 SO2c : 97
Na : 145 FiO2 : 21
Ca : 8,1 HCO3- : 21,9
Cl : 108 T : 37
K : 3,8
Alb : 2,9
2. Mr. Wardi, 35 y.o (Spv: Boedy Setya Santoso, dr., ORL-HNS(C), FICS)

A: R. Sinonasal Non-Hodgkin’s Lymphoma + Anemia +


Thrombocytopenia + Hypoalbuminemia + Hyponatremia +
Hypokalemia + Non Specific Reactive Hepatitis  †
Time GCS BP HR RR T SaO2 Note

12.30 445 90/60 92x 30x 37.8 95% O2 mask 10 lpm

13.30 445 90/70 102x 26x 38.0 95%

14.30 224 90/60 130x 26x 38.9 80% Patient with DNR

15.30 224 80/60 140x 14x 39.0 76%

16.00 111 60 108x 10 37.9 72%


palpable weak
16.30 111 60 Not 8x 37.1 74%
palpable palpable
17.00 111 50 Not 8x 37.1 60%
palpable palpable
17.15 111 - Carotid
artery
apneu - -

not
palpable
No New Patient

No Consulted Patient

THANK YOU