Morning Report internship
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MORNING REPORT KAMIS 03-09-2015
PASIEN DARI HARI MINGGU MALAM TANGGAL 30 AGUSTUS 2015 S/D RABU SIANG TANGGAL 2 SEPTEMBER 2015
PENYAJI : 1. dr. dewi sartika sari 2. Dr. fitri wahyuni pane3. Dr. intan sari simbolon 4. Dr. sandy saputra5. Dr. selly tristianty6. Dr. suci ramadani 7. Dr. sundari
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De IINO NAMA JAM DIAGNOSA STATUS
1 tn F / 45th 21.20 wita CKR e.c KLLD Rawat jalan
2. A n.M .a / 3,5th 21.30 wita Obs vomitus e.c intake kurang MRS . Rg anak
3. Tn A.m /60th 10.00 wita Epigastric pain Rawat jalan
4. An. T / tahun 05.00 wita GEA dehidrasi ringan sedang MRS rg anak
5. Ny.N / 58 tahun 10.20 wita PPOK dgn hipoalbumin Rg paru
6. Nn.N / 16 tahun 09.30 wita Dispepsia syndrome Rawat jalan
7. An F / 1th 10.30 wita Tonsilitis akut Rawat jalan
8. Ny.Hj / 63 tahun 11.50 wita CKD stage V MRS RPD
9. An S/ 15th 14.10 wita CKR dgn closed fx antebrachii MRS. Rg bedah
10. Tn . S /38 th 22.10 Hemiparese SNH Rg saraf
11. Ny. B / 76 th 19.40 wita Susp SH dengan Ht emergency MRS . Rg saraf
12. Ny. N /42 th 08.00 wita Post op laparotomi dengan isk MRS rg . Bersalin
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NO NAMA JAM
12. Ny. K/55th 08.30 Wita Kolelitiasis MRS . RPD
13. Tn. J / 56 th 10.30 wita Obs feris H+3 / Ht urgency MRS . Rg VIP
14. An. N /18th 18.15wita Thypoid fever MRS . RPD
15. Nn K / 25 th 07.00 wita G1P0Ao dgn VE Rawat jalan
16. An. F / 7 bulan 17.45wita Diare akut dehodrasi ringan sedang
MRS . Rg anak
17. An. M / 12 th 16 .00 wita Thypoid fever MRS.Rg anak
18. An.N /6 th 06.00 wita Vomitus dengan intake kurang MRS rg anak
19 Tn H / 34th 23.30 wita Gastritis akut , Rawat jalan
20. Ny. E/ 33 th 11.00wita Asma bronkial Rawat jalan
21. An. M / 8 th 23.30 wita Obs vomitus dyspepsia syndrome
MRS anak
22. Ny.J / 58th 12.30 wita Nefrophaty diabetik MRS RPD
23. Tn . M / 45th 1330 wita Penurunan kesadaran e.c ? Rncn ICU
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NO PASIEN ASS
1. By J / 8 bln GEA dehidrasi ringan sedang
2. NY. I / 27 th Dyspneu e.c pneumothoraks D dgn TB paru
3. Tn A 61 th ASS: - Colic renal ec. Nefrolitiasis dextra - CKD stg - Hipertensi stge II
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By. J 8 bln datang Tgl 02.09.2015 jam 15.30 wita
• Anamnesa :• Os datang dengan keluhan mencret . Mencret
sejak ± pagi ini frekuensi > 5 kali, lendir(-), darah(-) air > ampas, BAK(+)N.Mual(-), muntah(+) , anak rewel (+) Os juga demam sejak 1 hari ini
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Vital sign:N: 108 RR:22 S:39,1BB:5,4 KgKu: lemahKepala/leher :conj.anemis (-/-) ikterik (-/- ) mata cekung(+/+) UUB cekung +/+Torak : simetris (+) retraksi (-) Bj S1 S2 tunggal, bising (-) ronkhi (-/-), wheezing(-/-) Abdomen : bising usus (+) supel (+), H/L/M tidak terabaEkstremitas : akral hangat (+)
O
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•GEA dengan dehidrasi ringan sedangACo dr. Emmy Hayatun, Sp.A, adv:•Inj kaen 3B 300 cc/3 jam→ maintenance 550 cc/24 jam•Inj PCT 60 mg / 8 jam•Inj Tomit 1 mg / 8 jam•P.O – lacto B 1x1 sach• - Zink Syr 1 x 10 mg
P
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Hasil Lab
• HGB : 12.1• HCT : 38.4• RBC: 4.20• WBC: 12.2• Plt: 407• GDS :
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Ny.DI\ 27th datang 1-08-2015 pukul 12.45 dengan keluhan
sesak nafas Sejak tiba-tiba dirasakn setelah batuk mulai malam
dan makin memberat sampai subuh tadi pagi . Dada terasa berat .Os sedang program TB paru 4 bulan . Saat ini OS batuk (+) , dahak (+) ↑ ↑, darah (-) , selama 1 minggu ini . Riwayat demam disangkal . 1 bulan SMRS OS dirawat di RS HHB dengan pneumothoraks D dengan TB paru dan dilakukan pemasangan WSD .ma / mi << . RPT : Ht(-) , DM (-) / RPO : (obat TB) . BAB dan BAK (+)
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OKU : tampak LemahGCS E4V5M6TD : 110/80 mmHg HR : 92x/I RR : 32x/I T : 35,4 Sa O2 : 84 %
