Professional Documents
Culture Documents
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
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%
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
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)
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
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
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