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MORNING REPORT

MONDAY, SEPTEMBER 24th 2018
Residents on duty :
WAG/DRE - LEY
IKI - MAS/DEV - FAN/LIM - HIN - GUD
YAS - ELA

Morning Report and Multidiciplines Group Coordinator :
dr. Imam Suseno Bayuadi, SpBTKV.

Consultants in charge :
dr. J. D. P. Wisnubroto, SpB(K)Onk.
dr. Istan Irmansyah Irsan, SpOT(K).
Dr. dr. Basuki B. Purnomo, SpU(K).

DENNYTA/M/45yo/11318601/1835128
ToArr : 13.00
ToAdm : 19.00
MORNING ADMISSIONS
Time General Status Problem Working Problem Solving / Final Diagnosis
Diagnosis Management

13.00 HR = 84 x/min Decreased of ICH Oxygenations Non traumatic ICH
BP = 190/100 conciousness Fluid administration (I61.9)
mmHg History of Hypertension Analgetics
RR = 22 x/min on hypertension for 3 Neuroprotectants Hypertension
Ventilator years Anticonvulsants (I10)
Isocoric pupil Vomiting Tranexamid acid
GCS = 1x1 Observation for VS,
R hemiparese (+) GCS, vomiting, seizures
and lateralization

Head CT Scan : Trephination
30cc of ICH in L decompression
Subcortex region evacuation ICH
ICP monitoring
(02.1)

Joint care with
Neurologic Department

00 RR=28x/min Pain in all the area of the Generalized Oxygenations Acute Gastric Ulcer HR= 110x/ abdomen since 2 days peritonitis dt Fluid administrations with Perforation min previously perforation of Analgetics (K25.PURNADI/M/74yo/11298603/1620203 ToArr : 18.1) BP=100/70 Nausea gaster Blood Culture Tax = 36.0°c Vomiting CVC Insertion Sepsis Antibiotics History of NSAID NGT and Urine Consumption since 6 catheter insertion month Previously Peritoneal Lavage Laboratory Result: (54.00 AFTERNOON OPERATIONS Time General Problem Working Problem Solving / Final Diagnosis Status Diagnosis Management 18.000 .25) Leococyte: 18.00 ToS : 22.

00 AFTERNOON ADMISSIONS PS : 96.5 (86.81) Abdominal US: Enlargment of Liver and Joint Care with Spleen Internal Medicine Head CT: no intracranial hemorrhage .00 ToAdm : 21. had sutured Chronic Myeloid Observation for VS.000 Primary suture accident (8.355.0) symmetrical Vomiting Open wound of head Fluid administration RR : 24x/min Headache Antibiotics Open wound of head C: Anemia Analgetics (S01) HR : 100x/min Open wound in Upper Lips Transfusion of PRC D: region.9) isochoric pupils Enlargment Of spleen and lateralization Liver Cellulitis Of L Knee Chronic Myeloid Leukimia Laboratry Result: Debridement (C92. seizures and (D64.8% Time General Status Problem Working Problem Solving / Final Diagnosis Diagnosis Management 19.1) MOI: Hb: 4.00 A : Patent History of loss of Mild head injury Head Elevation Concussion B : Spontaneous conciousness Oxygenation (S06.28) Motorcycle Leucocyte: 4. Anemia GCS : 356 Leukimia GCS.841 ToArr : 19.SULAIMAN/M/22yo/11318679/1835189 ISS : 9 ToAcc : 3 days previously RTS : 7.

841 ToArr : 19. medicine fluctuation (+).SULAIMAN/M/22yo/11318679/1835189 ISS : 9 ToAcc : 3 days previously RTS : 7.00 PS : 96.30 Swelling in the left Sellulitis L Knee Antibiotic Sellulitis L Knee knee Sensitization Infection marker Improve general Status Local: condition L Knee : Consult to L: swelling (+) internal F: tenderness (+).8% ToAdm : 21. NV distal (+) M: ROM limited .00 AFTERNOON ADMISSIONS Time General Status Problem Working Problem Solving / Final Diagnosis Diagnosis Management 19.