SL : K/L : normocepali , pupil isokor ka /ki , KA (-/-) , SI (-/-) . Pe >> KGB (-) , pe ↑ TVJ (-) bibir tampak kering
Thoraks : Paru : I : asimetris , gerakan tertinggal pada paru kanan , retraksi (+) , tampak cicatrix post insisi emfisema kutis dan cicatriks post pemasangan WSD di midaksila kanan P : SF melemah di kanan ,P : hipersonor /sonor hipersonor /sonor hipersonor /sonor A : SD : vesikuler ↓ / + ST : Rh : -/+ Wh : - /- ↓ / + -/+ -/-
↓ / + -/+ -/-Jantung : S1S2 regu;er . BJ (-) , murmur (-)
Abdomen : simetris , soepel , nyeri tekan (-) , H/L ≠ teraba , tympani , BU (+) N ,
Eks : AH -/- puca t +/+ oedema -/- clubbing finger (+) , -/- +/+ -/- sianosis +/+
+/+
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Hasil laboratorium • RBC 4,64 GDS 124• MCV 91,1 SGOT/PT : 31/15• RDW 19,2 % Ur/Cr: 13/0,71• HCT 42,3 alb 3,6• PLT 259• WBC 7,4• HGB 13,0• MCH 28,1• MCHC 30,9• GRAN 4,7
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Ass : dyspneu e.c pneumothoraks D disertai TB paru
Penatalaksanaan : O2 sungkup pasien menolak Pasang O2 nasal kanul 7-8 lpm SaO2 89 % Co dr Isa Sp.P pukul 12.55 WiTA Pro pemasangan thoraks drain cito .dan
pemasangan kontraventil di ICS 2-3 IVFD NS 20tpm
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Follow up 1-09-2015Telah dilakukan pemasangan WSD pukul 13.15 WITA S : sesak << , batuk (+) << , dahak <<O : TD : 110/80 / HR : 92 x/I / RR : 29x/I T : 36A : pneumothoraks berulang spontan D P : O2 6lpm RL : gelafusal : D5 1:1:1 =20tpm
diet bubur TKTP 2100 Kalinj levofloxacin 500mg/24 jam dripinj ceftazidine 1gr /8jam (skin test )inj antrain 1amp/8jam inj ranitidin 1amp/12 jam
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Follow up 2-09-2015S : sesak << , batuk (+) << , dahak <<O : TD : 110/80 / HR : 92 x/I / RR : 29x/I T : 36A : pneumothoraks berulang spontan D P : O2 6lpm RL : gelafusal : D5 1:1:1 =20tpm
diet bubur TKTP 2100 Kalinj levofloxacin 500mg/24 jam dripinj ceftazidine 1gr /8jam (skin test )inj antrain 1amp/8jam inj ranitidin 1amp/12 jam
Ro Thoraks AP +lat D Evaluasi pemasangan thoraks drain
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Definisi: Pneumotorak udara bebas di dalam rongga pleura
Dalam keadaan N udara(-)
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KIRCHER & SWARTEL
A . B – a . b A . B
X 100% = LUAS PNEUMOTORAK
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Jenis pneumotorak berdasarkan fistel • Pneumotorak tertutup
– Setelah terjadi pneumotorak vistel tertutup secara spontan
• Pneumotorak terbuka– Ada hub antara pleura dengan brokus– Ada hub antara pleura dengan dinding dada
• Pneumotorak ventil– Berbahaya oleh karena termasuk kegawatan
paru– Sifat ventil dimana udara bisa masuk tapi
tidak bisa keluar – Gejala mendadak dan makin lama makin
berat – Segera pasang wsd atau mini wsd ( kontra
ventil )
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Jenis Pneumotorak Menurut kejadian
n P. spontann Primer ( idio patik )n Sekunder ( disertai py dasar )
n P. traumatikn P. iatrogenik ( oleh karena efek
samping tindakan )n P. katamenialn Terapeutik
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Pneumotoraks Spontan Primer (PSP)Pneumotorak yang tidak diketahui penyebabnya sering terjadi pada ;
n Laki-laki mudan Tinggi dan kurus ( Astenik )
n setiap kelebihan tinggi 2 inchi dan penurunan BB lebih dari 25 pound tekanan intra pleura akan turun sekitar 0,2 cm H2o keadaan ini akan meningkatkan distensi/ reegangan dari alveolin Perokok / bekas perokokn Kanan (55%) > kiri (45%)n Bilateral 2%
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Pneumotorak spontan sekunder
Defenisi adalah pneumotorak yang terjadi akibat dari suatu penyakit paru
Seperti, asma , ppok, tb paru, bekas tb paru dll
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PNEUMOTORAK KATAMENIAL
Pneumotorak yg terjadi pada wanita saat menstruasi oleh karena adanya jaringan endometrium di pleura.
