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    Morning Report Jum'at Andika

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    Andiicha Andiiche Tomaat
    This morning report from Friday, August 29th 2014 contains information on 3 patients: 1. Dwii Budi, age 23, with a diagnosis of right femur fracture who is status post open reduction and internal fixation. Laboratory results were normal and he is classified as ASA 2. 2. Agung, age 16, with a diagnosis of left femoral neck fracture who underwent multiple pinning. Laboratory results were normal and he is classified as ASA 2. 3. Paryanto, age 46, with diagnoses of left clavicle and left tibial plateau fractures who underwent open reduction. Laboratory results showed mild anemia but were otherwise normal and he is classified as ASA 2.

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    Morning Report Jum'at Andika

    Uploaded by

    Andiicha Andiiche Tomaat
    13 views13 pages
    This morning report from Friday, August 29th 2014 contains information on 3 patients: 1. Dwii Budi, age 23, with a diagnosis of right femur fracture who is status post open reduction and internal fixation. Laboratory results were normal and he is classified as ASA 2. 2. Agung, age 16, with a diagnosis of left femoral neck fracture who underwent multiple pinning. Laboratory results were normal and he is classified as ASA 2. 3. Paryanto, age 46, with diagnoses of left clavicle and left tibial plateau fractures who underwent open reduction. Laboratory results showed mild anemia but were otherwise normal and he is classified as ASA 2.

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    This morning report from Friday, August 29th 2014 contains information on 3 patients: 1. Dwii Budi, age 23, with a diagnosis of right femur fracture who is status post open reduction and internal fixation. Laboratory results were normal and he is classified as ASA 2. 2. Agung, age 16, with a diagnosis of left femoral neck fracture who underwent multiple pinning. Laboratory results were normal and he is classified as ASA 2. 3. Paryanto, age 46, with diagnoses of left clavicle and left tibial plateau fractures who underwent open reduction. Laboratory results showed mild anemia but were otherwise normal and he is classified as ASA 2.

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    13 views13 pages

    Morning Report Jum'at Andika

    Uploaded by

    Andiicha Andiiche Tomaat
    This morning report from Friday, August 29th 2014 contains information on 3 patients: 1. Dwii Budi, age 23, with a diagnosis of right femur fracture who is status post open reduction and internal fixation. Laboratory results were normal and he is classified as ASA 2. 2. Agung, age 16, with a diagnosis of left femoral neck fracture who underwent multiple pinning. Laboratory results were normal and he is classified as ASA 2. 3. Paryanto, age 46, with diagnoses of left clavicle and left tibial plateau fractures who underwent open reduction. Laboratory results showed mild anemia but were otherwise normal and he is classified as ASA 2.

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    of 13

    MORNING

    REPORT
    OK II
    Jumat, 29 Agustus 2014

    Hari/ tgl : Jumat, 29 Agustus 2014


    Nama : Dwii Budi
    Usia : 23 thn
    No RM : 00889291
    Ruang : Seruni
    Diagnosis : Fr. Femur dextra
    Pro
    : Orif

    A : clear, gipong (+), giyang (-), gisu (-),


    MP 1
    B : spontan, RR 20 x/m, SD ves +/+, Rh
    -/-, Wh -/C : TD 120/80, N 80 x/m, teg & isi
    cukup, s1>s2, m (-), g(-)
    D : BB 65 kg, S 36.5 C

    Lab

    Hb 15.8
    12.0 16.0
    Leu 236.000
    4000 10800
    Ht 45
    37 47
    Eri 5.7 jt
    4.2 jt 5.4 jt
    Tromb 326 rb
    150rb 450 rb
    Kesimpulan : ASA 2

    Hari/ tgl : Jumat, 29 Agustus 2014


    Nama : Agung /mei
    Usia : 16 thn
    No RM : 00889129
    Ruang : Seruni
    Diagnosis : Fr.Collum femur sinistra
    Pro : multipel pining

    Riw asma (-), DM (-), peny jantung (-), HT (-),


    operasi (-)

    A : clear, gipong (+), giyang (-), gisu (-), MP


    1
    B : spontan, RR 16 x/m, SD ves +/+, Rbh -/
    +, Rbk -/-, Wh -/C : TD 100/70, N 80 x/m, teg & isi cukup,
    s1>s2, m (-), g(-)
    D : BB 40 kg, S 36.5 C

    Lab 21/10/13

    Hb 12.1
    12.0 16.0
    Leu 11100 4000 10800
    Ht 37 37 47
    Eri 5.1 jt 4.2 jt 5.4 jt
    Tromb 343rb 150rb 450 rb

    PT 16 11.5 15.5
    APTT 34 26.0- 36.0

    Kesimpulan : ASA 2

    Hari/ tgl : Jumat, 29 Agustus 2014


    Nama : Paryanto
    Usia : 46 thn
    No RM : 00889943
    Ruang : Seruni
    Diagnosis :Fr. Clavikula sinistra + Fr, Tibia plateu
    sinistra
    Pro : orif

    Riw asma (-), DM (-), peny jantung (-), HT (-), operasi (-)

    A : clear, gipong (+), giyang (-), gisu (-),


    MP 1
    B : spontan, RR 16 x/m, SD ves +/+
    menurun, Rbh +/+ basal paru, rbk -/-,
    Wh -/C : TD 120/80, N 80 x/m, teg & isi
    cukup, s1>s2, m (-), g(-)
    D : BB 60 kg, S 36,3 C

    Hb 12 12.0 16.0
    Leu 9010 4000 10800
    Ht 33 37 47
    Eri 4.2 jt 4.2 jt 5.4 jt
    Tromb 180 rb 150rb 450 rb
    PT 16.1
    11.5 15.5
    APTT 29.4
    26.0- 36.0

    Kesimpulan : ASA 2

    Terima kasih

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