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  • MORNING REPORT TGL 23/02/2023: Rumkital Merauke

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    khalida
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    This document contains a morning report from Rumkital Merauke Hospital dated February 23, 2023. It reports that there are currently 222 total patients, with 85 inpatient and 137 outpatient. It then presents a case of a 2 year old male patient who presented with seizures, fever for 1 day, and was conscious but crying strongly after the seizure. On examination, he had a temperature of 39.4°C with other vital signs stable. He was assessed with seizures and observation for fever. The therapy prescribed included IV fluids, paracetamol, diazepam, and other medications.

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    This document contains a morning report from Rumkital Merauke Hospital dated February 23, 2023. It reports that there are currently 222 total patients, with 85 inpatient and 137 outpatient. It then presents a case of a 2 year old male patient who presented with seizures, fever for 1 day, and was conscious but crying strongly after the seizure. On examination, he had a temperature of 39.4°C with other vital signs stable. He was assessed with seizures and observation for fever. The therapy prescribed included IV fluids, paracetamol, diazepam, and other medications.

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    6 views13 pages

    MORNING REPORT TGL 23/02/2023: Rumkital Merauke

    Uploaded by

    khalida
    This document contains a morning report from Rumkital Merauke Hospital dated February 23, 2023. It reports that there are currently 222 total patients, with 85 inpatient and 137 outpatient. It then presents a case of a 2 year old male patient who presented with seizures, fever for 1 day, and was conscious but crying strongly after the seizure. On examination, he had a temperature of 39.4°C with other vital signs stable. He was assessed with seizures and observation for fever. The therapy prescribed included IV fluids, paracetamol, diazepam, and other medications.

    Copyright:

    © All Rights Reserved
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    of 13

    MORNING REPORT TGL 23/02/2023

    Rumkital Merauke
    TOTAL PASIEN : 222

    Jadwal dinas BPJS PC Rawat Inap Rawat Jalan Total


    Tgl 16/02/2023 7 24 9 22 31
    Tgl 17/02/2023 4 21 8 17 25
    Tgl 18/02/2023 11 16 10 7 27
    Tgl 19/02/2023 16 22 15 23 38
    Tgl 20/02/2023 16 30 14 32 46
    Tgl 21/02/2023 11 15 9 17 26
    Tgl 22/02/2023 14 15 10 19 29

    Total : 222 Pasien


    Rawat Inap: 85 Pasien
    Rawat jalan: 137 Pasien
    CASE PRESENTATION
    01
    IDENTITY

    NAME : an. T
    GENDER : Male
    AGE : 2th
    INSURANCE : BPJS
    CONSULTAN : dr. Ester,Sp.A (K)
    RM : 23.00.12.46
    MRS : 17/02/2023
    PRESENT MEDICAL HISTORY
    (AUTOANAMNESIS)

    • KU: kejang
    • RPS: pasien datang dibawa orang tua dalam keadaan kejang. Kejang kelonjotan dan mata melirik ke arah
    kanan, kejang kurang lebih sejak 10 menit SMRS. Kejang didahului demam naik turun sejak 1 hari
    SMRS,setelah kejang pasien sadar menangis kuat , batuk pilek disangkal. Bab bak normal. Mual muntah
    disangkal.
    • RPO: -
    • RPD: :
    • R. alergi: -
    PHYSICAL EXAMINATION

    LOC : E4V5M6
    BP :-
    PR : 158x/MNT REGULAR
    RR : 30 X/MIN
    TEMP : 39,4ºC
    SpO2 : 99% ROOM AIR
    EYE : CONJUNGTIVA ANEMIC -/-, ICTERIC -/-
    MOUTH : SIANOSIS (-), ORAL PLAQUE (-)
    NECK : LYMPHNODE ENLARGEMENT (-)
    THORAX : BARREL CHEST (-)
    HEART
    • INSPECTION : IC UNSEEN
    • PALPATION : IC PALPABLE 2 CM LATERAL OF MIDCLAVICULA LINE (S), ICS V
    • PERCUSSION :
     RIGHT BORDER : PARASTERNAL LINE DEXTRA
     LEFT BORDER : 2 CM MEDIAL OF ANTERIOR AXILLARY LINE (S), ICS VI
    • AUSCULTATION : S1 S2 SINGLE, REGULAR, MURMUR (-)

    LUNG
    • INSPECTION : SYMMETRIC ON STATIC AND DYNAMIC, RETRACTION (-)
    • PALPATION : FOCAL FREMITUS N/N
    • PERCUSSION : SONOR /SONOR
    • AUSCULTATION : VESICULAR +/+, RHONCI -/-, WHEEZING -/-
    ABDOMEN
    • INSPECTION : DISTENDED (-)
    • AUSCULTATION : BOWEL SOUND ( + ) NORMAL 6 X/MIN
    • PALPATION : DEFANS MUSCULAR (-)
     LIVER : NOT PALPABLE
     SPLEEN : NOT PALPABLE
    • PERCUSSION : SHIFTING DULLNESS (-)

    EXTREMITIES
    WARM +/+ EDEMA -/-
    +/+ -/-
    ASSESMENT

    • KDS
    • Obs febris H1
    T H E R A P Y

    • - IVFD KAEN 3B 40 tpm mikro- paracetamol 3x 100 mg po pulv- diazepam


    3x 1 mg iv- stesolid 5mg (sudah diberikan)- pct supp 100mg ( sudah
    diberikan)
    02
    Terima Kasih

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