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Morning Report IGD

27-28 mei 2019

DM JAGA : GRASIA ANGGER AYU


WILUJENG

Dokter Jaga : dr. Novian


dr. Lydia
Tn. FA/36 Obs febris ec Sup DHF dd demam FLY
tyfoid +ISK + DM tipe 2 + obs ikterus
susp sirosis hati + F.15

Ny. SA/ 59 th CHF FC III-IV + AF RVR ICCU


Tn. F/ 32 th Dispepsia syndrome Pulang

Tn. A/ 50 th Sirosis hati + DM tipe 2 + Seruni


Hipoalbumin
Tn. R/ 55 th CKD on HD Fly

Nn. S/ 65 th CKD on HD+hiperkalemia Anggrek

Ny. H/ 60 th Abses perirenal+Hipoalbumin+DM EDW


tipe 2 + Anemia

Ny. L/ 45 th Prolonged Fever + anemia pro


evaluasi
Tn S/ 54 th Obs vommiting + CKD stage V +
anemia+Hiperkalemia

Ny K/39 th Obs Ikterus ec Susp Kolestatis


ekstrahepatik+anemia+riwayat
tumor abdomen
Keteranga
No. Identitas Diagnosa Planning
n

Terapi IGD :
Dx IGD : Obs febris ec Sup
DHF dd demam tyfoid +ISK - RL 20 tpm
+ DM tipe 2 + obs ikterus - Inj ranitidin 1 ampul/12 jam
susp sirosis hati + F.15
- Inj ceftriaxone 1 gr/12 jam
1 Tn.FA/ 36 th - PCT tab 3x500mg (k/p) fly
Dx Dm : Obs febris ec Sup
DHF dd demam tyfoid +ISK - Cek ur/cr,bil tot/dir/indir
+ DM tipe 2 + obs ikterus - Cek DL/hari
susp sirosis hati + F.15
- Diet DM
- Cek GDS jam 06.00 dan 22.00
No. Identitas Diagnosa Planning Keterangan

Sp. JP
Dx IGD : CHF FC III-IV + O2 nasal kanul 4 lpm
AF RVR Furosemide 1 ampul/8jam
2 Ny. SA/ 59 th Spironolacton 25 mg/12 jam ICCU
Dx DM : CHF FC III-IV + Ramipril 5 mg/ 24jam
AF RVR Simvastatin 20mg/24jam
Protap digoksin
No. Identitas Diagnosa Planning Keterangan

Penatalaksanaan IGD:
Dx IGD : Dispepsia Drip OMZ dalam PB NS
syndrome
Metoclopramide 1 ampul/iv
Plg
3 Tn. F/ 32 th Dx DM :Dispepsia
syndrome Obat pulang:
Sucralfat 3x10cc
Domperidone 3x1
Ketoprofen 100 mg (k/p)
No. Identitas Diagnosa Planning Keterangan

Dx IGD : Sirosis hati + Penatalaksanaan IGD:


DM tipe 2 + - Inj lasix 1 ampul/iv
Hipoalbumin
- Oksigen nasal kanul 3 lpm
Seruni
4 Tn A / 50th Dx DM :Sirosis hati +
Konsul Sp.PD
DM tipe 2 +
Hipoalbumin + Inj lasix 1 ampul/12jam
Trombositopenia Transfusi albumin 25% 100cc
Terapi oral lanjut
No. Identitas Diagnosa Planning Keterangan

Penatalaksanaan IGD:
Dx IGD : CKD on HD - Inj lasix 1 ampul/iv
- Oksigen nasal kanul 3 lpm
Flyi
5 Ny. R / 55 th Dx DM :CKD on HD +
ALO Konsul Sp.PD
Inj lasix 1 ampul/8jam
Obat oral lanjut
No. Identitas Diagnosa Planning Keterangan

Konsul Sp.PD
Dx IGD : CKD on furosemide SP 10mg/jam
HD+hiperkalemia
D40% 2 flash + insulin 10 unit
Anggrek
6 Tn S / 65 th Ca glukonas 1 ampul
Dx DM :CKD on HD +
anemia + hiperkalemia Kalitake 3x1 sascet
R/HD dari ruangan
Obat rutin lanjut
No. Identitas Diagnosa Planning Keterangan

Dx IGD : Abses
perirenal+Hipoalbumin
+DM tipe 2 + Anemia Konsul Sp.PD
SP Furosemide 10mg/jam EDW
7 Ny H / 60th
Dx DM :Abses Ceftadizin 1gr/8jam
perirenal+Hipoalbumin Metronidazole 500mg/8jam
+DM tipe 2 + Anemia Micardis 1x80mg
No. Identitas Diagnosa Planning Keterangan

Dx IGD : Prolonged
Fever + anemia pro Konsul Sp.PD
evaluasi
Cek HDT
8 Tn L / 45th Nacl 0,9% 20tpm
Dx DM :Prolonged
Fever + anemia pro PCT 3x500mg (k/p)
evaluasi Ceftriaxone 1 gr/12 jam
Transfusi PRC 1 kolf/hari
No. Identitas Diagnosa Planning Keterangan

Konsul Sp.PD
Dx IGD : Obs vommiting
+ CKD stage V + Eas Primer 20tpm
anemia+Hiperkalemia D40% 2 flash + insulin 10 unit
Ca glukonas 1 ampul

9 Tn S / 54 th Dx DM :Obs vommiting Kalitake 3x1 sascet


+ CKD stage V + Metoclopramide 1ampul/8jam
anemia+ Leukositosis Ranitidine 1ampul/12 jam
Hiperkalemia+ Ceftriaxone1gr/12jam
Hiponatremia
Asam folat 2x1
Caco3 2x1
Cek SE
No. Identitas Diagnosa Planning Keterangan

Dx IGD : Obs Ikterus ec


Susp Kolestatis
ekstrahepatik+anemia+
riwayat tumor
abdomen Konsul Sp.PD
NaCl 0,9% 20 tpm
10 Ny. K / 39 th
Dx DM :Obs Ikterus ec Omeprazole 1ampul/12jam
Susp Kolestatis Sucralfat syr 3 x10cc
ekstrahepatik+anemia+ Transfusi PRC 1 kolf/12 jam
riwayat tumor
abdomen+melena
Terima Kasih