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Morning Report 6th August2015
Morning Report 6th August2015
Morning Report 6th August2015
Ambulatory Patient
Mr. S, 30 y.o. Vulnus Laceratum et
regio cephal.
Hospitalized Patient
Name : Mrs. S
Age : 47 years old
Religion : Islam
Occupation : Housewife
Primary Survey
Airway
: Clear
Breathing : Spontan, 24x/minute
Circulation : BP: 130/70mmHg, Pulse:
84x/minute, CRT < 2
Disability : Alert
Expossure : -
Secondary Survey
Chief Complain:
Benjolan di belakang leher yang terasa
nyeri
Secondary Survey
History :
Pasien datang dengan keluhan
terdapat benjolan di leher belakang
sejak 15 hari SMRS
Physical Examination
General Status: Normal
Local Status: Left wrist
Look : theres an open wound on her left
wrist with 8 cm long and 4 cm width,
active bleeding(+)
Feel : swollen (-), tenderness (+), CRT
>2,
Move : limited ROM
Planning of additional
examination
DL, GDS, SGOT-SGPT, Ur, Cr, BT, CT,
HBsAg
Ro wrist Joint AP/Lateral sinistra
Ro Thorax PA
Laboratory Findings
Hb: 8,0
HCT : 25,5
PLT: 265.000
WBC : 21,4
GDS : 208
Hbs Ag : Reaktif
BT : 430
CT : 600
SGOT : 22
SGPT : 23
Ur : 3,6
Cr : 1,1
Working Diagnosis
Schizum Wound of vollar wrist
sinistra
Suspect Rupture tendon
Suspect rupture median nerve
Suspect rupture radial artery
Treatment
IVFD RL 20 tpm
Opimer 2x1 gr
Ketorolac 3x30 mg
ATS 1500 IU/IM
Planning for Operation
Informed Consent
Fasting 6 hours before op
Consultation with aenesthesiologist
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