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  • Morning Report 10032016

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    Meivi Sampakang
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    A 42-year-old male farmer presented to the local health clinic with a chief complaint of an abdominal stab wound. He reported being stabbed around 6 hours prior. On examination, he was alert and oriented with stable vital signs. A 2cm stab wound was located near his umbilicus, penetrating 1.5cm deep. His treatment plan included intravenous fluids, antibiotics, pain medications, and wound care with observation of vital signs.

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    A 42-year-old male farmer presented to the local health clinic with a chief complaint of an abdominal stab wound. He reported being stabbed around 6 hours prior. On examination, he was alert and oriented with stable vital signs. A 2cm stab wound was located near his umbilicus, penetrating 1.5cm deep. His treatment plan included intravenous fluids, antibiotics, pain medications, and wound care with observation of vital signs.

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    3 views9 pages

    Morning Report 10032016

    Uploaded by

    Meivi Sampakang
    A 42-year-old male farmer presented to the local health clinic with a chief complaint of an abdominal stab wound. He reported being stabbed around 6 hours prior. On examination, he was alert and oriented with stable vital signs. A 2cm stab wound was located near his umbilicus, penetrating 1.5cm deep. His treatment plan included intravenous fluids, antibiotics, pain medications, and wound care with observation of vital signs.

    Copyright:

    © All Rights Reserved
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    of 9

    MORNING REPORT

    VULNUS ICTUM REGIO UBILICUS

    DATA DIRI PASIEN


    Nama
    : Tn. JN
    Jenis kelamin : Laki - laki
    Umur
    : 42 thn
    Pekerjaan
    : petani
    Alamat
    : Bira

    ANAMNESIS
    Os rujukan puskesmas kuma dengan keluhan
    utama luka tusuk di perut.
    Kejadian terjadi sekitar 6 jam SMRS ( pukul
    02.00)
    Riwayat trauma (-)

    PRIMARY SURVEY
    A : clear
    B : 24x/menit
    C : TD : 130/80 mmHg, N: 86x/m
    D : GCS : 15, pupil bulat isokor 3mm-3mm,
    refleks Cahaya (+)
    E : Sb : 37 derajat celcius

    SECONDARY SURVEY
    Allergic : (-)
    Medication
    : IVFD RL
    Past Illness
    : (-)
    Last meal : 10 jam SMRS
    Exposure : abdomen

    SECONDARY SURVEY
    Kepala : conj an -/- scl ict -/- jejas (-), luka (-)
    Thoraks: jejas (-), luka (-), simetris
    C : Si-ii (N) bising (-), Gallop (-)
    P : Sp. Vesikuler Rh -/- Wh -/Abdomen : datar, lemas, BU(+) N , H/L: ttb,
    NTE (-)
    st. Lokalis : luka tusuk ukuran 2cm
    dalam luka 1,5cm

    st. Lokalis : luka tusuk ukuran


    2cm kedalaman luka 1,5cm
    x

    Ekstremitas : akral hangat, edema (-)

    Wdx : Vulnus ictum regio umbilicus


    Terapi :
    IVFD RL : 14gtt/m
    Ranitidin 2x1 amp IV
    Ketorolac 3x1 amp IV
    Tetagam inj (IM)
    Rawat luka
    Hecting
    Observasi vital sign

    TERIMA KASIH

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