NOTULENSI MORNING REPORT 20 JULI 2022

SENIN 18/07/2022
1. BY. NY DILLA/L/1HR
DX : MALFORMATION ANORECTAL WITHOUT FISTULA

TX :
- SUPLEMENTASI OKSIGEN
- FLUID ADMINISTRATION
- OGT DAN KATETERISASI
- OBSERVASI VS DAN TANDA AKUT ABDOMEN
- GASTROSTOMY
- COLOSTOMY
- PLAN FOR : EXCISION OF UMBILICAL CORD CYST

2. BY. ALWI/L/6BL
DX : SEVERE OBSTRUCTIVE HIDROCEPHALUS

TX :
- SUPLEMENTASI OKSIGEN
- FLUID ADMINISTRATION
- ANALGESIK
- OBSERVASI VS
- PLAN FOR ETP DOUBLE SET UP VP SHUNT

3. BY. ALWI/L/6BL
DX : SEVERE OBSTRUCTIVE HIDROCEPHALUS

TX :
- SUPLEMENTASI OKSIGEN
- FLUID ADMINISTRATION
- ANALGESIK
- OBSERVASI VS
 - PLAN FOR ETP DOUBLE SET UP VP SHUNT

4. NY. WAKINI/P/48TH
DX : MODERATE HEAD INJURY + SUBDURAL HYGROME BILATERAL
FRONTAL REGION + LEFORT II MAXILLAR FRACTURE + NOE FRACTURE
+ LEFT FRONTO ZYGOMA FRACTURE

TX :
- HEAD ELEVATION
- SUPLEMENTASI OKSIGEN
- FLUID ADMINISTRATION
- ANALGESIK
- OBSERVASI VS, KEJANG, LATERALISASI
- HUMAN ANTITETANUS IMUNOGLOBULIN
- BS : NON OPERATIVE MANAGEMEN
- BP : WOUNDCARE WITH HIDROCOLLOID DRESSING, PLAN FOR
FACIAL BONE RECONTRUCTION

5. TN. HERI PURNOMO/L/38TH

DX : MODERATE TETANUS

TX :
- SUPLEMENTASI OKSIGEN
- FLUID ADMINISTRATION
- ANTIBIOTIK
- ANTICONVULSAN
- NGT AND URETHRAL KATETERISASI

6. NY. MISTRI/P/48TH
DX : TOTAL BOWEL OBSTRUCTION DT SUSP MALIGNANT NEOPLASMA
TRANVERSE COLON T3N1M0

TX :
 - SUPLEMENTASI OKSIGEN
- FLUID ADMINISTRATION
- ANTIBIOTIK
- ANALGESIK
- OBSERVASI VS DAN TANDA AKUT ABDOMEN
- EXPLORASI LAPAROTOMI
- LEFT HEMICOLECTOMI
- HARTMAN PROSEDUR
- END TRANSVERSOSTOMY

7. TN. MOCH RAMDANI/L/18TH

DX : MILD HEAD INJURY + BLUNT CHEST INJURY + BLUNT ABDOMINAL
INJURY + RETENSIO URINE DT PELVIC FRACTURE + URETHRA INJURY +
PELVIC RING INJURY APC TYPE II WITH STABLE HEMODYNAMIC + CF L
SUPERIOR RAMUS PUBIS + CF MIDDLE SHAFT R FEMUR

TX :
- HEAD ELEVATION
- SUPLEMENTASI OKSIGEN
- FLUID ADMINISTRATION
- ANALGESIK
- HUMAN ANTITETANUS IMUNOGLOBULIN
- OBSERVASI VS, KEJANG
- BS : NON OPERATIVE MANAGEMEN,
- BT : NON OPERATIVE MANAGEMEN
- BD : NON OPERATIVE MANAGEMENT
- BR :
- PELVIS : PELVIC BANDAGE, ORIF PLANNED
- R THIGH : SKIN TRACTION, ORIF PLANNED
SELASA 19/07/2022

1. TN. KASPIN/L/57TH
DX : INTERNAL BLEEDING WITH STABLE HEMIDYNAMIC + BLUNT
CHEST TRAUMA + MILD HEAD INJURY + SUBDURAL HYGOME IN
FRONTAL + STRITCHED WOUND REGIO FRONTAL + OPEN WOUND LABIO
ORIS SUPERIOR REGION + ABRASION OF FACE + CLOSED DEGLOVING +
MULTIPLE ABRASION WOUND

