19 maret 2015 morpot
DESCRIPTION
pptTRANSCRIPT
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Night Shift ReportMarch 19th 2015
Asisten: dr. Hendy / dr. Jubil
Ko-Asisten:
Lilik Handayani (Chief)
Devira Fitrisia
Maria Tarry Mirani
Stephanie Dian Tanjung
Noviana Delima
Hana Ayunda Dewayanti
Raga Manduaru
Hendra Manurung
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Trauma: 1
Non-Trauma: 3
Hospitalize: 1
Non-Hospitalize: 3
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1. Mrs. D. ( 44 years old)No. MR 04-45-06-00
• Mechanism of trauma : terserempet motor• Injury organ : regio maleolus medial• Signs and symptoms : nyeri• Treatment pre hospital : as. mefenamat
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PRIMARY SURVEY
• Airway : CLEAR– Look : pergerakan dinding dada simetris kanan = kiri– Listen : tidak ditemukan suara nafas tambahan– Feel : terasa udara hangat dari hidung
• Breathing : CLEAR– Ins : pergerakan dinding dada simetris, RR 20x/menit,
hematoma (–) – Pal : vocal fremitus simetris– Per : sonor simetris kanan = kiri– Aus : BND vesikuler, rh -/-, wh -/-
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• Circulation : tidak ada tanda syok– Akral hangat, D 130/80 mmHg– Pulse = 73 x/menit– Temp = 36,10C– CRT <2”
• Disability– GCS 15 (E4M6V5)
pupil bulat isokor 3/3 mm, letak ditengah– RCL+/+ , RCTL +/+
• Exposure
Tidak ditemukan jejas yang membahayakan
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History of illness
Pasien datang dengan keluhan bengkak di kaki kanan. Bengkak yang dirasakan makin lama makin bertambah dan dirasakan terus menerus. Awal mulanya pasien terserempet motor. Sebelumnya pasien sudah berobat ke UGD RSUKI dan luka dibersihan dan diberi obat. Namun, keluhan bengkak timbul perlahan dan makin terasa nyeri. Selain itu, terdapat luka pada kaki kanannya. Riwayat trauma kepala -, muntah muncrat -, pingsan negatif, perdarahan negatif.
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SECONDARY SURVEY
AMPLE• Allergy : -• Medication : kompres rivanol, dan
minum as.mefenamat• Past Illness : -• Last Meal : siang hari• Event : terserempet motor
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HEAD TO TOE
Head : hematom -, jejas -.
Eyes : Pupil bulat, isokor 3mm/3mm, ditengah, RCL +/+, RCTL +/+, CA -/-
Ear : Normal, LCS (-), Blood (-)Neck : jejas (-), Hematoma (-)
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Thorax :- Inspection : jejas -, hematom -, pergerakan
dinding dada simetris kanan = kiri- Palpation : Vocal fremitus simetris - Percussion : sonor kanan = kiri, nyeri perkusi (-)- Auscultation: BND vesicular
kanan = kiri, wh-/-, rh-/-.
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Abdomen :- Inspection : tampak datar- Auscultation: bowel sound (+) 3x/min- Palpation : nyeri tekan (-), defense muscular
(-)- Percussion : tympani, nyeri perkusi (-)
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Status lokalis
• Regio maleolus medial dextra
L : oedema, darah (-), pus (-), vulnus ekskoriasi 4x1 cm, dasar jaringan subkutis
F : nyeri (+), hangat (+), krepitasi (-)
M: ROM aktif
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Clinical Photo
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Working diagnose
Vulnus ekskoriasi regio maleolus medial dextra
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TREATMENTNon-Medicamentosa:
Wound toilet
debridement
Medicamentosa :
Sefalosporin generasi III ( cefixime) tab 2 x 200mg
NSAIDs ( dexketoprofen) tab 3x 1
H2 blocker ( ranitidin) 2 x 1 tab
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2. Mr. N (40 years old)No. MR : 91.46.06.00
• Keluhan utama: BAB berdarah• Keluhan tambahan: nyeri di daerah
dubur
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History of illnessPasien datang dengan keluhan BAB berdarah sejak 3 hari SMRS. Darah yang keluar berwarna merah segar, menetes, dan tidak bercampur feses. Darah sampai merembes ke celana pasien dan pasien ganti celana dalam sampai 4x perhari. Awalnya, 7 hari SMRS pasien merasa ada benjolan kecil sebesar kacang tanah pada dubur pasien tetapi benjolan masih dapat dimasukkan ke dubur saat BAB. 3 hari SMRS pasien mengeluh benjolan semakin besar dan tidak dapat didorong masuk ke dubur lagi, dan dirasakan sangat nyeri. Pasien belum buang air besar sejak 2 hari SMRS. BAK tidak ada keluhan. Mual muntah disangkal.
