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MORNING REPORT

MONDAY, SEPTEMBER 24th 2018


Residents on duty :
WAG/DRE - LEY
IKI - MAS/DEV - FAN/LIM - HIN - GUD
YAS - ELA

Morning Report and Multidiciplines Group Coordinator :


dr. Imam Suseno Bayuadi, SpBTKV.

Consultants in charge :
dr. J. D. P. Wisnubroto, SpB(K)Onk.
dr. Istan Irmansyah Irsan, SpOT(K).
Dr. dr. Basuki B. Purnomo, SpU(K).
DENNYTA/M/45yo/11318601/1835128
ToArr : 13.00
ToAdm : 19.00
MORNING ADMISSIONS
Time General Status Problem Working Problem Solving / Final Diagnosis
Diagnosis Management

13.00 HR = 84 x/min Decreased of ICH Oxygenations Non traumatic ICH


BP = 190/100 conciousness Fluid administration (I61.9)
mmHg History of Hypertension Analgetics
RR = 22 x/min on hypertension for 3 Neuroprotectants Hypertension
Ventilator years Anticonvulsants (I10)
Isocoric pupil Vomiting Tranexamid acid
GCS = 1x1 Observation for VS,
R hemiparese (+) GCS, vomiting, seizures
and lateralization

Head CT Scan : Trephination


30cc of ICH in L decompression
Subcortex region evacuation ICH
ICP monitoring
(02.1)

Joint care with


Neurologic Department
PURNADI/M/74yo/11298603/1620203
ToArr : 18.00
ToS : 22.00 AFTERNOON OPERATIONS
Time General Problem Working Problem Solving / Final Diagnosis
Status Diagnosis Management

18.00 RR=28x/min Pain in all the area of the Generalized Oxygenations Acute Gastric Ulcer
HR= 110x/ abdomen since 2 days peritonitis dt Fluid administrations with Perforation
min previously perforation of Analgetics (K25.1)
BP=100/70 Nausea gaster Blood Culture
Tax = 36,0°c Vomiting CVC Insertion
Sepsis Antibiotics
History of NSAID NGT and Urine
Consumption since 6 catheter insertion
month Previously

Peritoneal Lavage
Laboratory Result: (54.25)
Leococyte: 18.000
SULAIMAN/M/22yo/11318679/1835189 ISS : 9
ToAcc : 3 days previously RTS : 7.841
ToArr : 19.00
ToAdm : 21.00 AFTERNOON ADMISSIONS PS : 96.8%

Time General Status Problem Working Problem Solving / Final Diagnosis


Diagnosis Management
19.00 A : Patent History of loss of Mild head injury Head Elevation Concussion
B : Spontaneous conciousness Oxygenation (S06.0)
symmetrical Vomiting Open wound of head Fluid administration
RR : 24x/min Headache Antibiotics Open wound of head
C: Anemia Analgetics (S01)
HR : 100x/min Open wound in Upper Lips Transfusion of PRC
D: region, had sutured Chronic Myeloid Observation for VS, Anemia
GCS : 356 Leukimia GCS, seizures and (D64.9)
isochoric pupils Enlargment Of spleen and lateralization
Liver Cellulitis Of L Knee Chronic Myeloid
Leukimia
Laboratry Result: Debridement (C92.1)
MOI: Hb: 4.5 (86.28)
Motorcycle Leucocyte: 4.355.000 Primary suture
accident (8.81)
Abdominal US:
Enlargment of Liver and Joint Care with
Spleen Internal Medicine

Head CT:
no intracranial hemorrhage
SULAIMAN/M/22yo/11318679/1835189 ISS : 9
ToAcc : 3 days previously RTS : 7.841
ToArr : 19.00 PS : 96.8%
ToAdm : 21.00 AFTERNOON ADMISSIONS
Time General Status Problem Working Problem Solving / Final Diagnosis
Diagnosis Management

