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MORNING REPORT

EMERGENCY DEPARTMENT
RSUD DR.KANUJOSO DJATIWIBOWO

Wednesday, November 8th 2017


INTERNAL MEDICINE
No Time Name Age Sex Diagnosis Information

1. 13.05 Tukirun 62 yo M Hematokezia pro Dr. Trisya, Sp.PD


evaluation + Anemia e.c • IVFD NaCL 0,9 % 20 tpm
bleeding • Inf. Metronidazole 3 x 500 mg i.v
• Transfusi PRC 2 unit
• Fecal examination

2. 18.45 Djaenab 56 yo F Obs. Penurunan Dr. Trisya, Sp.PD :


kesadaran e.c -IVFD D10% 20 tpm
hipoglikemia + DM Tipe - Cek GDS/3 jam
II + Ulkus Diabetic - Ceftriaxone inj 2 x 1 gr
- Obat rutin stop
- Jika GDS > 200 mg/dl --. Inf. NaCl
0,9% 20 tpm
INTERNAL MEDICINE
No Time Name Age Sex Diagnosis Information

3. 19.30 Muhammad 57 yo M CML + Pneumonia Dr. Trisya, Sp.PD


Chariri • IVFD NaCl 0,9% 1500 cc / 24 jam
• Transfusi PRC II unit/hari, sampai Hb ≥
10 g/dl
• Ceftriaxone inj. 2x1 gr i.v
• Codipront 3x1 tab p.o
• Hydroxyurea 2x500 mg p.o
• As.folat 3x1 tab p.o
4. 00.45 Petrus Pasiakan 45 yo M Ulkus gaster Dr. Trisya, Sp.PD
-IVFD RL 20 tpm
-Pantoprazole 1x40 mg iv
-Ondansentron 3x4 mg iv
-Sucralfat syr 3x1
-Ceftriaxone 2x1 gr iv
INTERNAL MEDICINE
No Time Name Age Sex Diagnosis Information

5. 00.45 Siutik 58 yo F CKD on HD + HT gr II + Dr Trisya, Sp.PD


Dyspepsia -IVFD NaCl 0,9% 16 tpm
-Ranitidin 2x1 amp
-Ondansentron 3x4 mg iv
-Amlodipin 1x10 mg
-Candesartan 1x8 mg
RESPIROLOGY
No Time Name Age Sex Diagnosis Information

1. 09.20 Saude 63 yo M Pleural Effusion Dextra + Dr. Mufida, Sp.P


Coronary Artery Disease • IV catheter
post PCI • Nasal canule oxygent
• Inj. Dexamethasone /8 hour
• Inj. Ranitidine / 12 hour
• Inj. Ceftriaxone 1 gr / 12 hour
•USG Thorax with marker
• Pro pleural aspiration
• Co. Cardiologist

Dr. Ria, Sp.JP


• Furosemide 40 mg / 24 hour
2. 19.20 Welas 53 yo F PPOK + CHF Dr. Mufida, Sp.P :
-Nebulizer combivent/8 hours
- MP 3 x 8 mg p.o
- NAC 3 x 200 mg p.o
- Konsul Sp.JP

Dr. Ria, Sp.JP


-Micardis 1x80 mg p.o
- Echocardiografi
RESPIROLOGY
No Time Name Age Sex Diagnosis Information

3. 20.00 Supardan 72 yo M Pneumonia + PPOK + Dr. Mufida, Sp.P


Bekas TB • nebulizer combivent / 8 hours
• NAC 3 x 200 mg p.o
• Retaphyl SR 1 x ½ tab p.o
• Levofloxacin 1x500 mg p.o
• MP 3 x 62,5 mg i.v
CARDIOLOGY
No Time Name Age Sex Diagnosis Information

1 07.15 Suradi 56 th M UAP Dr. Ria, Sp.JP


-Aptor (4 tab)
-Arixtra 1x2,5 mg
-ISDN 3x5 mg
-Atorvastatin 1x20 mg
-Rawat ICCU
PEDIATRIC
No Time Name Age Sex Diagnosis Information

