5. Jaga Malam, Rabu 25 Juni 2015
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Transcript of 5. Jaga Malam, Rabu 25 Juni 2015
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Identitas PasienNama : WardiahUmur : 41 tahunJenis Kelamin : PerempuanAlamat : keude, pante rajaPekerjaan : IRTAgama : IslamNo. CM : 135318Jam MRS : 01.25 wib
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Keluhan Utama : Sakit pinggang kanan menjalar sampai ke perut bagian kanan.
Keluhan Tambahan : mual muntah
Riwayat Penyakit Sekarang : pasien datang dengan keluhan sakit pinggang kanan menjalar sampai ke perut bagian kanan sejak ± 4 hari yang lalu. Riwayat nyeri BAK (-), BAK berdarah (+), BAK berpasir (-)
RPD : nefrolithiasis dextra et sinistraRPO : -ROS : nefrolitotomi dextra ± 3 tahun yll
nefrolitotomi sinistra ± 1 tahun yll
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Status Generalisata
Vital SignTD : 130/90 mmHgHR : 88 x/mRR : 21 x/mT : 36,2°c
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Status Lokalisata
• Regio Flank Dextrainspeksi : -palpasi : nyeri tekan (+)perkusi : nyeri ketok CVA (+)
• Regio Abdomeninspeksi : skar post nefrolitotomi dextra et sinistrapalpasi : nyeri tekan a/r lumbal dextraperkusi : timpaniauskultasi : BU (+)
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Diagnosa Sementara : flank pain ec. Susp. Nefrolithiasis dextra
Pemeriksaan Penunjang : -
Diagnosa Kerja : flank pain ec. Susp. Nefrolithiasis dextra
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Penatalaksanaan:- Ivfd RL 20 tts/menit- Inj. Ceftriaxone 1 gr/12 jam- Inj. Ketorolac 1 amp/8 jam- Inj. Ranitidin 1 amp/12 jam- Inj. Ondansetron 1 gr/12 jam
Planning : laboratoriumUSG urologi
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PASIEN II
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Nama : zainuddin
JK : laki-laki
Umur : 60 tahun
Alamat : msjd. Kemangan, mutiara
Pekerjaan : -
Status : menikah
Suku : aceh
No. CM : 135285
Jam MRS : 00.45
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• Keluhan Utama : Kencing tertahan• Keluhan Tambahan : -• RPS : pasien datang dengan keluhan kencing
tertahan sejak 1 hari yang lalu. Riwayat nyeri BAK (+), BAK berpasir (+), BAK berdarah (-).
• RPD : -• RPO : -• ROS : -
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• STATUS GENERALISATATD : 130/90 mmHgN : 82 x/menitRR : 20 x/menitT : 36,1°C
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• STATUS LOKALISATARegio Flank Sinistrainspeksi : -palpasi : nyeri tekan (+)perkusi : nyeri ketok CVA (+)
Regio Suprapubikinspeksi : -palpasi : nyeri tekan (+)perkusi : tympaniauskultasi : BU (+)
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• Diagnosa Sementara : Retensio urin ec. dd:1. BSK2. ISK3. BPH
• Pemeriksaan Penunjang : laboratorium
• Diagnosa Kerja : Retensio urin ec. dd:1. BSK2. ISK3. BPH
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• PENATALAKSANAAN- IVFD RL 20 tts/menit- inj. Fosmicyn 1 gr/12 jam- inj. Ketorolac 1 amp/8 jam- inj. Ranitidin 1 amp/12 jam- harnal 1x1-asam pipemidat 2x1
• Planning : USG urologi
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PASIEN III
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Nama : M.AliJk : Laki lakiUmur : 20 tahunAlamat : MurongPekerjaan : MahasisaStatus : Belum menikahSuku : AcehNo.Cm :22923Jam MRS : 23.05 Wib
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Ku: Luka robek ditangan kananKt : -Rps :Pasien datang dengan keluhan luka robek ditangan kanan
terkena seng ± 30 menit SMRS. Riwayat pusing (-), mual (-), muntah (-).
Mekanisme trauma : Pasien sedang bekerja didepan rumah, lalu ada teman pasien yang memperbaiki atap rumah , tidak sengaja seng yang di pegang temannya jatuh kebawah dan mengenai tangan pasien.
RPD : -RPO : -ROS : -
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Primary surveyA : clearB : spontan, RR: 21 x/menitC : TD: 120/70 mmHg, N: 81 x/menitD : GCS : 15E : T: 36,2°C
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• Secondary surveyRegio Brachii DextraL : vulnus Laceratum dg ukuran 3x3 cmF : nyeri (+)M : ROM tidak terbatas
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• Diagnosa Sementara : vulnus laceratum a/r brachii dextra + susp. Ruptur tendon biceps brachii dextra
• Pemeriksaan penunjang : -
• Diagnosa kerja : vulnus laceratum a/r brachii dextra + susp. Ruptur tendon biceps brachii dextra
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• Tindakan : wound toilet hecting
• Penatalaksanaan : - ivfd RL 20 tts/menit- inj. Cefotaxime /12 jam- Inj ketorolac 1 amp/8 jam- inj. Ranitidin 1 amp/12 jam- Inj. Tetagam