Notulensi Morning Report

Hari : Ranu, 06 juli 2022

Selasa, 5 Juli 2022

1. Ny Siti Maryam/P/60th
Dx: DOC+CVA ICH R Temporoparietal Vol 108cc+ivh+HT Emergency+DM Type II

Tx:
⁃ suplementasi oksigen
⁃ Head elevation
⁃ terapi cairan
⁃ analgetic
⁃ asam tranexamat
⁃ antikonvulsan
⁃ manitol
⁃ observasi VS,GCS, dan peningkatan tekanan intrakranial
⁃ rawat bersama neurology dan pulmonology

2. Tn Mudhori/l/50th
Dx: hernia inguinal inkaserata D

Tx:
⁃ terapi cairan
⁃ NGT dan kateter urine
⁃ Observasi VS,dan tanda akut abdomen

3. Ny. Naumiati/P/68th
Dx: Mild head injury+DM Type II+HT Type II

Tx:
⁃ head elevation
⁃ suplementasi oksigen
⁃ terapi cairan
⁃ analgetic
⁃ observasi vs,gcs.kejang dan lateralisasi

4. Tn. K Hariana/L/62th
Dx: mild head injury+subdural hygroma frontal region+open wound in L supraorbital
region+HT type II+cerebral atrophy+Fr maxilla le fort 1+Fr of bilateral inferior orbital
rime+dental avulsion+joint effusion L knee dt Susp Hemarthrosis+CF L patella
incomplete

Tx:
⁃ Head elevation
⁃ Suplementasi oksigen
⁃ Terapi cairan
⁃ Analgetik
⁃ Human tetanus immunoglobulin
⁃ Observasi VS,GCS ,kejajang dan lateralisasi
BS:
⁃ Debridement
⁃ Primary hecting
⁃ Muscle suturing
⁃ Clot hematoma evacuation
BP:
⁃ Moist dressing with hydrocolloid
⁃ Urgent facial bone reconstruction
BR:
⁃ Joint aspiration
⁃ Koker Cast

5. Tn. M Hasan/L/53th
Dx: Moderate head injury+ EDH R frontal region+EDH R Occipital regiom+SAH+ Fr
linier frontal D+ Fr maxilla D non lefort+Fr rima orbita superior D+ Fr rima orbita
inferior D + Subgalealhematoma FTP D+ Multiple vulnus abrasion facial region+Chronic
wound Dorsal Side R Ring Finger+ CF Subtrochanter L Femur+ CF R ankle weber B

Tx:
⁃ head elevation
⁃ suplementasi oksigen
⁃ terapi cairan
⁃ analgetik
⁃ asam tranexamat
⁃ observasi VS,GCS,kejang dan lateralisasi

BS:
⁃ non operative management
⁃ rencana CT Scan kepala jika GCS turun 2 poin
BP:
⁃ Wound dressing with hydrocolloid
⁃ Pro urgent facial bone reconstruction
BR:
⁃ R Ring Finger:
-Wound care
⁃ L Thigh:
- Skin Traction
- ORIF

⁃ R Ankle:
- Backslab
- ORIF

6. Ny. Siti Maryam/P/60th

Dx: DOC+ CVA ICH R temporoparietal vol 108cc+IVH+HT Emergency+DM type
II+Moderate Hydrocephalus

Tx:
⁃ suplementasi oksigen
⁃ head elevation
⁃ terapi cairan
⁃ analgetik
⁃ asam tranexamat
⁃ anti konvulsan
⁃ manitol
⁃ observasi VS,GCS,dan peningkatan tekanan intrakranial

BS:
⁃ Trephination decompression and evacuation for ICH+ICP Contralateral

7. Tn M Wahyu Maulana/L/8th
Dx: Chronic Wound dt Superficial mild Dermal Burn Injury 22% back, R superior upper
extremity,R superiorlower extremity region due to fire accident

Tx:
⁃ terapi cairan
⁃ analgetik
⁃ observasi VS,dan produksi urin
⁃ Plan for urgent debridement