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  • 4.1 Consultation Report in Medical Ward

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    Rositania MB
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    This consultation report from the medical ward documents patient assessments and care from June 2-8. On June 5, patient Hary Tan Naya was assessed for possible infective endocarditis prior to valve replacement surgery, and found to have no ENT infection. On June 6, patient Siti Rodiyah was found to have oropharyngeal dysphagia and was scheduled for a flexible endoscopy exam. The report also documents care for several other patients assessed for issues like acute rhinitis, ear cerumen, sudden deafness, and more. No procedural reports are included from June 2-8.

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    This consultation report from the medical ward documents patient assessments and care from June 2-8. On June 5, patient Hary Tan Naya was assessed for possible infective endocarditis prior to valve replacement surgery, and found to have no ENT infection. On June 6, patient Siti Rodiyah was found to have oropharyngeal dysphagia and was scheduled for a flexible endoscopy exam. The report also documents care for several other patients assessed for issues like acute rhinitis, ear cerumen, sudden deafness, and more. No procedural reports are included from June 2-8.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
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    5 views9 pages

    4.1 Consultation Report in Medical Ward

    Uploaded by

    Rositania MB
    This consultation report from the medical ward documents patient assessments and care from June 2-8. On June 5, patient Hary Tan Naya was assessed for possible infective endocarditis prior to valve replacement surgery, and found to have no ENT infection. On June 6, patient Siti Rodiyah was found to have oropharyngeal dysphagia and was scheduled for a flexible endoscopy exam. The report also documents care for several other patients assessed for issues like acute rhinitis, ear cerumen, sudden deafness, and more. No procedural reports are included from June 2-8.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
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    of 9

    CONSULTATION REPORT FROM MEDICAL WARD

    2nd - 8th June 2023


    CONSULTATION REPORT FROM MEDICAL WARD
    2nd - 8th June 2023
    Day/Date No Name Assessment Action plan Doctor in Charge
    Friday DAY OFF
    02/06/23

    Saturday DAY OFF


    03/06/23

    Sunday DAY OFF


    04/06/23
    CONSULTATION REPORT FROM MEDICAL WARD
    2nd - 8th June 2023
    Day/Date No Name Asessment Action plan Doctor in Charge
    Monday 1 Hary Tan Naya Currently we assess the patient with No treatment in ENT. SAR
    05/06/23 M, 44 y.o no sign and symptom of infection in
    CM 23028183 ENT.
    Ward : Integrated Heart Center,
    HCU

    Patient consulted from Cardiology


    with possible Infective
    Endocarditis (IE), planned for
    aortic and mitral valve
    replacement. Consulted for
    evaluation of focal infection in
    ENT.
    CONSULTATION REPORT FROM MEDICAL WARD
    2nd - 8th June 2023
    Day/Date No Name Asessment Action plan Doctor in Charge
    Monday 2 I Gede Juniawan Sukrama Currently we assess the patient with - Nasal irrigation with NaCl WLN
    05/06/23 M, 39 y.o acute rhinitis. 0,9%
    CM 20011645 - Illiadin nasal spray 2 puffs
    Ward : Mahottama every 12 hours in both nasal
    cavity
    Patient consulted from Oncology
    Surgery with right massive pleural
    effusion. Consulted for upper
    airway infection.
    Tuesday 1 Siti Rodiyah Currently we assess the patient with - Planned for flexible AEP
    06/06/23 F, 46 y.o oropharyngeal dysphagia endoscopy examination in the
    CM 23027340 ENT clinic on June 7th 2023
    Ward : Lely

    Patient consulted from Neurology


    with primary cerebral SOL.
    Consulted for evaluation of
    dysphagia.
    CONSULTATION REPORT FROM MEDICAL WARD
    2nd - 8th June 2023
    Day/Date No Name Asessment Action plan Doctor in Charge

    2 Nyoman Rastama Currently we assess the patient with No treatment in ENT. AEP
    M, 41 y.o no sign and symptom of infection in
    CM 23029190 ENT.
    Tuesday Ward : Medical Surgical
    06/06/23
    Patient consulted from Neurology
    with suspect TB
    meningoencephalitis. Consulted
    for evaluation of focal infection in
    ENT.
    CONSULTATION REPORT FROM MEDICAL WARD
    2nd - 8th June 2023

    Day/Date No Name Asessment Action plan Doctor in Charge

    3 Cille Ayla Pilgard Currently we assess the patient with - Ear toilets DAP
    F, 49 y.o left impacted cerumen + left hearing - Suggest tympanoaudiometry
    CM 23028860 disorder. examination in the ENT clinic
    Ward : Anggrek

    Patient consulted from Psychiatry


    with depressive phase of bipolar
    disorder. Consulted for evaluation
    of pain in the left ear.
    Tuesday
    06/06/23 4 I Ketut Toya Currently we assess the patient with - Suggest tympanoaudiometry WND
    M, 66 y.o bilateral sudden deafness. examination in the ENT clinic
    CM 15040461 when the patient able to sit for
    Ward : Mawar, HCU more than 30 minutes
    - Joint care with ENT
    Patient consulted from Neurology - Oxygen 4 lpm ~ 15 minutes
    with suspect bacterial every 6 hours
    meningoencephalitis. Consulted - Steroid & mecobalamine ~ TS
    for evaluation of sudden hearing Neurology
    loss
    CONSULTATION REPORT FROM MEDICAL WARD
    2nd - 8th June 2023
    Day/Date No Name Asessment Action plan Doctor in Charge
    Wednesday 1 Dewa Ketut Ngurah Currently we assess the patient with - NGT inserted succesfully AND
    07/06/23 M, 60 y.o with lung adenocarcinoma pro NGT
    CM 22004109 insertion.
    Ward : Sanjiwani

    Patient consulted from


    Pulmonology with lung
    adenocarcinoma. Consulted for
    NGT insertion.
    Thursday 1 Jero Dangan Currently we assess the patient with - Tracheostomy on June 9th DAP
    08/06/23 M, 58 y.o pneumonia + severe ARDS + type 1 2023
    CM 23029074 respiratory failure + intubation day 6.
    Ward : West ICU

    Patient consulted from Anesthesia


    with pneumonia + severe ARDS +
    type 1 respiratory failure.
    Consulted for early tracheostomy.
    INPATIENT PROCEDURAL REPORT
    2nd - 8th June 2023
    INPATIENT PROCEDURAL REPORT
    2nd - 8th June 2023

    Day/Date No Name Diagnosis Action plan Surgical Finding Operator


    Friday DAY OFF
    02/06/23

    Saturday DAY OFF


    03/06/23
    Sunday DAY OFF
    04/06/23
    Monday NONE
    05/06/23

    Tuesday NONE
    06/06/23

    Wednesday NONE
    07/06/23

    Thursday NONE
    08/06/23

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