SULAIMAN/M/22yo .

SULAIMAN/M/22yo .

SULAIMAN/M/22yo .

SULAIMAN/M/22yo .

SULAIMAN/M/22yo .

SULAIMAN/M/22yo .

SULAIMAN/M/22yo .

SULAIMAN/M/22yo .

SULAIMAN/M/22yo .

4°C Fever Septic condition CVC insertion Septic conditon NGT and Urine catheter (A41.39 Exploratory laparotomy (54.000 Alb: 1.30 RR= 32x/min Abdominal pain since 7 Generalized peritonitis Oxygenation Perforation of BP=130/70 days previously dt.09) Leucocytes : 16.00 EVENING OPERATIONS Time General Status Problem Working Problem Solving / Final Diagnosis Diagnosis Management 16.7) Ileostomy (46.9) Muscular Rigidity Hypoalbumin insertion Observation for VS. Susp.11) Abdominal X-Ray Free air (+) Open and Other Partial excision Large Intestine (45. signs of acute Hypoalbumin Laboratorium: abdomen (E88.30 ToS : 23.2) . Perforation of Fluid administration intestine mmHg Deffiicult to deffecate hollow organ Analgetics (K63.1) HR= 110x/min since 2 days previously Antibiotics Tax: 38.ISMUJADI/M/73YO/11302318/1822901 ToArr : 16.

00 RTS : 7.00 MORNING OPERATION Time General Status Problem Working Problem Solving / Final Diagnosis Diagnosis Management 20.00 PS : 99.00 A : Patent Pain and open wound Open Wound In Analgetic Open Wound of Lip B : spontaneous in Tongue Tongue Antibiotic And Oral Cavity symmetrical (S01.28) MOI : fallen from Primary suture stairs (8.5) RR= 22x/min C : HR= 98 x/min Open Wound in D: Tongue sized 3x1 cm GCS=456 Debridement isocoric pupils (86.5% ToS : 07.WULAN/F / 3yo/ 11334318/1809276 ISS : 4 ToAcc : 20.81) .841 To Adm: 22.

00 RR=20x/min General weakness R malignant Of Breast Fluid administrations Malignant neoplasm BP=130/80 MmHg Mass with ulceration in T4bN1M0 Analgetic of breast HR=86x/min R breast Since 1 Years Post Chemoteraphy PRC transfusion (C50.0) lympnode in Axilla Region Chest X-Ray: No Metastatic Process Biopsy: Invasive ductal Carcinoma Grade III Laboratory Results: Hb: 7 .8) Alert Previously CAF 1x Anemia in neoplastic Mass and Ulcer in R Anemia disease Breast.00 EVENING ADMISSIONS Time General Status Problem Working Problem Solving / Final Diagnosis Diagnosis Management 19.LASEMI/11299828/1820154 ToArr : 19.00 ToAdm : 21. With enlargment (D63.

MARFUA/F/57yo/11318687/1635131 AFTERNOOON ADMISSIONS ToArr : 20.92) Heterogen solid mass multiple in R breast with characteristic to malignancy .00 Time General Status Problem Working Problem Solving / Final Diagnosis Diagnosis Management 20.8) Alert breast for 1 year Observation for VS and respiratory distress History Of Chest Tube Improve general Insertion in condition Bhayangkara Hospital 2 Oxygenation weeks Previously Thorax X-ray: Metastase Process And Efusi pleura with Re-Insertion of Chest Tube intercostal catheter for drainage Abdominal US: (34.04) Metastase (-) Pleurodesis Chemical Breast US: (34.00 ToAdm : 02.00 RR=20x/min Pain and mass in R R breast Malignancy Oxygenation Malignant neoplasm BP=130/80 MmHg breast T4bN1M1(Lung) Fluid administration of breast HR=86x/min History of mass in R On Chest Tube Analgetics (C50.

