Scribd Logo
Upload

Welcome to Scribd!

  • MornRep OK II 8 Sept 14

    Uploaded by

    Anna Rumaisyah
    4 views16 pages
    This document contains the morning report from Senin, 8 September 2014 of 5 patients at the hospital. It summarizes key details for each patient including their name, age, diagnosis, symptoms, vital signs and medical test results. The patients include a 13 year old with a broken wrist, a 42 year old with a bone tumor, a 35 year old with rectal issues, a 59 year old with a foot infection and a 57 year old with a foot ulcer and infection. For each patient, the report lists their medical history, examination findings and lab test results.

    Original Description:

    jctycttvgv

    Original Title

    MornRep OK II 8 Sept 14-

    Copyright

    © © All Rights Reserved

    Available Formats

    PPTX, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    Report this Document
    This document contains the morning report from Senin, 8 September 2014 of 5 patients at the hospital. It summarizes key details for each patient including their name, age, diagnosis, symptoms, vital signs and medical test results. The patients include a 13 year old with a broken wrist, a 42 year old with a bone tumor, a 35 year old with rectal issues, a 59 year old with a foot infection and a 57 year old with a foot ulcer and infection. For each patient, the report lists their medical history, examination findings and lab test results.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    4 views16 pages

    MornRep OK II 8 Sept 14

    Uploaded by

    Anna Rumaisyah
    This document contains the morning report from Senin, 8 September 2014 of 5 patients at the hospital. It summarizes key details for each patient including their name, age, diagnosis, symptoms, vital signs and medical test results. The patients include a 13 year old with a broken wrist, a 42 year old with a bone tumor, a 35 year old with rectal issues, a 59 year old with a foot infection and a 57 year old with a foot ulcer and infection. For each patient, the report lists their medical history, examination findings and lab test results.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 16

    Morning report

    Senin, 8 September
    2014

    Nama : An.Agus Sunandar


    Usia : 13th
    No RM : 00896269
    Ruang : Seruni
    Diagnosis : fr. Distal radius sinistra
    Pro : rep. gips

    S : pasien merasa sesak


    Riw DM (-), HT (+), penyakit lain (-), riw.
    Op-

    A : clear, gipong (-), giyang (-) , gisu


    (-), MP 3
    B : spontan, RR 24 x/m, SD ves +/+,
    Rh -/-, Wh -/C : TD 120/80, N 123 x/m, teg & isi
    cukup, D : BB 48 kg, S 38C

    Hb 12.6 14.0 16.0


    Leu11930 4800 10800
    Ht 39 42 52
    Eri 6.9jt 4.7 jt 6.1 jt
    Tromb 157rb 150rb 450
    rb
    Ureum - 14.98 38.5
    Krea - 0.80 1.30
    GDS - <=200
    Kesimpulan : Asa 1

    Na - 136 145
    K - 3.5 5.1
    PT 11.2 11.5 15.5
    APTT 42.4 26.0- 36.0
    Cl - 98 107
    Ca - 8.4 10.2
    SGOT SGPT -

    Nama : Bp durohman
    Usia :42thn
    No RM : 00894786
    Ruang : seruni
    Diagnosis
    : primer bone tumor
    Pro
    : insisi biopsi

    S : nyeri bagian lutut kanan


    Riw DM (-), HT (+), penyakit lain (-), riw. Op -

    A : clear, gipong (-), giyang (-) , gisu (-),


    MP 1
    B : spontan, RR 20 x/m, SD ves -/+, Rh -/-,
    Wh -/C : TD 120/70, N 71 x/m, teg & isi cukup
    D : BB 50 kg, S 36.6C

    Hb 13 14.0 18.0
    Leu11.110 4000 10800
    Ht 38 42 52
    Eri 4.8jt 4.7 jt 6.1 jt
    Tromb 356rb 150rb 450 rb
    Ureum 11.6 14.98 38.52
    Krea
    0.80 0.80 1.30
    GDS 115
    <=200
    Kesimpulan : Asa 2

