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  • Morning Report: Alfin Jam'Annuri Erlinda Rhestu Syah Putri

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    - The patient is a 50-year-old female who was brought to the emergency department after being hit from behind by a motorcycle. She lost consciousness after the accident. - On examination, she has a head injury with a laceration on the right occipital area and a Glasgow Coma Scale of 225. - Her treatment includes controlling bleeding, IV fluids, antibiotics, pain medications, and anti-seizure drugs. She is being monitored for changes in her condition.

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    - The patient is a 50-year-old female who was brought to the emergency department after being hit from behind by a motorcycle. She lost consciousness after the accident. - On examination, she has a head injury with a laceration on the right occipital area and a Glasgow Coma Scale of 225. - Her treatment includes controlling bleeding, IV fluids, antibiotics, pain medications, and anti-seizure drugs. She is being monitored for changes in her condition.

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    13 views13 pages

    Morning Report: Alfin Jam'Annuri Erlinda Rhestu Syah Putri

    Uploaded by

    Alfin Jam Annuri
    - The patient is a 50-year-old female who was brought to the emergency department after being hit from behind by a motorcycle. She lost consciousness after the accident. - On examination, she has a head injury with a laceration on the right occipital area and a Glasgow Coma Scale of 225. - Her treatment includes controlling bleeding, IV fluids, antibiotics, pain medications, and anti-seizure drugs. She is being monitored for changes in her condition.

    Copyright:

    © All Rights Reserved
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    of 13

    Morning Report

    Alfin Jam’Annuri
    Erlinda Rhestu Syah Putri

    KSM Bedah
    RSUD Syarifah Ambami Ratu Ebo
    Bangkalan
    2018
    Rabu, 31 Oktober 2018
    No Identitas Diagnosa Terapi
    1. Ny. K, 90 th COR GCS 456 + Vulnus laceratum Kontrol perdarahan, IVFD triofusin 20 tpm, IM ATS 1 amp, Inj.
    frontalis sinistra Santagesic 3x1 amp, terfacef 2x1 amp, Nicolin 2x1 amp.

    2. Tn. S, 63 th Anemia + Hemoroid interna grade IVFD NaCl 0,9% 20 tpm, Inj. Kalnex 3x500 mg, viccilin 3x1 amp,
    II ketorolac 3x1 amp, ranitidine 2x1 amp, Pro PRC 2 bag/hari

    3. Ny.F, 50 th COS GCS 225 + SAH + ICH + SDH + Kontrol perdarahan, IVFD triofusin 20 tpm, Inj. Pycin 3x750 mg,
    Vulnus laceratum occipital dextra santagesic 3x1 g, phenytoin 3x1 amp, IM ATS 1 amp

    4. Tn. M, 45 th Vulnus ictum phalanx proximal IVFD RL 20 tpm, Inj. Ceftriaxone 2x1 g, ketorolac 3x1 amp,
    digiti II manus sinistra ranitidine 2x1 amp, IM ATS 1 amp

    5. Tn. S, 50 th Ileus Obstruksi + Hipertensi grade IVFD Tutofusin 20 tpm, Inj. Ranitidin 2x1 amp, ondansetron 2x1
    I + dehidrasi ringan vial, Kaltrofen supp. 2, Pasang NGT & kateter

    6. Ny. S, 51 th Mucinous carcinoma mammae Oksigen simple mask


    Sinistra + metastase KGB
    pumonum
    • Primary Suvey :
    • Airway :
    Clear (+), obstruksi (-), deviasi trakea (-), suara tambahan (-)
    • Breathing :
    pergerakan dinding dada simetris, RR: 32x/m, SpO2: 99%, jejas (-)
    • Circulation :
    TD : 140/90 mmHg, N : 56x/m,regular, kuat angkat, T: 360C, akral hangat, CRT <2s
    Perdarahan di occipital dextra
    • Disability:
    GCS 25, pupil bulat isokor 3 mm, Reflek cahaya +/+
    • Exposure:
    Hematom occipital dextra
    Vulnus laceratum occipital dextra ± 2 cm
    Identitas Pasien
    • Nama : Ny. F
    • Jenis Kelamin : Perempuan
    • Tgl lahir/usia : 1 Juli 1968/ 50 th
    • Alamat : Burneh
    • Agama : Islam
    • Suku : Madura
    • No. RM : 186866
    • Tgl Datang IGD : 31 Oktober 2018 jam 19.30 WIB
    • Pembiayaan : Jasa Raharja
    Secondary Survey
    • Kepala :
    • Mata : ptosis (-), anemis (-), ikterus (-), pupil bulat isokor 3
    mm, RC +/+
    • Hidung : krepitasi (-), septum deviasi (-), epistaksis (-)
    • Telinga : hematom (-), hematorea (-), otorea (-)
    • Mulut dan faring : bibir sianosis (-), laserasi (-), edema (-)
    • Hematom occipital dextra
    • Vulnus laceratum occipital dextra ± 2 cm
    • Leher : deformitas (-), krepitasi (-), lesi (-), edema (-),
    massa (-)
    Secondary Survey cont.
    • Thorax :
    • Inspeksi : pengembangan dada simetris, tidak tampak jejas
    • Palpasi : pengembangan dada asimetris, krepitasi (-),
    • Perkusi : Sonor Sonor
    Sonor Sonor
    Sonor Sonor

    • Auskultasi :
    • Jantung  S1/S2 regular, murmur (-)
    • Paru : Vesikuler Vesikuler
    Vesikuler Vesikuler
    Vesikuler Vesikuler
    Secondary Survey cont.
    • Abdomen :
    • Inspeksi : tampak datar, jejas (-)
    • Auskultasi : Bising usus normal
    • Perkusi : timpani
    • Palpasi : nyeri tekan (-), massa (-), asites (-)
    • Genitalia : dbn
    • Ekstremitas : dbn
    Anamnesa
    • Keluhan Utama : tidak sadar
    • Riwayat Penyakit Sekarang
    • Pasien tidak sadar setelah ditabrak oleh motor dari belakang sekitar 30 menit SMRS. Tidak
    ada yang tahu saat kejadian. setelah tertabrak, pasien jatuh dan masih sadar serta mengeluh
    pusing. Mual (-) muntah(-). Setelah kejadian, pasien dibawa ke RS dengan mobil, sekitar 10
    menit setelah kejadian, pasien mulai susah diajak berbicara dan tidak merespon saat
    dipanggil.
    • Riwayat Penyakit Dahulu : penyakit serupa (-), HT (-), DM (-), jantung (-), stroke (-), TB (-)
    • Riwayat Penyakit Keluarga : HT (-) DM (-), jantung (-), stroke (-), TB (-)
    • Riwayat Alergi : -
    • Riwayat Pengobatan : -
    Diagnosis
    • Cedera Otak Sedang GCS 225
    Pemeriksaan Penunjang
    Follow up pasien
    • Pada saat jam 22.00 WIB :
    Tatalaksana
    • Kontrol perdarahan
    • IVFD triofusin 20 tpm
    • Inj. Pycin 3x750 mg
    • Inj. santagesic 3x1 g
    • Inj. phenytoin 3x1 amp
    • IM ATS 1 amp
    Terima Kasih

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