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Morning Report

FAKULTAS KEDOKTERAN UNIVERSITAS MUHAMMADIYAH

MALANGRUMAH SAKIT MUHAMMADIYAH LAMONGAN

Dept o! S"rger#

 $%2&

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'(tient I)entit#

• N(*e + Mr D

• Age + 60 #o

•

A))re,, + L(*ong(n• O--"p(tion + F(r*er

• M(rri(ge ,t(t",+ M(rrie)

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're,ent Hi,tor#

'(tient re.ere) !ro* Se/(r(n ini- po,t tr(-(--i)ent t3i, e4ening '(tient 5(, 5(nte) to goto t3e e) 7# 7i-#-e8 t3en !ro* 7(-/5(r)t3ere 5(, ( *otor7i/e -r",3 3i*8 t3en p(tient!( )o5n 7"t 3e )on9t re*e*7er 3o5 3e !(,)o5n T3en p(tient -(rrie) to Se/(r(n -ini-(n) 3i, !ront 3e() (n) !ort3 rig3t nger 5(,,e5n A !e5 *in"te, (ter p(tient 5(,

4o*itting 5it3 7oo) D#,pnoe :%;8 No5 p(tient!ee )i

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'3#,i-( E=(*in(tion

Vit( ,ign+

 TD+ 11>?60 *Hg

N+ @& =*

RR+ 20=?*

 T+ &>SpO2+ 100B 5it3o"t O2 ,"pport

GS &6

'ri*(r# S"r4e#+

A + G(rging :%; ,noring :%; pot O7,tr"-tion :C;

+ Spont(n8 RR 22=?*8 4e,4e,8 r3 %%8 53 %%

+ E=tre*it# RD8 RT 2998 N @&=?*8 TD 11>?60

D+ GS &68 (ter(i,(,i :%; p"pi i,o-or &**&**

L' CC

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'3#,i-( E=(*in(tionSe-on)(r# S"r4e#+

He() (n) ne-/+ (%?% i %?% - %?% ) ri 3e*(to*e Sini,tr( :C;8 4"n",(pert"* !ront( 3e() ,ini,tr(,e5n otor3e(e :%; r3inro3e(e :%;e,ion retro ("ri/"( :%;Le,ion

,"pr(-(4i-"( :%; T3or(=+

In,pe-tion+ Si*etri,8 retr(-tion :%%;

-or+ ,1 ,2 ,inge reg8 * :%;8 g :%;

p"*o+ ,onor,onor8 4e,4e8 r3 %%8

53 %%A7)o*en+

F(t8 ,oe8 e,ion :%;8 t#*p(ni8 7o5e,o"n) :C; 5n

E=tre*it#+

Regio *(n", D 4"n", (pert"* ,e5n

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L(7or(tor# n)ing,

• GDA 161

• UN 2@? S 06

• OT >>? 'T 2>

•

Le" J@• Ne" J1

• L#*p3 @

• Mono 6 (, 1

• Eri &

• H-t &2&

• H7 10J

• 't 20@

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 T3or(= Ro

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"e (n) -"e

• He()(-3e

• 'o,t tr(- (--i)ent

• ri 3e*(to*e Sini,tr( :C;8 4"n",

(pert"* !ront( 3e() ,ini,tr( ,e5notor3e(e :%; r3inro3e(e :%; e,ion retro("ri/"( :%;Le,ion ,"pr(-(4i-"( :%;

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"e (n) -"e

• He()(-3e

• 'o,t tr(- (--i)ent

• ri 3e*(to*e Sini,tr( :C;8 4"n",

(pert"* !ront( 3e() ,ini,tr( ,e5notor3e(e :%; r3inro3e(e :%; e,ion retro("ri/"( :%;Le,ion ,"pr(-(4i-"( :%;

•

GS &6 'ro7e* i,t• Mi) He() In"r#

)) ,",p Fr (,i, -r(nii

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 T3er(p#

• In! RL 100--?2>

• In e!tri(=one 2=1 gr i4

• In R(niti)ine 2=0 *g i4

• In eteron &=J *g i4

• In 'ir(-et(* >= & gr i4

• In iti/oin &=20 *g i4

• 'ro T ,-(n  i! I' in-re(,e