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  • Morning Report 6th August2015

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    Ryan Arifin Suryanto
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    The morning report summarizes 4 patients, including 3 hospitalized patients and 1 ambulatory patient. It provides details on a 47-year-old female hospitalized patient, including her name, age, religion, occupation, vital signs, and chief complaint of a painful nodule on the back of her neck. It also lists the physical examination findings and working diagnoses for the patient, which include a schizum wound on her left wrist, suspected tendon rupture, suspected median nerve rupture, and suspected radial artery rupture. The report outlines the treatment plan, which involves IV fluids, medications, blood transfusion, fasting before surgery, and consultation with an anesthesiologist.

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    The morning report summarizes 4 patients, including 3 hospitalized patients and 1 ambulatory patient. It provides details on a 47-year-old female hospitalized patient, including her name, age, religion, occupation, vital signs, and chief complaint of a painful nodule on the back of her neck. It also lists the physical examination findings and working diagnoses for the patient, which include a schizum wound on her left wrist, suspected tendon rupture, suspected median nerve rupture, and suspected radial artery rupture. The report outlines the treatment plan, which involves IV fluids, medications, blood transfusion, fasting before surgery, and consultation with an anesthesiologist.

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    © All Rights Reserved
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    8 views18 pages

    Morning Report 6th August2015

    Uploaded by

    Ryan Arifin Suryanto
    The morning report summarizes 4 patients, including 3 hospitalized patients and 1 ambulatory patient. It provides details on a 47-year-old female hospitalized patient, including her name, age, religion, occupation, vital signs, and chief complaint of a painful nodule on the back of her neck. It also lists the physical examination findings and working diagnoses for the patient, which include a schizum wound on her left wrist, suspected tendon rupture, suspected median nerve rupture, and suspected radial artery rupture. The report outlines the treatment plan, which involves IV fluids, medications, blood transfusion, fasting before surgery, and consultation with an anesthesiologist.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
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    of 18

    Morning Report

    August 15th 2015

    Hospitalized Patient : 3 patient


    Ambulatory Patient : 1 patient
    Total
    : 4 patients

    Ambulatory Patient
    Mr. S, 30 y.o. Vulnus Laceratum et
    regio cephal.

    Hospitalized Patient

    Name : Mrs. S
    Age : 47 years old
    Religion : Islam
    Occupation : Housewife

    Primary Survey
    Airway
    : Clear
    Breathing : Spontan, 24x/minute
    Circulation : BP: 130/70mmHg, Pulse:
    84x/minute, CRT < 2
    Disability : Alert
    Expossure : -

    Secondary Survey
    Chief Complain:
    Benjolan di belakang leher yang terasa
    nyeri

    Secondary Survey
    History :
    Pasien datang dengan keluhan
    terdapat benjolan di leher belakang
    sejak 15 hari SMRS

    Examination from Head to


    Toe

    Head : Normocephal, injury (-)


    Eyes: Pupil isochor 3mm/3mm, Light Reflex (-/-)
    ENT : Bleeding (-), deviation of trachea (-)
    Neck : Injury (-), Pain (-)
    Chest: Pain (-), Dispnea (-)
    Cor : S1,S2 regular, M(-), G(-)
    Pulmo : VBS (+/+), Wh (-/-), Rh (-/-)

    Abdomen : Soepel, tenderness (-), Bowel sound


    (+) N.
    Hepar and Lien: Normal

    Extremity: perifer perfusion : cold, pale, crt>2

    Physical Examination
    General Status: Normal
    Local Status: Left wrist
    Look : theres an open wound on her left
    wrist with 8 cm long and 4 cm width,
    active bleeding(+)
    Feel : swollen (-), tenderness (+), CRT
    >2,
    Move : limited ROM

    Planning of additional
    examination
    DL, GDS, SGOT-SGPT, Ur, Cr, BT, CT,
    HBsAg
    Ro wrist Joint AP/Lateral sinistra
    Ro Thorax PA

    Laboratory Findings

    Hb: 8,0
    HCT : 25,5
    PLT: 265.000
    WBC : 21,4
    GDS : 208
    Hbs Ag : Reaktif
    BT : 430
    CT : 600
    SGOT : 22
    SGPT : 23
    Ur : 3,6
    Cr : 1,1

    Working Diagnosis
    Schizum Wound of vollar wrist
    sinistra
    Suspect Rupture tendon
    Suspect rupture median nerve
    Suspect rupture radial artery

    Treatment

    IVFD RL 20 tpm
    Opimer 2x1 gr
    Ketorolac 3x30 mg
    ATS 1500 IU/IM
    Planning for Operation
    Informed Consent
    Fasting 6 hours before op
    Consultation with aenesthesiologist

    THANK YOU

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