19.30 Swelling in the left Sellulitis L Knee Antibiotic Sellulitis L Knee


knee Sensitization
Infection marker
Improve general
Status Local: condition
L Knee : Consult to
L: swelling (+) internal
F: tenderness (+), medicine
fluctuation (+), NV
distal (+)
M: ROM limited
SULAIMAN/M/22yo
SULAIMAN/M/22yo
SULAIMAN/M/22yo
SULAIMAN/M/22yo
SULAIMAN/M/22yo
SULAIMAN/M/22yo
SULAIMAN/M/22yo
SULAIMAN/M/22yo
SULAIMAN/M/22yo
ISMUJADI/M/73YO/11302318/1822901
ToArr : 16.30
ToS : 23.00 EVENING OPERATIONS
Time General Status Problem Working Problem Solving / Final Diagnosis
Diagnosis Management
16.30 RR= 32x/min Abdominal pain since 7 Generalized peritonitis Oxygenation Perforation of
BP=130/70 days previously dt. Susp. Perforation of Fluid administration intestine
mmHg Deffiicult to deffecate hollow organ Analgetics (K63.1)
HR= 110x/min since 2 days previously Antibiotics
Tax: 38.4°C Fever Septic condition CVC insertion Septic conditon
NGT and Urine catheter (A41.9)
Muscular Rigidity Hypoalbumin insertion Observation for
VS, signs of acute Hypoalbumin
Laboratorium: abdomen (E88.09)
Leucocytes : 16.000
Alb: 1.39 Exploratory laparotomy
(54.11)
Abdominal X-Ray
Free air (+) Open and Other Partial
excision Large Intestine
(45.7)

Ileostomy
(46.2)
WULAN/F / 3yo/ 11334318/1809276 ISS : 4
ToAcc : 20.00 RTS : 7.841
To Adm: 22.00 PS : 99,5%
ToS : 07.00 MORNING OPERATION
Time General Status Problem Working Problem Solving / Final Diagnosis
Diagnosis Management

20.00 A : Patent Pain and open wound Open Wound In Analgetic Open Wound of Lip
B : spontaneous in Tongue Tongue Antibiotic And Oral Cavity
symmetrical (S01.5)
RR= 22x/min
C : HR= 98 x/min Open Wound in
D: Tongue sized 3x1 cm
GCS=456 Debridement
isocoric pupils (86.28)

MOI : fallen from Primary suture


stairs (8.81)
LASEMI/11299828/1820154
ToArr : 19.00
ToAdm : 21.00 EVENING ADMISSIONS
Time General Status Problem Working Problem Solving / Final Diagnosis
Diagnosis Management
19.00 RR=20x/min General weakness R malignant Of Breast Fluid administrations Malignant neoplasm
BP=130/80 MmHg Mass with ulceration in T4bN1M0 Analgetic of breast
HR=86x/min R breast Since 1 Years Post Chemoteraphy PRC transfusion (C50.8)
Alert Previously CAF 1x
Anemia in neoplastic
Mass and Ulcer in R Anemia disease
Breast, With enlargment (D63.0)
lympnode in Axilla
Region

Chest X-Ray:
No Metastatic Process

Biopsy:
Invasive ductal
Carcinoma Grade III

Laboratory Results:
Hb: 7
MARFUA/F/57yo/11318687/1635131

AFTERNOOON ADMISSIONS
ToArr : 20.00
ToAdm : 02.00

Time General Status Problem Working Problem Solving / Final Diagnosis


Diagnosis Management
20.00 RR=20x/min Pain and mass in R R breast Malignancy Oxygenation Malignant neoplasm
BP=130/80 MmHg breast T4bN1M1(Lung) Fluid administration of breast
HR=86x/min History of mass in R On Chest Tube Analgetics (C50.8)
Alert breast for 1 year Observation for VS and
respiratory distress
History Of Chest Tube Improve general
Insertion in condition
Bhayangkara Hospital 2 Oxygenation
weeks Previously

