morning report 28 november - copy - copy
TRANSCRIPT
7/23/2019 Morning Report 28 November - Copy - Copy
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MORNING REPORTDEPARTMENT OF
SURGERYBy: B22
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Identity
• Name : Tn. S
• Age : 44 yo
• O!"ation : #a$me$
• Add$e%% : &$ondong 'amongan• Date : No(em&e$) 2*t+ 2,-
• No RM : ,/.0/.10
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Anamnesis
Chief Complaint: "ain in +ead in!$ie% a#te$ #a''ing #$om a moto$
y'e
MOI: "atient $e#e$$a'% #$om P3U &'im&ing it+ Se(e$e &$ain in!$y.
T+e "atient om"'ained o# "ain in t+e +ead o!nd a#te$ an
aident %ie at ,*.,, PM. Patient #e'' #$om a moto$y'e d!$ing ao''i%ion it+ anot+e$ moto$y'e in #$ont o# +im &ea!%e t+ey do
not t!$n on t+e 'ig+t%. T+en t+e "atient !non%io!% and +ad
(omited 2 time% a""$o5iate'y - !" medi!m. 6ontaining #ood.
Patient a'%o did not ea$ a +e'met. 7eada+e 89) PTA 8;
Past Illness History : DM and 7T 8;
Family Illness History : DM and 7T 8;
Social Illness History: ;
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<ita' Sign
•BP : /4=> mm7g
•PR : /-5=mnt
•
t : 0>.2,
6•RR : -1 5=mnt
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P$ima$y S!$(ey
A: 6'ea$) ga$g'ing 8;) %no$ing 8;) %"ea? @!ent'y 89)"otentia' o&%t$!tion 8;
B: %"ontan) RR -15=mnt) (e%=(e%) R+ ;=;) + ;=; SaO2-,, it+ O2 %!""o$t NRM -, '"m
6: A$a' DR) 6RT C2) N /-5=mnt $eg!'a$) BP /4=/mm7g
D: G6S 0>) 'ate$a'i%ation 8;) PBI 0mm=0mm
E: tem" 0>)2 O6) (!'n!% a"" et $egio %!"$a o$&ita
de5t$a "anang m +eating) +ematome "a'"e$&$aD et S) (!'n!% a""e$te!m na%a' 25- m) ?$e"ita%ina%a' 89) e"ita5i% 89 edema ma5i'a D et S) @oatingma5i'a 89) #a'% mo(ement 89
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Seonda$y S!$(ey
G6S: 0>.
3=: a;=i;=;=d;) 3GB 8;) in$ea%ed o# <P 8;
T+o: %ymmet$ia' ) $et ;=;
P: (e% =(e%) $+ ;=;) + ;=;6: S-S2 t!ngga') m!$m!$ 8;) ga''o" 8;
A&d: de#an% m!%!'a$ 8;) met 8;) BU9N) tende$ne% 8;
E5t: aie ;) a$a' DR
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6'inia' "+oto
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6'!e and 6!e
ma'e) 44 yo
G6S 0>
(!'n!% a"" et $egio %!"$a o$&ita de5t$a "anang m
+eating) +ematome "a'"e$&$a D et S) (!'n!%a""e$te!m na%a' 25- m) ?$e"ita%i na%a' 89) e"ita5i%89 edema ma5i'a D et S) @oating ma5i'a 89) #a'%mo(ement 89
(omiting
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6'inia' A%%e%ment
Mi'd &$ain in!$y
F$at!$e ma5i'a
F$at!$e na%a'
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PANING DIAGNOSIS
• T+o$a5 5;$ay
• 6T S6AN
• D
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a&o$ato$i!m
Hematologi
•7emato?$it : 4./8 4,;4) P 0;4*
•7emog'o&in : -0., mg=d' 8P-2;-> mg=d')
-0;-1 mg=d'
•e!?o%it : -2.2 = ! 84,,,;--.,,,
•
T$om&o%it : -*> =! 8-,.,,,;4,.,,,•Ne!t$o"i' : **.0 8 4/.,;>*.,
•im#o%it : -.- 82.,;00.,
•Mono%it : .- 80.,;*.,
•
Eo%ino' : ,.0 8-.,;2.,•Ba%o' : 2.2 8,.,;-.,
•E$it$o%it : 0.10 = !80.1,,.,,,;.0,,.,,,
•MP< : 4 @ 8;-,
•M6< : 1.-, @ 81*.,,;-,,.,,,
•M67 : 2*.* "g 821.,,;0>.,,
•M676 : 02.>, g=d80-.,,;0*.,,
•
RD : -2 8-,;->.•GDA : -2,
•7&%AG negati#
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P'anning T+e$a"y
O2 NRM -, '"m
In#. oading a%e$ing -,,, maintenene-,,=24am
In. MatamiHo'e 05- g$ i(In. Panto"$aHo'e 254,mg i(
In. 6e#t$ia5on 25- g$ i(
In. Pi$aetam 450 g$ i(
in. A%am t$a?ne%amat 05,, mg i(
6on%!'t S".B3
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Monito$ing
6om"'aint
<ita' %ign
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Ed!ation
• E5"'aine to t+e #ami'y a&o!t t+e di%ea%e) a&o!t it%t+e$a"y and inte$(ention i'' &e done) and a'%o a&o!tom"'iation and "$ogno%i%.