Morning Report

(jumat, 2018)
 Identitas
Tanggal Ket Diagnosa Planning Dx Terapi
Pasien
02/8/201 MRS Tn. N/ 26 th Abdominal pain DL, UL, Widal Inj. Ranitidin 1 amp
8 RA ec sindrom IVFD RL 20 tpm
dispepsia Konsul dr. Ade, Sp.PD
Advice:
IVFD RL 20 tpm
Inj. Ranitidin 2x1 amp
Inj. Metoclopramide 3x1 amp
P.O:
Antasida 3x1C
02/8/201 Rujuk Ny. D/ 66 th Cirrosis Hepatis EKG, GDA Konsul dr. Ade, Sp.PD
8 RSSA child pugh B + Advice:
Obstruktif IVFD life line
jaundice + DM on Inj. Antrain 1amp
insuline RUJUK RSSA
02/8/201 MRS Tn. H/ 42 th Multiple open DL,CT,BT,GDA Konsul dr. Hanafi, Sp.B
8 RA wound ,EKG, Ro. Advice:
Thorax PA Rencana debridement
IVFD RL life line
Inj. Ceftriaxone 2x1 g
Inj. Norages 3x1 amp
Konsul dr. Bano, Sp.An
Rehidrasi RL 1000 cc
Inj. Ranitidin 1 amp encerkan
dalam 10 cc bolus pelan
Inj. Metoclopramide 1 amp
Masuk OK
 Identitas
Tanggal Ket Diagnosa Planning Dx Terapi
Pasien
02/8/201 MRS Tn. M/ 257 th Obs. Febris H+6 DL, UL, Widal Konsul dr. Ade, Sp.PD
8 RA ec susp typoid Advice:
fever IVFD RL : Frutolite 2:1 20 tpm
Inj. Cefoperazone 2x1g skintest
Inj. Novaldo 3x1g (kp)
Inj. Omeprazole 1x40 mg
P.O:
Paracetamol 3x500 mg (kp)
Antasida syr 3x1 C
03/8/201 Rujuk Ny. S/ 80 th Susp CVA EKG, GDA Konsul dr. Ade, Sp.PD
8 hemoragic Advice:
IVFD NS life line
Rujuk RSSA
Inj. Norages 1 amp
Inj. Ranitidine 1 amp
Inj. Metoclopramide 1 amp
NGT, Kateter
03/8/201 MRS Ny. N/ 24 th Abdominal pain DL, UL, PP test IVFD RL 20 tpm
8 RA Inj. Antrain 1 amp
Konsul dr. Ade, Sp.PD
Advice:
IVFD RL 20 tpm
Inj. Cefoperazone 2x1 g skintest
Inj. Antrain 3x1 g
P.O:
Antasida syr 3x2C
Omeprazole 2x20mg
Tanggal Ket Identitas Pasien Diagnosa Planning Dx Terapi
03/8/2018 MRS RA Tn. F/ 49 th Obs. Chest pain + HT DL, SGOT,SGPT, Oksigen 8lpm NRBM
Ur, Cr, GDA, UL, Konsul dr. Ade, Sp.PD
EKG, Ro. Thorax Advice:
PA IVFD NS 10 tpm
Inj. Antrain 1 amp
ISDN 5 mg (P.O) ekg ulang 15 menit
kemudian
Captopril 25 mg (SL)
30 menit kemudian tensi ulang +
Ro. Thorax PA
Konsul ulang
Advice:
O2 2lpm NK
IVFD NS 10 tpm
Inj. Pantoprazole 1x40mg
Inj. Antrain 3x1 amp
Inj. Ceftriaxone 2x1 g skintest
P.O:
Captopril 3x25 mg
ISDN 3X5 mg
CPG 1X75 mg
Allupurinol 1x100 mg
Methylprednisolon 1x4 mg

03/8/2018 MRS RB By. A/ 5 hari Ikterus Neonatorum - Konsul dr. Muchlis, Sp.A
BB: 2,9 Kg Advice:
Terapi sinar 1 seri
 Identitas Planning
Tanggal Ket Diagnosa Terapi
Pasien Dx
04/8/201 RJ An.L/ 5 th/ BPJS GEA tanpa - Domperidon syr 3x1 cth
8 dehidrasi Parasetamol syr 3x1 cth
Oralite prn
Zink 2x1/2 tab
04/8/201 RJ Ny.A/45th/BPJS Burn injury - Wound toilet
8 Amoxcicilin 3x1
Asam mefenamat 3x1
05/8/201 RJ Ny. S/ 37th/ BPJS Hematochezia - Inj. Vit K ekstra
8 pasca oprasi Asam traneksamat 3x1
(Herniektomi)
Rujuk Tn. M/55th CVA dengan - IVFD NS 20 tpm