1. 11.05 Nur Wahyu 3 yo M Near drowning + Dr. Daniel, Sp. A


Pneumonia aspiration + • IVFD D5 ¼ NS 36 cc/hour
konvulsion • Inj. Meropenem 250 mg/8 hour
• Erytromycin 120 mg/6 hour
• Inj. Dexamethasone 1,75 mg/8 hour
(administered 30 minutes before
Meropenem injection)
• Nebulizer ventolin + NaCl 0,9% 2
cc/8 hour
• Ambroxol syrup 3 ml/8 hour
• Salbutamol 0,8 mg/8 hour
2. 09.19 Aliesha 1 mo F Severe Pneumonia + Dr. Daniel, Sp.A
Severe Dehydration e.c • Inj. Ampicilin Sulbactam 180 mg / 12
Low Intake hour
• Inj. Gentamycin 18 mg / 12 hour
• Nebulizer NaCl 0,9% 2 cc / 8 hour
• Rehidration 30 cc/kgBB/1 hour → 70
cc/kgBB/5 hour (administer
maintenance fluid if dehydration
resolved)
• Oxygent with NRM → desaturation
→ CPAP
PEDIATRIC
No Time Name Age Sex Diagnosis Information

3. 19.00 Gasendra Azel 5 yo M Chronic Tonsilitis dd Dr. Daniel, Sp.A


Diphteria Tonsilitis -Ceftriaxone inj. 1 gr/24 jam
- swab tenggorok
OBSTETRI DAN GINEKOLOGI
No Time Name Age Sex Diagnosis Information
NEUROLOGY & NEURO SURGERY
No Time Name Age Sex Diagnosis Information

1. 13.05 Eddy 72 yo M Ischemic Stroke Dr. Uli, Sp.S


• Clopidogrel 75 mg / 24 hour
• Aspilet 80 mg / 24 hour
2. 18.15 Evelyn Lovelya 4 yo F Mild Head Injury Dr. Uli,Sp.S
-Ondansentron 4 mg 3x ½ amp. i.v
- Betahistin 3 x ½ tab p.o
3. 03.50 Jumaiyah 52 yo F Hemorrhagic Stroke Dr. Uli Sp.S
(IVH) -IVFD 16 tpm
-Manitol 6x150cc
-Amlodipin 1x5 mg
-Micardis 1x80 mg
-Vit K 3x1
-Kalnex 3x500 mg iv
-Titrasi Perdipin
-Rawat ICU

Dr. Syahyad, Sp.An


-Acc ICU
SURGERY
No Time Name Age Sex Diagnosis Information
1. 21.30 Satria Yoga 15 yo M Acute appendicitis Dr. Sumaryono, Sp.B (KBD) :
Pratama -Rencana Appendiktomi besok pagi
(rabu)
- Ceftriaxone 2x1 gr. Iv
- Ranitidin 2x1 amp. Iv
PEDIATRIC SURGERY
No Time Name Age Sex Diagnosis Information

1. 16.45 Abraruz Tsaqief 1 yo M HIL D inkarserata Dr. Iman, SP.BA


- Operation at OK emergency
2. 18.00 Ahmad Abidzar 4 mo M Fimosis + Hidrokel + Dr. Iman Sp. BA
Urinary Tract Infection -Perbaikan KU
(UTI) + Acute diarrhea - Raber Sp. A
mild dehidration
Dr. Daniel, Sp. A
- IVFD D5 ¼ NS 24 cc/jam
- Paracetamol drop 0,8 cc/5-8 hours
- cek UL
ONCOLOGY
No Time Name Age Sex Diagnosis Information
PLASTIC SURGERY
No Time Name Age Sex Diagnosis Information

1. 09.01 Murjanah 29 yo F Vulnus Laceratum Regio Dr. Anto, Sp.BP-RE


Frontalis Dextra et Regio • Amoxicillin tab 500 mg / 8 hour
Supra Labialis • Mefenamic Acid tab 500 mg / 8 hour
ORTHOPEDIC SURGERY
No Time Name Age Sex Diagnosis Information
UROLOGY
No Time Name Age Sex Diagnosis Information
EMERGENCY OPERATION

No Time Name Age Sex Diagnosis Information

1. 17.00 Abraruz Tsaqief 1 yo M HIL D inkarserata Dr. Iman, Sp.BA


- Operation ( herniotomi)
2. 06.30 Satria Yoga 15 yo M Susp. Acute appendicitis Dr. Sumaryono, Sp.B-KBD
-Appendektomi
RESUME

Outpatient 66
Inpatient 24
Emergency Procedures 2
Total 90
THANK YOU