00 EVENING OPERATIONS Time General Status Problem Working Problem Solving / Final Diagnosis Diagnosis Management 00.0) .30 ToS : 07. Muscular rigidity signs of acute abdomen Laboratory: Leucocytes : 16.30 RR = 22x/min Pain in all area of the Generalized Oxygenation Acute appendicitis BP = 110/60 abdomen starting from 2 peritonitis dt susp Fluid with generalized mmHg days previously appendicitis acute administration peritonitis HR = 90x/min Difficult to defecate starting perforata Analgetics (K35.4oC from 2 days previoulsly Antibiotics Vomiting NGT and urine Fever catheter insertion Observation for VS.11) Appendectomy (47.000 Exploratory laparotomy (54.SUDJONO/M//11305382/1625089 ToArr : 00.2) T = 38.

Invagination 2 Weeks signs of acute previously in abdomen Bhayangkara Hopital .7°C NGT and Urine History of Exploratory catheter insertion laparotomy ec Observation for VS.00 RR = 20x/min Defecutly to defecated Partial Bowel Oxygenations Intestinal adhesions BP = 120/80 since 3 days previously Obstruction dt susp Fluid with obstruction mmHg Nausea adhesion administrations (K56.5) HR = 88x/min Vomiting Analgetics Tax = 36.ELLYZA/F/38yo/11305346/1824798 ToArr : 04.00 ToAdm : 08.00 MORNING ADMISSION Time General Status Problem Working Problem Solving / Final Diagnosis Diagnosis Management 04.

seizures Traumatic D: and lateralization subarachnoid GCS = 225 CT Scan: Open Wound In haemorrhage isocoric pupils SDH in L L Auricula Trephination (S06.904 ToArr : 04. vomiting.1) symmetrical Vomiting Analgetics RR = 20x/min History of Alcohol SDH Neuroprotectant Traumatic subdural C: consumtion Anticonvulsant haemorrhage BP = 130/70 SAH Tranexamid acid (S06.6) 3mm/3mm frontotemporoparietal decompression Of Bone region (5.30 A : Patent Decreased Moderate head Oxygenations Traumatic cerebral B : spontaneous consciousness injury Fluid administrations edema (S06.00 MORNING OPERATION Time General Status Problem Working Problem Solving / Final Diagnosis Diagnosis Management 04.6% ToOp : 12.30 PS : 88.3mm.7) Car Cerebral edema Today condition: GCS = 225 .2) Open wound of Ear MOI : slices) with midline (S01.3) Motorcycle in Shift to the Right 8 mm Repair Of Auricular collision with SAH (18.ARIS/M/22YO/11305371/1824997 ISS : 16 To acc : 04.5) mmHg Open Wound Avultion Observation for VS. 6 (01.00 RTS : 6. HR = 88x/min in L Auricula Cerebral edema GCS.

Contusion of RR : 20x/min Laboratory: Blunt chest sign of respiratory thorasic wall C: Hb: 10 trauma distress and signs of (S20.00 RTS: 7. isocoric pupils Abdominal US: MOI: Free fluid in perivesica and High fall perispleenica .6% AFTERNOON ADMISSIONS Time General Problem Working Problem Solving / Final Diagnosis Status Diagnosis Management 04.EKO/M/27yo/11323392/1838913 ISS:18 ToAcc : 04.00 A : Patent Pain and bruishes in chest Internal bleeding. Oxygenations Internal bleeding B: and abdominal region hemodynamic Fluid administrations (R58) Spontaneous stable Analgetics symmetrical Obs of VS.841 ToAdm : 08.2) BP : 130/70 PF Ratio: 400/425 acute abdomen mmHg HR : 90x/min Chest X-ray : D: within normal limit GCS: 456.00 PS : 98.

THANK YOU .