Notulensi Morning Report

Hari : Senin, 11 juli 2022

Jumat, 08 juli 2022

1.Mrs. endang yuliani/F/56yo

Dx:
chronic wound dt diabetic foot wagner IV L foot + DM type 2 + AKI stage 3 dd CKD
Tx:
 fluid administrtion
 oxygen
 antibiotics
 analgetic
 obs of vital signs
 wound care
 join care internal medicine
 urgent debridement and disarticulation

Notes:
apabila bertemu pasien dengan kasus seperti ini cek CRT, saturasi oksigen di digiti 1, cek
pergerakan jari kaki

2.mrs. indari/F/53yo
Dx:
decrease of conciousness dt SOP cerebri dd intracerebral abcess
Tx:
 oxygen supplementation
 head elevation
 fluid administration
 analgetics
 anticonvulsants
 manitol
 tumor coctail
 observation of VS, GCS and elevation of ICP

3.mrs. Soekuem/F/82yo
Dx:
CVA ICH in R subcortex col 47cc + IVH + HT grII + type II DM
Tx:
 oxygen supplementation
 head elevation
 fluid administration
 analgetic
 anticonvulsants
 manitol
 tranexamid acid
 trephination decompresion evacuation of intracranial hemorrhage

notes:
tekanan darah tinggi diturunin 20% dahulu, lalu diturunkan bertahap, apabila terlalu cepat
diturunkan akan menyebabkan infark

4.mr. Tariono/M/44yo
Dx:
moderate ARDS + blunt chest trauma + obs. neck injury + fr. L ZMC + fr. R/L NOE +
Fr. R.maxillary lefort II + Fr. palatum bone type I + stitched wound frontal region +
stitched wound R supraorbital region + stitched wound L infraorbita region +brain
atrophy
Tx:
 oxygen supplementation
 head elevation
 fluid administration
 analgetic
 antibiotic
 debridement of wound + primary clossure
 plan for facial bone reconstruction

notes : apabila gangguan pada prefrontal area otak akan menyebabkan perubahan
perilaku seseorang menjadi lebih agresif

5.Sanipah/F/64yo
Dx:
pathological fracture intertrochanter R femur dt. susp MBD process + pressure ulcer at
sacral region Gr. III + anemia
Tx:
 analgetic
 skin traction
 wound care
 konsul internal medicine

6.Supriadi/M/49yo
Dx:
open degloving R geel pad
Tx:
 analgetic
 antibiotic
 human tetanus imunoglobulin
 debridement
 primary closure k/p secondary clossure

7.M. taufiq/M/17yo
Dx:
OF dislocation distal phalanx L ring with susp rupture contral slip + bone loss + multiple
vulnus laceratum
Tx:
 analgetic
 antibiotic
 human tetanus imunoglobulin
 debridement + explore + repair + K-wire insertion

sabtu, 09 juli 2022

1.mr. evan/M/20yo
Dx:
mild head injury + blunt chest injury + blunt chest injury + mild ARDS + right maxilary
fracture non lefort + right angulus mandible fractur + nasal bone fracture + multiple
Vulnus abarasion facial regions
Tx:
 oxygen supplementation
 head elevation
 fluid administration
 analgetics
 plan for nasal reposition and facial bone reconstructions
 debridement

2.mrs. lady/F/37yo
Dx:
decreasing consciousness dt SOP cerebri sisp. meningioma
Tx:
 oxygen supplementation
 head elevation
 fluid administration
 analgetics
 VP shunt left kocher point

3.mr. Supri/M/80yo
Dx:
CVA ICH R Ganglia basal + IVH + Hypertension stg II + ACS
Tx:
 oxygen supplementation
 head elevation
 fluid administration
 analgetics
 anticonvulsants
 manitol
 insertion of ECD

4.mrs. Endang/F/58yo
Dx:
CVA SAH dt susp ruptur aneurysm + HT stg II
Tx:
 oxygen supplementation
 fluid administration
 analgetics
 tranexamic acid
 mannitol
 anticonvulsants
 plan for CTA

5.mrs. mutmainah/F/41yo
Dx:
mild head injury + fracture of lateral 2nd ribs + open wound frontal region + open
wound nasal region + CF middle shaft clavicle + OF intercondylar R femur Gr.IIIA +
vulnus abrasion dorsal side R foot + closed chip fracture distal phalanx R great toe
Tx:
 oxygen supplementation
 head elevation
 fluid administration
 analgetics
 debridement muscle suturing
 debridement and advanced flap
 L shoulder : armsling if mobilized + plan for ORIF
 R tigh: debridement + skin traction + plan for ORIF

6.ms. dian/F/18yo
Dx:
Mild head injury + contusional hemorrhages frontal region
Tx:
 oxygen supplementation
 fluid administration
 analgetics
 tranexamic acid
 head CT if GCS drop > 2points

7.mrs. Niti/F/80yo
Dx:
decreasing concusiousness dt intracranial hemorrhages right capsula interna vol 10cc +
Ht stg II + cerebral edema + hydrocephalus
Tx:
 oxygen supplementation
 fluid administration
 analgetics
 tranexamic acid
 mannitol
 anticonvulsants
 Vp shunt left Kocher point

8.mrs. istiqomah/F/ 49yo

Dx:
DOC dt CVA ICH R capsula interna + HT emergency
Tx:
 oxygen supplementation
 head elevation
 fluid administration
 analgetics
 anticonvulsants
 manitol
 VP shunt Left kocher point

9.mr. Tomy/M/17yo
Dx:
mild head injury+ open wound R labium oris region + VL anterolateral side ankle
Tx:
 oxygen supplementation
 head elevation
 fluid administration
 analgetics
 debridement + advancement flap

10.mrs. lilik/F/46yo
Dx:
seizure dr SOP cerebri dr sphenoid meningioma left drontal region
Tx:
 oxygen supplementation
 fluid administration
 analgetics
 tumor coctail
 revision of shunt
 plan for urgent exicion of tumor

minggu 10 Juli 2022

1.Mr. Slamet/M/71yo
Dx:
Total bowel obstruction dt tumor reti 1/3 proxial T2N1M0 susp malignancy infiltrate to
mesenterium & transversum
Tx:
 oxygen supplementation
 fluid administration
 analgetics
 antibiotics
 exploratory laparotomy

2.Ms. nazila/F/18yo
Dx:
mild head injury + multiple vulnus abrasion at face regions
Tx:
 oxygen supplementation
 head elevation
 fluid administration
 analgetics
 wound car with hydrocoloid

3.Ms. Shafa/F/16yo
Dx:
blunt abdominal trauma
Tx:
 oxygenation
 fluid administration
 analgetic
 observation for VS & sign of acute abdomen

4.Mr. musal/M/63yo
Dx:
Total bowel obstruction dt susp malignancy + sepsis + Hypertension stg II
Tx:
 oxygen supplementation
 fluid administration
 analgetics
 antibiotics
 observation for VS signs acute abdomen
 exploratory laparotomy