hemiparese Konsul dr. Ade Sp.PD
sinistra RUJUK
MRS An. G/55th Obs. Vomiting + - IVFD Kaen 3b 20 tpm makro
RA Febris H ke 2 Konsul dr. Muchlis Sp.A
Advice:
Inj. Novalgin 400 mg ekstra
Inj. Primperan 1 cc ekstra
Inj ranitidin 2x3/4 amp
Po. Zink 2x1/2 tab
Po. Domperidone 3x1 tab
Po. Parasetamol 3x1 tab
 Identitas Planning
Tanggal Ket Diagnosa Terapi
Pasien Dx
05/8/2018 MRS An. D/5th Typhoid Fever DL Konsul dr. Muchlis Sp.A
RA Advice:
IVFD Kaen 1b 12 tpm makro
Inj. Cefotaxime 2x250 iv
Po. Domperidone syr 3x1/2 Cth
Po. Parasetamol 3x1 ¼ Cth
05/8/2018 RJ Tn. S/ 72 th Asma bronkhial - Nebu combivent : NS
Ambroxol 3x1 tab
Salbutamol 3x2 mg
Methylprednisolon 3x4 mg
Loratadine 1x10 mg
O5/8/2018 MRS Tn. J/ 75 th Obs dyspneu ec EKG,GDA, O2 10 lpm NRBM
RA susp PPOK Ro. Thorax, Nebu Combivent : NS
dd susp TB paru DL, Ko. dr. Novi, Sp.P
SSGOT,SGP 02 8 lpm NRBM
T, Ur, Cr, Advice:
Sputum IVFD Loading NS 250 cc
BTA 2x selanjutnya 20 tpm
(S,P) Inj. Ceftriaxone 1x2g dilarutkan
dalam NS 0,9% 100cc
Inj. Methylprednisolon 3x31,25 mg
Inj. Ranitidin 2x50 mg
P.O:
ACE 3x200 mg
Paracetamol 3x500 mg
Inhalasi combivent 3x/hari
 Identitas Planning
Tanggal Ket Diagnosa Terapi
Pasien Dx
05/8/201 MRS Ny. S/ 22 th G1P0000Ab000 - Konsul dr. Arifian, Sp.OG
8 RB UK 38-39 Minggu Advice:
dengan KPD ≥ 12 Observasi kemajuan persalinan di
Jam + IUGR ruangan
06/8/201 MRS Tn. M/ 59 th Hipertensi EKG Captopril 25 mg SL  TD:220/130
8 RA Urgency IVFD NS 20 tpm
Konsul dr. Ade Sp.PD
Advice:
IVFD NS 10 tpm
Inj. Metoclopramide 3x10mg
Inj. Novaldo 3x1 g
Po. Captopril 3x25mg
Po. Amlodipin 0-0-10mg
Po. ISDN 3x10 mg
Po. Betahistin 3x6mg
Cek DL, UL, cr, chol
06/8/201 MRS Ny. W/21 th G1P0A0 uk 39-40 - Konsul dr Yunus Sp.OG
8 RB mgg + PROM < Advice:
12 jam Inj. Ceftriaxone 2x1 skin test
 Identitas
Tanggal Ket Diagnosa Planning Dx Terapi
Pasien
07/8/201 MRS Ny. E/36 th OF hari ke 1 + DL, Widal IVFD NS 20 tpm
8 RA vomiting Inj. Metoclopramide 1 amp ekstra
inj. Ranitidin 1 amp ekstra
konsul dr. Ade sp.PD
- IVFD NS: Futrolit 2:1 20 tpm
- Inj. Cefoperazone 2x1 g skin test
- Inj. Omeprazole 1x40 mg
- Inj. Ondansentron 3x4 mg KP
- Inj. Antrain 3x1 amp Kp
07/8/201 MRS Ny.S/22 th G1P0A0 grav Konsul dr. Yunus sp. OG
8 RB 24-25 mgg + IVFD RL loading 500cc  lanjut
Dispepsia RL:D5 2:1 28 tpm
Inj. Ondansentron 1x4mg
Inj. Ranitidin 2x1 amp
Po. Antasida syr 3xC1
 Identitas
Tanggal Ket Diagnosa Planning Dx Terapi
Pasien
08/8/201 MRS Ny. T/ 64 th Abdominal pain DL,GDA,UL, Konsul dr. Ade, Sp.PD
8 RA Ur, Cr, EKG Advice:
IVFD NS 20 tpm
Drip neurobion 1 amp/hari
Inj. Metoclopramide 3x1 amp
Fleet enema extra
08/8/18 MRS Ny. L/ 21 th G1P0000Ab000 - Konsul dr. Arifian, Sp.OG
RB UK 39-40 Advice:
minggu dengan Obs. Kemajuan Persalinan 15 mnt
prolong kala II Jika ada kesulitan lapor ulang