MORNING REPORT

16.00 (17/07/19) – 03.00 (18/07/19)

CASE 1
 Identity
Name : Ny. M
Gender : Perempuan
Date of Birth : 01 – 07 -1967
Address : Kencong, Jember
No RM : 262xxx
Arrival : 18.00
 One Step Survey
Chief complain:
Sesak sejak 3 hari yg lalu, sesak disertai batuk 5 bulan yg lalu, memberat sejaak 3 minggu yg
lalu, batuk darah (-) demam (+) 7hr yg lalu. Riw pengobatan TB 1 bulan

A: patent (+)
B: Spontaneous breathing 30x/mnt, simetric, sonor +/+, ves +/+, rho +/+, whe –/-, SpO2
91%

Innitial Assesment:
-Dyspnue

Innitial Planning
-NRBM 10lpm
-Nebul Combivent 1 ampul
-Nebul pulmicort 1 ampul
- Foto Thorax
 SECONDARY SURVEY
A: patent (+)
B: Spontaneous breathing 20x/mnt, simetric,
sonor +/+, ves +/+, rho +/+, whe –/-, SpO2 98%
C: Reguler pulsation 80x/mnt , TD 100 /60
D: Alert, PBI 3mm/3mm, RC +/+
E:
 ASSESMENT
Dyspnue ec TB Paru + Efusi pleura Dextra

INITIAL PLANNING
- Oksigenasi
- Inj Bisolvon 3x1
- Inj Gentamicin 1x 160mg
- Nebul Combivent 3x1
- Nebul Pulmicort 2x1
- OAT dilanjutkan
CASE 2
 Identity
Name : Ny. SW
Gender : Female
Date of Birth : 15-04-1990
Address : Curahmalang, Rambipuji
No RM : 262xxx
Arrival : 20.00
 One Step Survey
Chief complain:
badan lemas
pasien rujukan dari PKM dengan keluhan badan lemas sejak 1 bulan yg lalu,
dan makin lemas hari ini, pasien juga mengeluhkan dada sempat berdebar
hari ini. riwayat menstruasi sebulan sekali selama 7 hari rutin. riwayat
perdarahan (-), mual muntah (-), riwayat bab hitam (-). nafsu makan baik.

A: patent (+)
B: Spontaneous breathing 20x/mnt, simetric, sonor +/+, ves +/+, rho -/-, whe
–/-, SpO2 98%
C: Reguler pulsation 80x/mnt , TD 125/60
D: Alert, PBI 3mm/3mm, RC +/+
E:
 INITIAL ASSESMENT
• Susp Anemia Aplastik

Planning Diagnostic
Foto Thorax
Lab Darah Lengkal, Faal ginjal, UL

INITIAL PLANNING
 ASSESMENT
Susp Anemia Aplastik

PLANNING
Inf PZ 20tpm
Inj Santagesik 3x1
CASE 3
 Identity
Name : Ny A
Gender : Female
Date of Birth : 63thn
Address : Jember
No RM : 2xxxxx
Arrival : 20.00
 One Step Survey
Chief complain: Nyeri pada kaki kanan disertai pusing

A: patent (+)
B: Spontaneous breathing 20x/mnt, simetric, sonor +/+, ves +/+, rho -/-, whe
–/-, SpO2
C: Reguler pulsation 76x/mnt , TD 150/80
D: GCS 4-5-6, PBI 3mm/3mm, RC +/+
E: laserasi cruris dextra + hematome frontal + ekimosis periorbital D
Status Lokalis cruris dextra:
L: deformitas (+) oedema (+) jejas (+) dressing (+)
bleeding (+)
F: Nyeri (+)
M: Rom Terbatas

Status Lokalis Regio Frontal

I: Hematome frontal (+) ekimosis periorbita D (+)
P: Nyeri (+)
 INITIAL ASSESMENT
• COR + OF Cruris D + HT

Planning Diagnostic
-Foto Thorax
- Foto Cruris D
-CT Scan

INITIAL PLANNING
-Inj Tetagam
- Inj Antrain 1g
- O2 masker 8lpm
 ASSESMENT
COR + OF Cruris D 1/3 medial + HHD