TX :
- HEAD ELEVATION 30°
- SUPLEMENTASI OKSIGEN
- FLUID ADMINISTRATION
- ANALGESIK
- HUMAN ANTITETANUS IMUNOGLOBULIN
- OBSERVASI VS, KEJANG
- BD : NON OPERATIVE MANAGEMEN, HCU
- BT : NON OPERATIVE MANAGEMEN, BGA AND CXR EVALUATION
- BS : DEBRIDEMENT, MUSCLE SUTURING
- BP : DEBRIDEMENT + ADVANCED FLAP, SPLIT THICKNESS SKIN
EXCISION REGIO BACK, WOUNDCARE ABRATION WITH
HIDROCOLLOID

2. BY. HAZMI/L/9BL
DX : R PENUMOTHORAX DT BAROTRAUMA INTUBATION

TX :
- HEAD ELEVATION
- SUPLEMENTASI OKSIGEN
- FLUID ADMINISTRATION
- ANALGESIK
- OBSERVASI VS,
 - INSERTION OF INTERCOSTAL CHATETER FOR DRAINAGE

3. TN. FERIADIANSYAH/L/21TH
DX : BLUNT CHEST TRAUMA + MILD HEAD INJURY + EDH FRONTAL
REGION + STRITCHED WOUND REGIO PALPEBRA SUPERIOR + MULTIPLE
ABRATION

TX :
- HEAD ELEVATION 30°
- SUPLEMENTASI OKSIGEN
- FLUID ADMINISTRATION
- ANALGESIK
- HUMAN ANTITETANUS IMUNOGLOBULIN
- OBSERVASI VS, KEJANG
- BS : NON OPERATIVE MANAGEMEN , HEAD CT EVALUATION
2X24JAMIF GCS DECREASED 2 POINT, HIGH CARE UNIT
- BP : RE-DEBRIDEMENT + ADVANCED FLAP, WOUNDCARE ABRATION
WITH HIDROCOLLOID
- BR : WOUNDCARE
-
4. TN. FAISOL/L/51TH
DX : ABDOMINAL PAIN DT ABSES PANKREAS

TX :
- FLUID ADMINISTRATION
- ANALGESIK
- ANTIBIOTIK
- OBSERVASI VS, TANDA AKUT ABDOMEN
- IMPROVE GENERAL CONDITION
- PLAN DRAINAGE ABSCES OF PANCREAS

5. BY. FATIMAH/P/1BL
 DX : LOW LEVEL BOWEL OBSTRUCTION DT SUSP NEC GR II DD
HIRSCHPRUNG DISEASE

TX :
- SUPLEMENTASI OKSIGEN
- FLUID ADMINISTRATION
- OGT DAN KATETER INSERTION
- OBSERVASI VS DAN TANDA AKUT ABDOMEN
- COLON WASHOUT

TAMBAHAN DARI SUPERVISOR

DR.ARI, SPB, SPBTKV.K (T) ;
- TEMAN-TEMAN PPDS MESTI ALERT, ADA BEBERAPA KASUS DI RS YANG
TERLAPOR KE DIREKTUR, MELALUI AKUN WA LANGSUNG KE DIREKTUR
- TIDAK LAGI MENYEPELEKAN SEMUA TUGAS YANG DIBERIKAN SPV, JUGA
JIKA ADA KONSULTASI ANTAR BAGIAN JANGAN SAMPAI TERABAIKAN
SEPERTI ITU TERJAD JIKA MENUNDA-NUNDA.

DR.STS,SP.B-KBD :
- KEMARIN SAYA MENERIMA KELUHAN PASIEN. KITA TERIKAT UNDANG
UNDANG PELAYANAN PUBLIK, BAGAIMANA INTEGRITAS KITA TENTANG
PELAYANAN, RESPON TIME, DAN BAGAIMANA BERSIKAP KETIKA
MELAYANAI PASIEN.
- JANGAN SAMPAI MENYEPELEKAN KEPERCAYAAN YANG SUDAH
DIBERIKAN DPJP.

DR.MED.DR.TAL,SP.BS K (SPINE), FINSS, FINPS, FICS :

- TADI MALAM SAYA SUDAH TELUSUR LANGSUNG.
- SAYA TEKANKAN PADA RESIDEN, REKAN-REKAN ADALAH SUDAH
SEORANG DOKTER, TOLONG LEBIH DEWASA, LEBIH SADAR DIRI, ANDA
BUKAN SEORANG SARJANA KEDOKTERAN LAGI TAPI SUDAH SEORANG
DOKTER. HARUS PUNYA RASA TANGGUNGJAWAB LEBIH.