Laporan Jaga Aviya Ariane 5-6 Agustus
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![Page 1: Laporan Jaga Aviya Ariane 5-6 Agustus](https://reader036.fdokumen.com/reader036/viewer/2022081503/563dba0b550346aa9aa23484/html5/thumbnails/1.jpg)
Di Susun Oleh :Ar iane N R ahmadhani & Av iya Ekutami
Koas BedahRSUD Soreang
Pembimbing :Dr. Dik Adi Nugraha Sp .B , M.Kes
LAPORAN JAGA IGD7 Agustus 2015
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Pasien 1
Identitas Nama : tn. YusufUmur : 24 tahunAgama : IslamAlamat : Sukawening CIwideyPekerjaan : Buruh bangunan
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Anamnesis
Pasien kecelakaan lalu lintas tampak lemas seluruh tubuh, luka robek (+) pingsan (-) mual (-) muntah (-) pusing (-)
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Pemeriksaan Fisik
A : clearB : RR : 24x / menit Bentuk dan gerakan simetris, tidak ada jejasC : Nadi 84x / menit, reguler TD : 120/90 mmHgD : GCS : 15 (E4 M6 V6)
Suhu: 36,5 ⁰CKesadaran : Compos mentisSuhu: 36,0
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Status Lokalis
Hematom a/r frontalis sinistra
VL a/r supersiliaris sinistra. Ukuran 2cm
VL a/r frontalis sinistra. Ukuran 2cm
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Pemeriksaan Penunjang
Schaedel AP/LU
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Diagnosis & Terapi
Diagnosa : Hematom ec Vulnus Laceratum et region frontalis sinistraTerapi : • WTH 4• ATS 1500 iv (st) im• Aclam 3 x 500mg• As. Mefenamat 3 x 500mg
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Pasien 2
IdentitasNama: Tn. SaepudinUmur: 25 TahunAgama: IslamAlamat: Londok, Pasir JambuPekerjaan: -
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Anamnesis
Pasien KU tampak luka robek +- 2cm. Hematom di mata kiri. Pingsn (+) mual (+) muntah (+) pusing (+)
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Pemeriksaan Fisik
A: clearB: RR: 40x/menit,
Bentuk dan gerakan simetris tidak ada jejasC: ND: 188x/menit, reguler
TD: 80/palpasiD: GCS: 14 kesadaran somnolen suhu : 36,8 ⁰C
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Status Lokalis
VL 2cmKrepitasi +VE a/r nasal ukuran 2 cmOthore +Rhinore +Hematom orbita +
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Pemeriksaan Penunjang
Foto Schaedel
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Diagnosis
Mild HI OS Cranii Open fracture depressed Tabula OS Frontalis
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Tindakan
WTH 3ATS 1500 unit (IM) (ST)Aclam 3 x 500 mg5Asam Mefenamat 3 x 500 mgDexamethason 3 x 1
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Pasien 3
IdentitasNama : Tn. RohendiUsia : 45 tahunAlamat : Kp. Gunung DukuhAgama : IslamPekerjaan : -
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Anamnesis
Pasien datang dengan keluhan nyeri perut bagian bawah, sesak sejak 3 hari SMRS. Kencing terasa nyeri saat akhir. Panas badan (-) mual (-) riwayat batu ginjal(-)
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Pemeriksaan Fisik
A : Clear B : RR 20x/menit bentuk dan gerakan simetris dan tidak ada jejas C : ND : 80x/menit reguler TD : 110/80 mmHgD : GCS 15 kesadaran compos mentis suhu afebris 36,4
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Status Lokalis
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Pemeriksaan penunjang
Pemeriksaan penunjang BNO 3 posisi
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Diagnosis
Peritonitis local et causa appendix perforasi
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Tindakan
IVFD RL 20 gttKetorolac 3x1Omeprazole 1x1 (PO)