    Na - 136 145
    K - 3.5 5.1
    PT 11.2 11.5 15.5
    APTT 40.9 26.0- 36.0
    Cl - 98 107
    Ca - 8.4 10.2
    SGOT SGPT -

    Nama : Bp. Sarwono


    Usia : 35th
    No RM : 00890782
    Ruang : kenanga
    Diagnosis
    : TM Rectie
    Pro
    : biopsi rectie

    S : Susah BAB
    Riw DM (-), HT (-), penyakit lain (-), riw. Op-

    A : clear, gipong (+) molar sinistra bawah,


    giyang (-) , gisu (-), MP 2
    B : spontan, RR 20 x/m, SD ves -/+, Rh -/-,
    Wh -/C : TD 120/90, N 74 x/m, teg & isi cukup
    D : BB 50 kg, S 36C

    Hb 11.5 14.0 18.0


    Leu7810 4000 10800
    Ht 34 42 52
    Eri 4.5jt 4.7 jt 6.1 jt
    Tromb 346rb 150rb 450 rb
    Ureum - 14.98 38.52
    Krea - 0.80 1.30
    GDS 107
    <=200
    Kesimpulan : Asa 1

    Na - 136 145
    K - 3.5 5.1
    PT 10.9 11.5 15.5
    APTT 33.7 26.0- 36.0
    Cl - 98 107
    Ca - 8.4 10.2
    SGOT SGPT -

    Nama : Bp. Suharto


    Usia : 59th
    No RM : 00012065
    Ruang : RSR L1
    Diagnosis
    : Granulasi pedis dextra
    Pro
    : STSG

    S : batuk sejak 2 hari lalu


    Riw DM (+) sejak tahun 2001, HT (-), penyakit
    lain (-), riw. Op katarak

    A : clear, gipong (+) premolar hingga


    molar dextra sinistra bawah, giyang (-) ,
    gisu (+) seri atas, MP 2
    B : spontan, RR 20 x/m, SD ves -/+, Rh -/-,
    Wh -/C : TD 150/90, N 71 x/m, teg & isi cukup
    D : BB 89 kg, S 36.2C

    Hb 12.8 14.0 18.0


    Leu8080 4000 10800
    Ht 37 42 52
    Eri 4.6jt 4.7 jt 6.1 jt
    Tromb 235rb 150rb 450 rb
    Ureum 33.2 14.98 38.52
    Krea 2.30 0.80 1.30
    GDP 187
    <=125
    Kesimpulan : Asa 3

    Na 142
    136 145
    K 3.3 3.5 5.1
    PT - 11.5 15.5
    APTT - 26.0- 36.0
    Cl 100
    98 107
    Ca - 8.4 10.2
    Albumin 2.46
    Globulin 2.70
    Tot. protein 5.16
    As. Urat 6.3

    Nama : Bp. Hasan


    Usia : 57th
    No RM : 000990742
    Ruang : kenanga
    Diagnosis
    : Ulc. Pedis c/ Ca Pedis
    Pro
    : Eksisi luas + STSG

    S : nyeri saat menapak kaki di lantai


    Riw DM (-), HT (-), penyakit lain (-), riw. Op-

    A : clear, gipong (+) molar bawah sinistra,


    giyang (-) , gisu (-), MP 3
    B : spontan, RR 20 x/m, SD ves +/+, Rh -/-,
    Wh -/C : TD 130/80, N 71 x/m, teg & isi cukup
    D : BB 60 kg, S 37.1C

    Hb
    14.0 18.0
    Leu
    4000 10800
    Ht
    42 52
    Eri jt 4.7 jt 6.1 jt
    Tromb rb 150rb 450 rb
    Ureum
    14.98 38.52
    Krea
    0.80 1.30
    GDP
    <=200
    Kesimpulan : Asa 1

    Na K PT APTT
    Cl Ca -

    136 145
    3.5 5.1
    11.5 15.5
    - 26.0- 36.0
    98 107
    8.4 10.2

    You might also like