ER MORNING REPORT

SATURDAY NIGHT, MARCH 9th 2019

Senior : Rosydiah Rahmawati, dr., ORL-HNS

ER : ARF
Ward : NIK / DFW / IKA / DEE
 Total Patients : 3
1. Ch. Veronica Febiola, 32y.o
Ass : R/L . Acute Otitis Media stage III
Tx : Antibiotic + Analgetic + Decongestant  C. OPD

2. Mr. Moch. Yusril Nurmahendra, 20 y.o

Ass : R. Otitis Media stage I
Tx : Antibiotic + Analgetic + Decongestant  C. OPD

3. Ch. Moch. Nur Irfani, 6 y.o

Ass : L. Nasal Cavity FB of “manik”
Tx : Extracted  discharged
 WARD MORNING REPORT
SATURDAY NIGHT, MARCH 9th 2019

Total patients : 14
1st class : 5
2nd class : 0
3rd class : 9

OPD and operation schedule will be reported

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

S : Decrease of consciousness

A: Susp. Nasopharyngeal Carcinoma +

Impending UAO + Decreased of
Consciousness ec Susp Encephalopaty DD Lab result 9/3/2019
Intracranial Process + Septic Shock + Multiple BUN : 43 BGA
Organ Dysfunctional Syndrome + Febrile SK : 2,35 PH : 7,34
neutropeni + Bicytopenia  †
GDA : 73 pCO2 : 43
pO2 : 72
BEecf : -2,6
SO2c : 93
FiO2 : 61
HCO3- : 23,2
T : 38
Jam GCS TD Nadi RR T SaO2 Ket
12.00 111 80/60 135x 18x 40 98%
14.00 111 70/50 144x 18x 40 98% Norepinephrine 150
nano
15.00 111 80/50 150x 20x 40 98%
16.00 111 86/57 143x 40 99% Norepinephrine 200
nano
17.00 111 67/49 152x 40,1 98%
18.00 111 54/31 139x 40,1 97% HES
19.00 111 78/50 150x - 41 98% urine production ± 200
cc
Jam GCS TD Nadi RR T SaO2 Ket
19.15 111 82/50 147x 41 98%
19.45 111 74/47 147x 41 98%
20.00 111 62/41 130x 41 96%
20.15 111 60/39 128x 40,8 93%
20.20 111 48/32 110x 40,8 91%
20.25 111 Not - - -
palpable
20.30 111 Not CPR 2 cycle
palpable Epinephrine inj. 1 amp IV

20.35 111 CPR 2 cycle

20.38 Maximal midriatic pupil
†
 Join Care Patient : 1

Mr. Naufan, 22 y.o

Ass : Susp Tonsillar Diphtheria
 No New Patient

No Consulted Patient

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