Notulensi Morning Report

Hari : Rabu, 13 juli 2022

1. Nn. faliha/P/7th/11543452
Dx: Hematothorak D+Perdarahan Internal+ Ruptur Hepar AAST Grade IV+Ruptur
Lien+Anemia+Hiponatremia

Tx:
⁃ suplementasi oksigen
⁃ terapi cairan
⁃ analgetik
⁃ Asam Tranexamat
⁃ Kateter Urin
⁃ suplementasi oksigen
⁃ observasi hemodinamik dan nyeri perut akut
⁃ Manajemen Nyeri
⁃ Tranfusi PRC
BT : Intercostal catheter for drainage
BA : Non Operatif Management

2. Ny. Mariati/P/43th
Dx: Mild Head Injury+Vulnus Laceratum regio parietal D
Tx:
⁃ head elevation
⁃ suplementasi oksigen
⁃ terapi cairan
⁃ analgetik
⁃ Anti Tetanus
⁃ Observasi VS, GCC, Muntah, Kejang dan Lateralisasi
⁃
3. Tn Joko/L/42th
Dx: Contusio pulmonum + Perdarahan Sub Arachnoid+ Fr Costa 4, 5, 6 Posterior D+
Edema Cerebri+Luka Lecet di wajah

Tx:
⁃ Inline Mobilization
⁃ suplementasi oksigen
⁃ terapi cairan
⁃ analgetik
⁃ mannitol
⁃ Observasi VS,Neurologic examination and signs of respiratory distress
⁃ Intensive Care
- BT : Planning for serial BGA and Chest Xray
- BS : Evaluasi CT scan kepala 2x24jam jika GCS turun 2 poin, Head Collar brace
application
- BP : Planning facial Bone recontruction

4. Tn. Kamari/L/53th
Dx: Mild Head Injury+edema cerebri+ fr orbital inferios D/S +Le Fort I maxillary
fracture

Tx:
⁃ Suplementasi oksigen
⁃ Head Elevation
⁃ terapi cairan
⁃ analgetik
⁃ Anti Tetanus
⁃ Observasi VS, GCS, Muntah, Kejang
BT : Non Operatif Manjemen
BS : Non Operatif Manjemen
BP :
- Plan for facial bone reconstruction
- Wound care with hydrocollod dressing

5. Tn. Suraksi/P/70th
Dx: Mild head injury+ subgaleal hematoma left frontoparietal region+ brain atrophy

Tx:
⁃ suplementasi oksigen
⁃ head elevation
⁃ terapi cairan
⁃ analgetik
⁃ Anti Tetanus
⁃ Observasi VS, GCS, Muntah, Kejang
⁃ Hematoma evacuation
6. Ny. Nurhalim/P/28th
Dx: Right Fluid pneumothorakx on chest tube+lung TB+ HIV on antiviral treatment

Tx:
⁃ terapi cairan
⁃ suplementasi oksigen
⁃ Antibiotik
⁃ Analgetic
Plan for thoracotomy and decortification
Join care with internal medicine dan pulmology department

7. Ny. Sarmi/P/71th
Dx: Total bowel obstruction dt susp malignancy+pneumonia

Tx:
⁃ Suplementasi oksigen
⁃ Terapi cairan
⁃ Analgesik
⁃ NGT And Urine Cathteter
⁃ Observasi VS, dan tanda akut abdomen
Eksplorasi Laparatomi
Join care with pulmology department

8. Tn Rahmad/L/62th
Dx: Mild Head Injury+ Fr posterior ribs 3,4

Tx:
⁃ Suplementasi oksigen
⁃ Elevasi Kepala
⁃ Terapi cairan
⁃ Analgesik
⁃ Observasi VS, GCS, Muntah dan Kejang
BT :
- Non Operatif Manjemen
- Serial blood gas analysis
- Chest x-ray evaluation
BS :
- Non Operatif Manjemen

9. Ny. Sri Rusmini/P/83th

Dx: Left partial body weakness+ CVA Intracerebral+Hipertensi Emergensi

Tx:
⁃ Suplementasi oksigen
⁃ Elevasi Kepala
⁃ Terapi cairan
⁃ Analgesik
⁃ Antikonvulsan
⁃ Asam tranexamat
⁃ Observasi VS, GCS, Muntah, Kejang dan lateralisasi
Non Operatif Management
Join care with neurologic Department

10. Tn. Dwi Isjanto/L/73th

Dx: Inkarserata Inguinal hernia

Tx:
⁃ Terapi cairan
⁃ Nasogatric tube insertion
⁃ Urethral catheter insertion
⁃ Observasi VS, tanda akut abdomen
⁃ Bilateral repairof inguinal hernia with mesh

11. Tn. Tari/L/73th

Dx: Open wound labia oris superior + multiple abrasion woun facial +CF L Patella
Incomplete + OF L tibial Plateau Sch VI + OF proximal shaft L fibula GrIIIA

Tx:
BR :
L Thigh :
- Wound care
L Knee :
- Wound care
- ORIF Planned
L Lower leg :
- Debridement
- - Transarticular external fixaton
- Primary Closure

12 An. M Gibran/L/7th
Dx: CK + Hematome L Subgaleal parietal + linier Fr. Linier occipital bone
Tx:
⁃ Suplementasi oksigen
⁃ Elevasi Kepala
⁃ Terapi cairan
⁃ Analgesik
⁃ Observasi VS, neurological examination
BS :
- Non operative management
- Plan for head CT Scan evaluation if GCS decreases > 2 point

13 Ny. Siti Nur Aisyah/P/42th

Dx: Encephalitis + Hidrocephalus + Tuberculosis of Lung

Tx:
⁃ Suplementasi oksigen
⁃ Elevasi Kepala
⁃ Terapi cairan
⁃ Analgesik
⁃ Anikonvulsan
⁃ LCS Culture
⁃ Observasi VS, GCS, Vomiting, Seizure and lateralitation
⁃ VP Shunt
⁃ Join care with departemen neurologi

14. by. Mrs. Wulandari/L/5hr

Dx: Necrotizing enterocolitis of newborn + redundant sigmoid colon + hipokalemia

Tx:
⁃ Suplementasi oksigen
⁃ Terapi cairan
⁃ Observasi VS, tanda akut abdomen
⁃ Colon Washout
⁃ Urgent rectal biopsy
⁃ Join care with pediatrik departemen

15. by. Mrs.Lilis/P/2BL

Dx: anorectal malformation + anal atresia with rectovainal fistula+ anemia

Tx:
⁃ Suplementasi oksigen
⁃ Terapi cairan
⁃ OGT and urethral cateterisation
⁃ Observasi VS, tanda obstruksi abdomen
⁃ VACTERL evaluation
⁃ Planning for urgen colostomy
⁃ Join care with pediatrik departemen

tambahan masukan dari mr. reza dan spv:

Bu Tir: Overall good, correcting pronunciation

Pak Jun: penggunaan kata “sleep away” pada kasus sebaiknya cukup di tulis “sleep”