Notulensi Morning Report

Hari : Senin, 04 juli 2022

Jumat, 1 Juli 2022

1. Nn. Aura sania/P/19th

Dx: Penurunan kesadaran + meningoencephalitis TB dd/ bacterial + pneumonia +
Hiponatremia+ anemia + hydrocephalus

Tx:
⁃ VP shunt R kocher point
⁃ Head elevation
⁃ suplementasi oksigen
⁃ terapi cairan
⁃ analgetik
⁃ antikonvulsan
⁃ observasi VS,GCS, muntah, kejang, lateralisasi
⁃ rawat bersama neurology dan pulmonology

2. Ny. Diana novitasari/P/23th

Dx: Generilized peritonitis dt adhesion gr III-IV omentoperitoneal, omentoileal,
ileocolica + perforated acute appendicitis + perforated caecum + perforated ileum +
hypokalemia

Tx:
⁃ explorasi laparotomi + adhesiolysis+ appendectomy + resection of ileum double
barrel ileostomy
⁃ suplementasi oksigen
⁃ terapi cairan
⁃ analgetik
⁃ antibiotik
⁃ NGT & kateter urine

3. Ny. Mamik/P/68th
Dx: Penurunan kesadaran + intracranial haemorrhage left internal capsule vol 18cc + HT
grade II

Tx:
⁃ ICP right kocher point insertion
⁃ head elevation
⁃ mannitol
⁃ suplementasi oksigen
⁃ terapi cairan
⁃ analgetik
⁃ antikonvulsan

4. Tn. wahit/L/21th
Dx: Superficial mid dermal burn injury 12% in face, neck, chest rught upper and lower dt
hot steam

Tx:
⁃ F: fluid administration
⁃ A: analgetics
⁃ T: nasogastric tube and uretrral catheterization
⁃ T: blood test
⁃ exicisional debridement of burn

5. Tn. Susiati/P/68th
Dx: Severe head injury+ subacute subdural hemorrhage left frontotemporoparietal region
+ linier fracture left occipital

Tx:
⁃ burnhole drainage 2 point at 1 side
⁃ head elevation
⁃ mannitol
⁃ suplementasi oksigen
⁃ terapi cairan
⁃ analgetik
⁃ antikonvulsan

6. Ny. Antin/P/27th
Dx: Mild head injury + open wound right frontal region + open wound right cheek region
+ closed degloving injury right tight region + open degloving wound anterior side R knee
+ vulnus laceratum dorsal side R foot

Tx:
BS:
⁃ exicional debridement
⁃ muscle suturing
BP:
⁃ exicisional debridement
⁃ advancement flap
BR:
⁃ armsling mobilized
⁃ pro ORIF

7. Ny. Lugiyen/P/69th
Dx: Total bowel obstruction dt transversum colon tumor T4bN1M1 (liver) + stenosis
ileum dt infiltration of malignancy

Tx:
⁃ explorasi laparotomy
⁃ ileum resection + double barrel ileostomy

8. Ny. Siti nur aisah/P/53th

Dx: Open wound of lower lip

Tx:
⁃ debridement
⁃ advancement flap

9. Ny. Ngatimin/P/83th
Dx: Mild head Injury

Tx:
⁃ debridement
⁃ muscle suturing

10. Tn. Bonasir/L/66th

Dx: Mild head injury 456 + complete spinal cord injury at level vertebra cervical 5 ASIA
A with neurogenic chock + teardrop fracture vertebra cervical 4

Tx:
BS: pro CT scan kepala
BR:
⁃ inline mobilization head collar brace
⁃ pro CT scan & MRI cervical
⁃ konsul anestesi untuk perawatan di ICU

catatan : oedema cerebri biasa muncul hari pertama, ketiga dan kelima

11. Ny. Suwati/P/48th

Dx: DOC dr SVA ICH in L Basal Ganglia + HT emergency + IVH

Tx:
⁃ trephination decompression and evacuation of ICH & ICP kontralateral
⁃ rawat bersama departemen neurologi

12. Tn. Ach. mur choi/M/68th

Dx: Severe head injury + susp DAI + cephal hematom L frontoparietal region + fr
maxilla Non lefort + open wound l frontal region + open wound L maxilla region

Tx:
BS: debridement + muscle suturing
BP: debridement + muscle suturing + urgent reconstruction of facial bone

Minggu 3 Juli 2022:

1. Ny. Dewi Halimah/P/34th

Dx: Seizure dt epilepsy + skull defect in L frontotemporal bone + mild Hydrocephalus

Tx:
⁃ VP shunt

2. Ny. Musringatin/P/53th
Dx: severe head injury + EDH R frontotemporal + ICH L temporal + fr linier R temporal

Tx:
⁃ head elevation
⁃ mannitol
⁃ suplementasi oksigen
⁃ terapi cairan
⁃ analgetik
⁃ antikonvulsan

3. Tn/ Subroto/L/51th
Dx: superficial mild dermal burn injury 26% in face, abdomen back, upper and lower
extremity dr fire

Tx:
⁃ F: fluid administration
⁃ A: analgetics
⁃ T: nasogastric tube and uretrral catheterization
⁃ T: blood test
⁃ exicisional debridement of burn

4. tn. M Rafi/M/64th
Dx: Mild head injury + SAH + fr R maxilla on lefort + fr of R zygoma + open wound R
superior palpebral + multiple facial abrasion

Tx:
BS: non operative management
BP: debridement + advancement flap + urgent recnsturction of facial bone

5. Tn. Sobri/38th
Dx: mild head injury + EDH + ICH + linier fracture of R frontotemporal + fr of R macilla
non lefort + fr of R ZMC + CF intertrochanter R femur

Tx:
BS: Non operatuve management
BP: urgent reconstruction of facial bone
BR: skin traction + ORIF

6. An. HA/9th
Dx: vulnus abrasion dorsal side R + CF methyseal L distal radius salter-harris type II +
CF metaphyseal L distal ulna incomplete

Tx:
⁃ woud care
⁃ backslab
⁃ pro closed reduction + long arm cast under C-arm