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  • Morning Report 25 JULI

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    Mohammed Ramzy Ghifari
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    This morning report summarizes information for two patients. The first patient is a 51-year-old man admitted to the Cempaka ward with back and abdominal pain. MRI results show a spinal tumor from C6-T2. The proposed treatment is laminectomy and excision of the tumor. The second patient is a 10-month-old boy admitted for vomiting every morning. He had VP shunt placement last month for hydrocephalus. Laboratory results show anemia. The proposed treatment is repositioning of the VP shunt due to suspected malfunction.

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    laporan pagi stase anestesi

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    This morning report summarizes information for two patients. The first patient is a 51-year-old man admitted to the Cempaka ward with back and abdominal pain. MRI results show a spinal tumor from C6-T2. The proposed treatment is laminectomy and excision of the tumor. The second patient is a 10-month-old boy admitted for vomiting every morning. He had VP shunt placement last month for hydrocephalus. Laboratory results show anemia. The proposed treatment is repositioning of the VP shunt due to suspected malfunction.

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    3 views16 pages

    Morning Report 25 JULI

    Uploaded by

    Mohammed Ramzy Ghifari
    This morning report summarizes information for two patients. The first patient is a 51-year-old man admitted to the Cempaka ward with back and abdominal pain. MRI results show a spinal tumor from C6-T2. The proposed treatment is laminectomy and excision of the tumor. The second patient is a 10-month-old boy admitted for vomiting every morning. He had VP shunt placement last month for hydrocephalus. Laboratory results show anemia. The proposed treatment is repositioning of the VP shunt due to suspected malfunction.

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    of 16

    MORNING REPORT

    OK XV
    M. Ramzy Ghifari
    G4A016036
    Identitas
     Nama : Tn. Muhnan
     Usia: 51 tahun
     Bangsal : Cempaka
     DPJP : dr. Agus budi setiawan, Sp.BS
     No cm : 02060908
    SubjektifRPD:
    - Stroke (-)
    Pasien merasakan punggung
    terasa nyeri (dari mulai leher - Penyakit jantung (-)
    bawah hingga belakang dada),
    perut sebah dan mudah - DM (-)
    kenyang, serta kaki sulit
    - Gangguan Ginjal (-)
    digerakkan
    - Riwayat Operasi (-)
    - Alergi (-)
    - Maag (-)
    - Asma (-)
    - Batuk (-)
    - Pilek (-)
    Objektif
    Status Generalis:
    -
     Ku/Kes: CM/E4V5M6 Kepala: mesocephal (+)
    TD : 120/80 mmhg
    - Mata: CA -/-, SI -/-, RC +/+,
    Nadi : 84 x/mnt reguler, isi
    isokor 3mm/3mm
    tekanan cukup
    - Telinga : bloody otore -/-
    RR : 20 x/mnt simetris
    - Hidung: bloody rhinore -/-
    S : 36.5 C
    - Mulut: discharge -
    BB: 73kg
    - Leher: deviasi trakea -
    TB: 163cm
    - Thoraks: simetris, jejas -,
    Airway: clear (+), buka 3 jari,
    P/ SDV +/+, RBK -/-, RBH -/-,
    TMD 6-7 cm, mallampati (II),
    Whz -/-,
    gitang(+) karies (+), gisu (-),
    C/ S1 > S2, M -, G -
    giyang (-), massa jalan
    - Abdomen : datar, supel,
    napas(-), massa leher(-)
    NT(-)
    -Ekstremitas : AH ++/++
    edema + -/ - -
    KM 5 5/2 2
    Hasil lab darah tgl 24/7/2018
     Hb 15.4
     Leu 19630 H
     Ht 47
     Erit 5.4
     Trombo 168.000
     Ureum 34.10
     Kreatinin 0.95
     A : tumor spinalis setinggi C6-T2

    P : pro laminektomi eksisi tumor

    Usul ASA : II
    FOTO MRI Tn. M 18/7/2018
    Identitas
     Nama : An. Erlangga
     Usia: 10 bulan
     Bangsal : Cempaka
     DPJP : dr. Agus budi setiawan, Sp.BS
     No. CM : 02069945
    Subjektif
     Orang tua Pasien mengaku anaknya muntah
    muntah setiap pagi hari, batuk (-)pilek(-) sesak (-).

    RPD:
    - HT (-)
    - DM (-)
    - batuk (-)
    - pilek (-)
    - Alergi (-)
    - Sesak (-)
    - Riw. Asma (-)
    - Riw. operasi (+) 1x di RSMS pemasangan VP
    Shunt bulan Juni 2018
    Objektif Status Generalis:
     : Ku/Kes: CM/E4V5M6
    TD : - - Kepala: hidrocephal (+)
    Nadi : 96 x/mnt reguler, isi tekanan cukup
    RR : 24x/mnt simetris - Mata: CA -/-, SI -/-, RC +/+, isokor 3mm/3mm
    S : 36.7 C
    BB: 7 kg - Telinga : bloody otore -/-
    TB: 73 cm
    Airway: clear (+), buka 2 jari, TMD 4-5 cm, - Hidung: bloody rhinore -/-
    mallampati (II), massa jalan napas(-), massa
    leher(-) - Mulut: discharge -

    - Leher: deviasi trakea -

    - Thoraks: simetris, jejas -,

    P/ SDV +/+, RBK -/-, RBH -/-, Whz -/-,

    C/ S1 > S2, M -, G -

    - Abdomen : datar, supel, BU (+) N

    - Ekstremitas atas: edema -/- akral hangat +/+


    KM 5|5

    Ekstremitas bawah: edema -/-, akral hangat +/+


    , KM5/5
    Hasil lab 24/07/2018
    Hb 10.1 L
    Leu 10450
    Ht 33
    Erit 4.6
    Trombo 663.000
    GDS 105
    Na 140
    K 5.3
    Cl 105
    HCTS 23/7/2018
     A : Malfungsi VP Shunt
    P : Reposisi VP Shunt


    Usul ASA : II
    Terima Kasih

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