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  • Morning Report Ibs Ok 5

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    Dannia Riski Ariani
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    The document summarizes two patient cases seen on Tuesday, September 10, 2013. The first case was a 43-year old female, Ny. Kainah, who had undergone L5 laminectomy and fixation for spondylitis and tuberculosis of the lumbar spine. Her vital signs and labs were stable. The second case was a 13-day old infant, Ny. Irodatun Nimah, who had undergone ventriculoperitoneal shunt placement for hydrocephalus. The infant's vital signs were stable but showed tachycardia. Both patients were concluded to have an ACC ASA score of II-III.

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    The document summarizes two patient cases seen on Tuesday, September 10, 2013. The first case was a 43-year old female, Ny. Kainah, who had undergone L5 laminectomy and fixation for spondylitis and tuberculosis of the lumbar spine. Her vital signs and labs were stable. The second case was a 13-day old infant, Ny. Irodatun Nimah, who had undergone ventriculoperitoneal shunt placement for hydrocephalus. The infant's vital signs were stable but showed tachycardia. Both patients were concluded to have an ACC ASA score of II-III.

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    9 views3 pages

    Morning Report Ibs Ok 5

    Uploaded by

    Dannia Riski Ariani
    The document summarizes two patient cases seen on Tuesday, September 10, 2013. The first case was a 43-year old female, Ny. Kainah, who had undergone L5 laminectomy and fixation for spondylitis and tuberculosis of the lumbar spine. Her vital signs and labs were stable. The second case was a 13-day old infant, Ny. Irodatun Nimah, who had undergone ventriculoperitoneal shunt placement for hydrocephalus. The infant's vital signs were stable but showed tachycardia. Both patients were concluded to have an ACC ASA score of II-III.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPTX, PDF, TXT or read online from Scribd
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    of 3

    Morning Report OK VI Selasa 10 September 2013

    Koas Dannia Riski Ariani G4A013048

    Hari/Tanggal Nama/Usia Diagnosis Pro A B C

    : : : :

    Selasa/10 September2013/08.30 Ny. Kainah/43 thn Spondilitis TB Vt. Lumbal V Laminektomi fixasi

    : clear, gipong (+), gisu (-), MP (1) : spontan, RR (20x), suara vesikuler, wh (-), Rbh (-) : TD 110/80 , tegangan dan isi cukup, HR 80x, S1>S2, G(-),M(-), : GCS 15, BB 37 kg, Suhu 36 C

    Px Lab 7/9/13 ;Hb 12.8 ; Leu 4130 ;Ht 39 ;Eritrosit 4,4; Trombo 239000 ;MCV 89,9 ; MCH 29,7; MCHC 33,0 ; RDW 13,3 ; .MPV 10,4 ; LED 15; PT 13.8 ;APTT 34; Na 141; K 4,5 ; Cl 105 ; Ca 8,4 ; SGOT 40; SGPT 21; ureum darah 14,8 ; kreatinin 0,67 ; GDS 68 Riw asma (-), riw jantung (-), riw alergi (-), HT (-), DM (-) riw OP sebelumnya (+) Kesimpulan : ACC ASA II

    Hari/Tanggal Nama/Usia Diagnosis Pro A B C D : : : :

    : : : :

    Selasa/10 September2013/ 09.30 Ny. Irodatun Nimah /13 hari BBLR dengan hidrochepalus ETV K/P VP SHUNT

    clear spontan, RR (38x), suara vesikuler, wh (-), Rbh (-) HR 128x/menit regular, S1>S2,G(-),M(-), BB 4000g, Suhu 36,8 C

    Px Lab (09-9-2013) HB 20,6 Hematokrit 61. Leukosit 16440 ertrosit 6,2 trombosit 370000 pt 15,2 aptt 54,6 Gds 58 Na 140 kalium 6,1 klorida 99 kalsium 7.3.

    Riw asma (-), riw jantung (-), riw alergi (-), HT (-), OP sebelumnya (-), ketika lahir asfiksia berat dan mengalami distress pernapasan
    Kesimpulan : ACC ASA III

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