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Vital Sign
• Keadaan umum : tampak sakit sedang
• Kesadaran : E4M6V5• BP : 130/70mmHg• Pulse: 110 x/minute• RR: 20 x/minute• Temperature : 36,5 oC
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HEAD TO TOE
Head : Normocephaly
Eyes : Pupil bulat, isokor 3mm/3mm, ditengah, RCL +/+, RCTL +/+, CA -/-, SI -/-
Ear : NormalNeck : pembesaran KGB tidak ditemukan
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Thorax :- Inspection : pergerakan dinding dada simetris
kanan = kiri- Palpation : Vocal fremitus simetris- Percussion : sonor kanan = kiri- Auscultation: BND vesikuler, wh-/-, rh-/-.
![Page 20: 19 Maret 2015 Morpot](https://reader030.vdocuments.us/reader030/viewer/2022033106/55cf917e550346f57b8de707/html5/thumbnails/20.jpg)
Abdomen :- Inspection : tampak datar- Auscultation: bising usus + 3x/menit- Palpation : nyeri tekan (-), defense muscular
(-)- Percussion : hypertympani, nyeri perkusi (-)
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Extremities
CRT< 2”, akral hangat
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Locale status
• Regio perianal :
I : tampak benjolan pada rektum, ukuran sebesar jempol pasien, perdarahan aktif (-), hiperemis (+), ulserasi (+).
F: nyeri (+), reposisi (-).
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Foto pasien
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Laboratorium18/03/2015
Pemeriksaan Hasil Normal
Hemoglobin 14,1 g/dl 12 -14
Leukosit 10,4 ribu/uL 5-10
Hematokrit 44,1% 37-43
Trombosit 247 ribu /uL 150-400
Na 136 mmol/L 136-145
K 3,5 mmol/L 3,5-5,1
Cl 100 mmol/L 99-111
GDS 139 mg/dl <200
ureum 22 mg/dl 15-45
kreatinin 0,80 mg/dl 0,70-1,10
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Working diagnose
Hematokezia e.c. Hemoroid externa grade IV
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Treatment
• Diet : lunak• IVFD
– III RL/24 jam
• Medikamentosa– Micronized
flavonoid fraction (Ardium) tab 2x2
– Antibiotik cephalosporin (Ceftriaxon) 2 x 1 gr
– NSAIDs (Ketorolac tromethamine) II amp/24 jam
– H2 blocker (Ranitidin) 2x1 amp
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3. Tn.F (23 years old)No. MR : 93.46.06.00• Keluhan utama: kencing berdarah• Keluhan tambahan: nyeri pinggang
kanan
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History of illnessPasien datang dengan keluhan kencing berdarah sejak 1 minggu SMRS. Frekuensi buang air kecil meningkat, pancaran melemah, jumlah kencing lebih sedikit dibanding saat pasien sehat. Awalnya pasien mengeluh nyeri dari pinggang kanan belakang, menjalar ke depan, hingga ke buah zakar. Nyeri terus menerus ada fase pasien mengeluh sangat nyeri hingga meringkuk dan setelah itu nyeri berkurang. Pasien telah berobat ke klinik, diberi obat penghilang nyeri, keluhan sedikit berkurang namun muncul kembali. Mual (+) pada siang hari diikuti dengan muntah. BAB teratur 1x / hari. 5 tahun yang lalu pasien pernah mengalami hal yang sama hanya dibawa ke pengobatan alternatif.
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Vital Sign
• Keadaan umum : tampak sakit sedang
• Kesadaran : E4M6V5• BP : 130/80mmHg• Pulse: 72 x/minute• RR: 20 x/minute• Temperature : 36,5 oC
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HEAD TO TOE
Head : Normocephaly
Eyes : Pupil bulat, isokor 3mm/3mm, ditengah, RCL +/+, RCTL +/+, CA -/-, SI -/-
Ear : NormalNeck : pembesaran KGB tidak ditemukan
![Page 31: 19 Maret 2015 Morpot](https://reader030.vdocuments.us/reader030/viewer/2022033106/55cf917e550346f57b8de707/html5/thumbnails/31.jpg)
Thorax :- Inspection : pergerakan dinding dada simetris
kanan = kiri- Palpation : Vocal fremitus simetris- Percussion : sonor kanan = kiri- Auscultation: BND vesikuler, wh-/-, rh-/-.