Pneumotoraknya sering berulang sesuai dengan siklus menstruasi .
Petalakasanaan ndikasikan untuk dilakukan pleurodesis
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Udara Ruptur / kebocoran dinding alveol Intertisial paruSepta lobuler
Perifer Sentral Bleb Pneumomediastinum
Distensi
Pecah
Pneumotoraks
Pato fisiologi
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• Mekanisme pneumotorak
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An : Gejala penyakit dasar
Sesak napas mendadakNyeri dadaTanpa atau dg penyakit paru
sebelumnya
Diagnosis pneumotorak
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PF ; Takipnea Taki kardiPF Paru
:In ; Tertinggal pada pergerakan napasLebih cembung , sela iga melebar
Pal ; Fremitus melemah , Deviasi trakea Per; Hipersonor, tanda 2 pendorongan
organ Aus;Suara napas melemah / tidak
terdengar
Diagnosis pneumotorak
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Ro : Paru kolaps Pleural line
Daerah avascularHiper radio lusenSela iga melebartanda-tanda pendorongan
Kalau kurang jelas ro torakRo Densitas lemahCT Scan Thorak
Diagnosis pneumotorak
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AGD ( analisa gas darah )Tidak khas ut pneumotorak
Diagnosis pneumotorak
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PNEUMOTORAKS
WSD
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HIDROPNEUMOTORAKS
Air fluid level
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Penatalaksanaan Operatif
Fistulo rapiNon operatifn Observasin Aspirasin Water sealed drainage (WSD)
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n Tanpa keluhan / ringann luas pneumotorak < 15% Alasannya ; Dalam keadaan normal
absorbsi pneumotorak 1,25 %/ harin Terapi dengan oksigenn Ro ulang beberapa harin Hati-hati pneumotoraks tension
Observasi Indikasi
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n Venocath 14n Infus set / blood setn Spuit 50 mln Keberhasilan PSP 65%
PSS 35%
ASPIRASI
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Indikasi Water sealed drainage (WSD)
• PSP luas pneumotorak > 15% • Pneumotoraks ventil • PSS luas pneumotorak > 15%• PSS luas pneumotorak < 15%
• Disertai keluhan sesak berat• Disertai kelainan paru kontra lateral
Operatif
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POINT OF ENTRY(First)
Standard:Mid Axillar LineICS 5, 6, 7 for Pleural Effusion
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Anamnesis
• Keluhan Utama : Sesak Nafas• Pasian datang dengan keluhan sesak nafas sejak ± 1 minggu SMRS dan
semakin bertambah sesak dari sebelumnya. Sesak dirasakan pasien sepanjang hari dan dalam aktivitas ringan dan berat. Pasien merasakan lebih enak jika pasien berbaring miring kesebelah kanan. Pasien juga mengeluhkan demam pada pagi hari dan tidak terlalu tinggi, mengigil (-), pasien sudah minum obat penurun panas tapi panas tidak turun. Pasien juga mengeluhkan batuk bersamaan dengan sesaknya, batuk berdahak (-) darah (-) paling sering kambuh pada saat malam hari. Pasien juga mengeluhkan penurunan Berat badan secara cepat dan nafsu makan pasien berkurang. Pasien juga berkeringat dingin malam. Pasien tidak pernah menjalani pengobatan paru 6 bulan. Di lingkungan keluarga tidak ada yang batuk lama atau pengobatan paru 6 bulan.