PLANNING
Inf PZ 20tpm
Inj Antrain 3x1
Inj Ceftazidime 2x1
Candesartan 1x 8mg
Concor 1x2,5mg
CASE 4
 Identity
Name : Ny. K H
Gender : Female
Date of Birth : 24-06-1986
Address : Sukowono
No RM : 262xxx
Arrival : 15.00
 One Step Survey
Chief complain:
Pasien hamil pertama usia kandungan 8 bulan lebih tidak merasakan gerakan bayi
sejak 1 hari yg lalu
A: patent (+)
B: Spontaneous breathing 20x/mnt, simetric, sonor +/+, ves +/+, rho -/-, whe –/-,
SpO2 99%
C: Reguler pulsation 88x/mnt , TD 180 /120
Initial Assesment
-PEB

Initial Planning
- Inj MgSO4 20% IV bolus
- Inj MgSO4 40% IM boka-boki
- Nifedipine 2x10mg
 Secondary Survey
A: patent (+)
B: Spontaneous breathing 20x/mnt, simetric, sonor +/+,
ves +/+, rho -/-, whe –/-, SpO2 99%
C: Reguler pulsation 80x/mnt , TD 150 /90
D: Allert, RC+/+
E:

Status Obstetrik
TFU 26cm
TBJ 1620g
DJJ Dopler (-) HIS (-)
 INITIAL ASSESMENT
• G1P0000Ab000 Uk 34-36 J/T dengan
pergerakan janin (-) + PEB

Planning Diagnostic
USG : DJJ (-)
 ASSESMENT
G1P0000Ab000 Uk 34-36 J/T/M IUFD + PEB

PLANNING
Inf PZ
Inj MgSO4 40% IM tiap 6jam
Nifedipine 2x10mg
Dopamet 3x20mg
Misoprostol ¼ tab intravaginal lanjut drip oksitosin
mulai 8tpm
Pro Ekspetative pervaginam
CASE 5
 Identity
Name : Tn M
Gender : Male
Date of Birth : 04-06-1983
Address : Tanggul
No RM : 20xxxx
Arrival : 21.00
 One Step Survey
Chief complain:
Pasien terkana paku, nyeri (+)

A: patent (+)
B: Spontaneous breathing 16x/mnt, simetric, sonor +/+, ves +/+, rho -/-, whe
–/-, SpO2 99%
C: Reguler pulsation 72x/mnt , TD 110 /60
D: Alert, PBI 3mm/3mm, RC +/+
E: Vulnus Ictum pedis S

Status Lokalis
I: Vulnus Ictum pedis S
P: pain (+)
 ASSESMENT
Vulnus Ictum Pedis S

PLANNING
-Rawat Luka
-Inj Tetagam
-Analsik 3x1
-Asam Mefenamat 3x1 k/p
CASE 6
 Identity
Name : Tn.E
Gender : Male
Date of Birth : 01 -07-1986
Address : Tanggul
No RM : 25xxxx
Arrival : 23.10
 One Step Survey
Chief complain:
Sesak sejak tadi sore post HD rutin rabu-sabtu, sejak 2 bulan yg lalu

A: patent (+)
B: Spontaneous breathing 24x/mnt, simetric, sonor +/+, ves +/+, rho -/-, whe –/-, SpO2 95%

Innitial Assesment
- Dyspnue

Inntitial Planning
- Masker NRMB 10lpm
- Inj lasix 1amp

C: Reguler pulsation 92x/mnt , TD 100/60

D: Alert, PBI 3mm/3mm, RC +/+
E:

Status Lokalis
 Secondary Survey
A: patent (+)
B: Spontaneous breathing 20x/mnt, simetric,
sonor +/+, ves +/+, rho -/-, whe –/-, SpO2 98%
C: Reguler pulsation 96x/mnt , TD 100/60,
Anemis +/+
D: Alert, PBI 3mm/3mm, RC +/+
E:
 INITIAL ASSESMENT
CKG Grade V+ Dyspnue

Planning Diagnostic
-Cek Lab
 ASSESMENT
CKG Grade V HD Reguler + Dyspnue + Anemia

PLANNING
- Inf 14tpm
- Inj Lasix 1x1
- Inj Transfusi PRC 1 kolf
CASE 7
 Identity
Name : Tn B
Gender : Male
Date of Birth : 40thn
Address : Jember
No RM : 2xxxxx
Arrival : 22.00
 One Step Survey
Chief complain:
Nyeri pada regio perianal, Riw DM (+)