![Page 32: 19 Maret 2015 Morpot](https://reader030.vdocuments.us/reader030/viewer/2022033106/55cf917e550346f57b8de707/html5/thumbnails/32.jpg)
Abdomen :- Inspection : tampak datar- Auscultation: bising usus + 3x/menit- Palpation : nyeri tekan (+) regio iliaca
dextra dan suprapubik, defense muscular (-)- Percussion : tympani, nyeri perkusi (+) regio iliaca
dextra, dan suprapubik
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Extremities
akral hangat , CRT< 2”
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Locale status
• CVA: nyeri ketok +/-• Regio suprapubik: bulging -, nyeri
tekan +• Genitalia eksterna: tidak ada kelainan
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Foto BNO
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Laboratorium19/03/2015
Pemeriksaan Hasil Normal
Hemoglobin 15,5 g/dl 12 -14
Leukosit 12,3ribu/uL 5-10
Hematokrit 47,3% 37-43
Trombosit 316 ribu/uL 150-400
ureum 33 mg/dl 15-45
kreatinin 1,06 mg/dl 0,70-1,10
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Pemeriksaan Hasil Normal
warna kuning
BJ 1,015 1,003-1,030
Blood +3 Negatif
Leukosit esterase +1 Negatif
Nitrit - Negatif
Protein -
Billirubin - Negatif
Aseton - Negatif
Reduksi - Negatif
urobilinogen 0,2
leukosit 8-10 1-3
Eritrosit 12-14 0-1
Epitel +1 +1
bakteri - -
Silinder - -
kristal - -
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Working diagnose
Suspek nephrolithiasis dextra
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Treatment
• Diet : Bebas• IVFD
– I hidramal/24 jam
• Medikamentosa1. NSAIDs (dexketoprofen)
2 amp/24 jam
2. Fluoroquinolon (Levofloxacin)
1x750 mg
3. PPI inhibitor (omeprazol) 1x40 mg
Planning :
Pro USG ginjal dan buli
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4. Tn. R (35 years old)No. MR : 05.80.02.00• Keluhan utama: nyeri pada perut kiri
depan• Keluhan tambahan: -
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History of illnessPasien datang dnegan keluhan nyeri pada perut kiri depan sejak 3 jam SMRS. Nyeri dirasakan seperti diremas remas dan nyeri hilang timbul. Awalnya pasien merasakan nyeri pada pinggang kiri lalu menjalar ke perut bagian kiri depan dan menjalar sampai ke kantung buah zakar kiri. Sebelumnya pasien sudah pernah mengeluh gejala yang sama 1 minggu yang lalu. BAK tidak ada keluhan, BAB tidak ada keluhan, mual muntah disangkal. Demam disangkal.
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Vital Sign
• Keadaan umum : tampak sakit sedang
• Kesadaran : E4M6V5• BP : 150/90mmHg• Pulse: 92 x/minute• RR: 16 x/minute• Temperature : 36,8 oC
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HEAD TO TOE
Head : Normocephaly
Eyes : Pupil bulat, isokor 3mm/3mm, ditengah, RCL +/+, RCTL +/+, CA -/-, SI -/-
Ear : NormalNeck : pembesaran KGB tidak ditemukan
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Thorax :- Inspection : pergerakan dinding dada simetris
kanan = kiri- Palpation : Vocal fremitus simetris- Percussion : sonor kanan = kiri- Auscultation: BND vesikuler, wh-/-, rh-/-.
![Page 45: 19 Maret 2015 Morpot](https://reader030.vdocuments.us/reader030/viewer/2022033106/55cf917e550346f57b8de707/html5/thumbnails/45.jpg)
Abdomen :- Inspection : tampak datar- Auscultation: bising usus + 5x/menit- Palpation : nyeri tekan (+) regio illiaca
sinistra , defense muscular (-)- Percussion : tympani, nyeri perkusi (-) regio
illiaca sinistra
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Extremities
CRT< 2”, akral hangat
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Locale status
• CVA : nyeri ketok -/+• Suprapubik : nyeri tekan (-)• Genitalia eksterna : tidak ada
kelainan
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Foto BNO
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Laboratorium19/03/2015
Pemeriksaan Hasil Normal
Hemoglobin 15,4 g/dl 12 -14
Leukosit 13,1 ribu/uL 5-10
Hematokrit 46% 37-43
trombosit 359.000 150-400 ribu/ul
ureum 28 mg/dl 15-45
kreatinin 1,50 mg/dl 0,70-1,10
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Pemeriksaan Hasil Normal
warna Kuning muda
BJ 1,010 1,003-1,030
Blood - Negatif
Leukosit esterase - Negatif
Nitrit - Negatif
Protein -
Billirubin - Negatif
Aseton - Negatif
Reduksi - Negatif
urobilinogen Normal
leukosit 2-4 1-3
Eritrosit 0-2 0-1
Epitel + +1
bakteri - -
Silinder - -
kristal - -
![Page 51: 19 Maret 2015 Morpot](https://reader030.vdocuments.us/reader030/viewer/2022033106/55cf917e550346f57b8de707/html5/thumbnails/51.jpg)
Working diagnose
Suspek neprolithiasis sinistra
![Page 52: 19 Maret 2015 Morpot](https://reader030.vdocuments.us/reader030/viewer/2022033106/55cf917e550346f57b8de707/html5/thumbnails/52.jpg)
Treatment
• Diet : bebas• IVFD
– I RL/24 jam + NSAIDs(dexketoprofen) 2 amp / 24 jam
• Medikamentosa
1. NSAIDs (dexketoprofen) 2 amp/24 jam
2. Fluoroquinolon (Levofloxacin)
1x750 mg
3. PPI inhibitor (omeprazol) 1x40 mg
Planning :
USG ginjal dan buli