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Pemeriksaan FisikKeadaan Umum : Tampak sakit sedang Kesadaran : kompos mentis, Tanda-tanda vital : TD : 100/70
Nadi : 92 x/ m Pernapasan : 27 x/m
Suhu : 36,9 ⁰C Kepala : CA -/- , SI -/- Leher : limfonodi (-), ↑ JVP (-) KGB>> (-)Jantung : S1 S2 tunggal regular, murmur (+) diastolik,
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Paru : Inspeksi Anterior : simetris +/+, retraksi intercostal (+), spider nevi
(-)Palpasi Anterior : Fremitus vocal +/+. Fremitus taktil +/+, ekspansi
baikPerkusi Anterior : hipersonor / sonorAuskultasi Anterior : Vesikuler ↓ / vesikuler (+), Rh +/+, Wh -/- Inspeksi Posterior : simetris +/+, retraksi intercostal (+),
spider nevi (-)Palpasi Posterior : Fremitus vocal +/+. Fremitus taktil +/+, ekspansi
baikPerkusi Posterior : hipersonor / sonorAuskultasi Posterior : Vesikuler ↓ / vesikuler (+), Rh +/+, Wh -/-
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Tn.A/61thn datang pada tanggal 1 september 2015 pkl 14:00 WITA dengan keluhan nyeri pinggang sebelah kanan.
Keluhan Utama :Nyeri pinggang sejak 1 tahun yang laluTelaah :
pasien datang dengan keluhan nyeri pinggang sebelah kanan sejak 1 tahun yang lalu. Pasien mengeluh sakit pinggang sebelah kanan sampai menjalar keperut bagian depan, sakit dirasakan hilang timbul. Selain itu, pasien mengeluh sedikit sesak (+), nyeri dada (-), bengkak pada seluruh tubuh (-). BAK sering tersendat, nyeri saat berkemih (+), BAK sedikit (+), berwarna kuning (+), darah (-). Keluhan lain mual (+), muntah (-), makan dan minum <<, demam (-). BAB : (+) normal.
RPD : HT(+), DM(-)
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O Vital sign : GCS E4V5M6TD : 160/90HR : 89 x/iRR : 23 x/iT : 36,7 C
SL : K/L : normocepali, KA(+/+) , SI (-/-) Pe>>KGB (-)
Thoraks : P/ simetris , retraksi (-) , sonor SD: vesikuler , ST ; rh -/- wh (-/-)
C / S1S2 reguler , murmur (-)
Abdomen : Soepel, H/L/ tidk teraba, distensi (-), massa (-), nyeri tekan epigastric (+), tympani, BU (+).Nyeri ketok CVA (D).
Ekstremitas Akral hangat , oedema (-) , anemis (+/+).
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Hasil laboratorium
GDS : 106RBC : 3,92HCT : 35,1PLT : 151WBC : 10,5HGB : 11,3 g/dlSGOT/SGPT : 31/38Ur/Cr : 194,7/12,46
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• Hasil USG :Renal dextra : Ukuran mengecil (± 6cm),
parenkim tipis(0,5cm), ukuran stone 2,7cmRenal sinistra : ukuran membesar 13cm,
hidronefrosis grade 1Planing: Inisiasi HD( cek CT/BT, HbSag, anti HCV )
GFR : (140-61)x 83/72x12,46 = 6557/897 = 7,3
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ASS: - Colic renal ec. Nefrolitiasis dextra - CKD stg V- Hipertensi stge II
• PenatalaksanaanCo. Dr. Suhastinah Sp.PD
- IVFD NS 10 tpm- inj. Ketorolac 1amp/8jam- inj. Ranitidin 1 amp/12 jam - inj. Antrain 1amp/8jam- inj. Furosemid 1amp/12jam
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Follow up tgl 2-9-2015
S : pasien mengeluh nyeri pinggang (+), mual (+), muntah (-), pasien tampak gelisah.O : TD: 180/100 mmHg
N : 90 x/i RR : 22 x/i T : 36,7
A :- Cronic Kidney Injury stage V- Colic renal ec. Nefrolitiasis dextra- Hipertensi stage II
P : IVFD NS 10 tpm- inj. Ketorolac K/P- inj. Ranitidin 1 amp/12 jam - inj. Antrain 1amp/8jam- inj. Furosemid 1amp/24jam- Inj. Ceftriaxone 1gr/24jampro : HD
Planing : EKG, foto thorax PA, UL
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