A: patent (+)
B: Spontaneous breathing 20x/mnt, simetric, sonor +/+, ves +/+, rho -/-, whe
–/-, SpO2 99%
C: Reguler pulsation 100x/mnt , TD 115/75
D: Alert, PBI 3mm/3mm, RC +/+
E: Pus diperianal sinistra

Status Lokalis
I: Massa diperianal sinistra, keluar pus aktif, darah (-)
P: Konsistensi kenyal, batas tidak tega, hangat (+) berdungkul (-) imobile
 ASSESMENT
Abses Perianal Terdrainage + DM

PLANNING
Rawat Luka
Cefixim 2x100mg
Metronidazole 3x500mg
Asam Mefenamat 3x500mg
RCI 3x5 unit
Rendam duduk dengan detol
CASE 8
 Identity
Name : Ny I
Gender : Female
Date of Birth : 37 thn
Address : Jember
No RM : 2xxxxx
Arrival : 19.00
 One Step Survey
Chief complain:
Pasien post kll motor vs motor mengeluhkan kaki kiri nyeri

A: patent (+)
B: Spontaneous breathing 18x/mnt, simetric, sonor +/+, ves +/+, rho -/-, whe –/-,
SpO2 99%
C: Reguler pulsation 100x/mnt , TD 135/80
D: Alert, PBI 3mm/3mm, RC +/+
E: laserasi cruris S

Status Lokalis
L: Deformitas (+) Bleeding (+)
F: Nyeri (+) krepitasi (+)
M: ROM Terbatas
Sensorik digiti 1-5 99%
 INITIAL ASSESMENT
Open Fractur Tibia Sinistra 1/3 medial

Planning Diagnostic
Foto Polos Cruris S

INITIAL PLANNING
Inj Tetagam
Inj Antrain 1g
 ASSESMENT
Open Fractur Cruris 1/3 Medial

PLANNING
Inf PZ 7tpm
Inj Ceftazidine 2x1g
Inj Antrain 3x1
Pro ORIF + debridement
CASE 9
 Identity
Name : Ny. I
Gender : Female
Date of Birth : 20-01-1958
Address : Patrang
No RM : 26xxxx
Arrival : 18.00
 One Step Survey
Chief complain:
Pasien hamil anak kedua (pertama cukup bulan hidup) 7bulan mengeluhkan
perdarahan dari jalan lahir

A: patent (+)
B: Spontaneous breathing 18x/mnt, simetric, sonor +/+, ves +/+, rho -/-, whe
–/-, SpO2
C: Reguler pulsation 88x/mnt , TD 120 /70
D: Alert, PBI 3mm/3mm, RC +/+
E:
 Status Obstetrik

k/l: a/i/c/d : +/-/-/-

TFU: 24cm
TBJ 1086
DJJ (+) 136x
Perdarahan dari jalan lahir (+)
 INITIAL ASSESMENT
G2P1001Ab000 uk 30-32 + Ante Partum Bleeding

Planning Diagnostic
USG
Lab DL

INITIAL PLANNING
Nifedipine 20mg (Tokolitik)
 ASSESMENT
G2P1001Ab000 uk 30-32 J/T/H + Plasenta previa
partialis + Anemia

PLANNING
- Nifedipine 2x2Omg
- Induksi Maturasi Paru
Inj Dexametasone 4x5mg
CASE 10
 Identity
Name : Ny B
Gender : Male
Date of Birth : 12 thn
Address : Jember
No RM : 2xxxxx
Arrival : 23.00
 One Step Survey
Chief complain:
Keluar darah pada daerah post khitan

A: patent (+)
B: Spontaneous breathing 20x/mnt, simetric, sonor +/+, ves +/+, rho -/-, whe
–/-, SpO2 99%
C: Reguler pulsation 100x/mnt
D: Allert, PBI 3mm/3mm, RC +/+
E: Hiperemis di regio post khitan
 Status Urologi
• R. Plank: nyeri ketok cva (-/-)R. Supra pubik:
nyeri tekan (-), kesan vu penuh (-), massa (-)R.
Genital: edem penis(-), nyeri (-), kemerahan
(+),
 ASSESMENT
Hematome preputium post khitan

PLANNING
-Rawat luka dengan kasa dibasahi epinefrin
2ampul
-KRS