Thorax X-ray:
Metastase Process
And Efusi pleura with Re-Insertion of
Chest Tube intercostal catheter for
drainage
Abdominal US: (34.04)
Metastase (-)
Pleurodesis Chemical
Breast US: (34.92)
Heterogen solid mass
multiple in R breast with
characteristic to
malignancy
SUDJONO/M//11305382/1625089
ToArr : 00.30
ToS : 07.00 EVENING OPERATIONS
Time General Status Problem Working Problem Solving / Final Diagnosis
Diagnosis Management
00.30 RR = 22x/min Pain in all area of the Generalized Oxygenation Acute appendicitis
BP = 110/60 abdomen starting from 2 peritonitis dt susp Fluid with generalized
mmHg days previously appendicitis acute administration peritonitis
HR = 90x/min Difficult to defecate starting perforata Analgetics (K35.2)
T = 38,4oC from 2 days previoulsly Antibiotics
Vomiting NGT and urine
Fever catheter insertion
Observation for VS,
Muscular rigidity signs of acute
abdomen
Laboratory:
Leucocytes : 16.000 Exploratory
laparotomy
(54.11)

Appendectomy
(47.0)
ELLYZA/F/38yo/11305346/1824798
ToArr : 04.00
ToAdm : 08.00 MORNING ADMISSION
Time General Status Problem Working Problem Solving / Final Diagnosis
Diagnosis Management
04.00 RR = 20x/min Defecutly to defecated Partial Bowel Oxygenations Intestinal adhesions
BP = 120/80 since 3 days previously Obstruction dt susp Fluid with obstruction
mmHg Nausea adhesion administrations (K56.5)
HR = 88x/min Vomiting Analgetics
Tax = 36.7°C NGT and Urine
History of Exploratory catheter insertion
laparotomy ec Observation for VS,
Invagination 2 Weeks signs of acute
previously in abdomen
Bhayangkara Hopital
ARIS/M/22YO/11305371/1824997 ISS : 16
To acc : 04.00 RTS : 6.904
ToArr : 04.30 PS : 88.6%
ToOp : 12.00 MORNING OPERATION
Time General Status Problem Working Problem Solving / Final Diagnosis
Diagnosis Management

04.30 A : Patent Decreased Moderate head Oxygenations Traumatic cerebral


B : spontaneous consciousness injury Fluid administrations edema (S06.1)
symmetrical Vomiting Analgetics
RR = 20x/min History of Alcohol SDH Neuroprotectant Traumatic subdural
C: consumtion Anticonvulsant haemorrhage
BP = 130/70 SAH Tranexamid acid (S06.5)
mmHg Open Wound Avultion Observation for VS,
HR = 88x/min in L Auricula Cerebral edema GCS, vomiting, seizures Traumatic
D: and lateralization subarachnoid
GCS = 225 CT Scan: Open Wound In haemorrhage
isocoric pupils SDH in L L Auricula Trephination (S06.6)
3mm/3mm frontotemporoparietal decompression Of Bone
region (5.3mm, 6 (01.2) Open wound of Ear
MOI : slices) with midline (S01.3)
Motorcycle in Shift to the Right 8 mm Repair Of Auricular
collision with SAH (18.7)
Car Cerebral edema

Today condition:
GCS = 225
EKO/M/27yo/11323392/1838913 ISS:18
ToAcc : 04.00 RTS: 7.841
ToAdm : 08.00 PS : 98.6%
AFTERNOON ADMISSIONS
Time General Problem Working Problem Solving / Final Diagnosis
Status Diagnosis Management
04.00 A : Patent Pain and bruishes in chest Internal bleeding, Oxygenations Internal bleeding
B: and abdominal region hemodynamic Fluid administrations (R58)
Spontaneous stable Analgetics
symmetrical Obs of VS, Contusion of
RR : 20x/min Laboratory: Blunt chest sign of respiratory thorasic wall
C: Hb: 10 trauma distress and signs of (S20.2)
BP : 130/70 PF Ratio: 400/425 acute abdomen
mmHg
HR : 90x/min Chest X-ray :
D: within normal limit
GCS: 456,
isocoric
pupils
Abdominal US:
MOI: Free fluid in perivesica and
High fall perispleenica
THANK YOU

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