bakterial vaginitis

7/25/2019 bakterial vaginitis

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Morning Report11th 12thof September

2014

Co-ast : Dwi Permana Putra

Doctor in charge

1 !r Ratih

2 !r "i#i!

$ !r Rio


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%!entit& '1(

)ame : Ms )ur*ae*a

Se+ : ,ema*e

ge : .$ &o

Re*igion : mos*em

/ccupation : housewife

!!ress : Parit Mamur St Siantan i*ir ospita*ie! : 11thof /ctober 201.3 at

1000 pm


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Primar& Sur#e&

irwa& : 5oo : agitation '-(3 sianotic '-(3 retraction '-(3

musc*e use! on breathing '-(

5isten : snoring '-(3 gurg*ing '-(3 crowingsoun! '-( 6 stri!or '-(

,ee* : 7rachea !e#iation'-(

8reathing : respiration rate 24+9menit3 t&pe of

breathing ab!ominothoraca*3 7hora+s&mmetrica**& e+pansion '(3 chest pain whi*ebreathing '(3 percussion sonor '(3 5ung soun!#esicu*ar '9(


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Circu*ation : b*ee!ing '-(3 pu*se;;+9min regu*ar3 pa*e of the sin '-(3b*oo! pressure 1n#ironment : -


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Chief comp*aint Pain on the be*ow *eft *eg when mo#ing


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istor& of present i**nesses

Patient came to the emergenc& !epartment at1000 pm accompanie! b& her fami*& with usingcar 12 hours before arri#ing in hospita* 8eforethat3 the patient ha! an se*f-acci!ent !ue to s*ip

of her motorc&c*e tire when she wante! to turn tothe *eft er *eft *eg was struc !own a coup*e ofminutes an! su!!en*& she fe*t her be*ow *eft *egrea**& painfu* an! !i?cu*t to mo#e it nother

comp*aint such as hea!ache '-(3 !iiness '-(3nausea '-(3 #omitting '-( Me!ica* histories such ashipertension '-(3 !iabetes me**itus '-(3 uric aci! '-(3an! cho*estero* '-(


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**erg& : asthma '-(3 a**ergic onme!ications '-(

Me!ication :there was no me!icationafter in@ur&

Past %**ness: trauma '-(3 surger& '-(

5ast Mea* : - >#ent : -


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Ph&sica* >+amination

"ita* Signs : Aenera* con!itions : fe*t pain

wareness : Compos Mentis

8*oo! Pressure : 1


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ea! to 7oe >+amination

ea! 6 ma+i*ofacia*

%nspection : *aceration '-(3 b*ee!ing '-(3 contusio '-(3fracture '-(3 hematoma '-(

Pa*pate : crepitation '-(3 ten!erness '-( !e+tra

>&e: b*ee!ing '-(3 penetrating in@ur& '-(3 soft*enseuse! '-(3 optic ner#e !amage '-(3 anemia '-(3 icteric'-(

)>7 : 8*ee!ing '-(3 unstea!& teeth '-(3 !entures

use! '-(3 batt*e sign '-( )ec : h&peremia '-(3 !eformit& '-(3 swo**en '-(3

subcutaneous emph&sema '-(3 trachea !e#iation'-(3musc*e use breathing assistance '-(3ten!erness '-(


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Chest : s&mmetric '-(3 !eformit& '-(3h&peremia '-(3 scar '-(3 musc*e use breathingassistance '-(3

Cor %nspection : ictus cor!is is in#isib*e

Pa*pasi : %ctus cor!is fee* at S%C 4 mi!c*a#iu*asinistra *ine

Perusi : upper site S%C 2 Mi!*a#iu*as sinistra*ine3 right site at S%C 4 Parasterna* sinistra *ine3*eft site @antung S%C 4 Mi!c*au*a sinistra *ine

uscu*tation : Murmur '-(3 Aa**op '-(


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Paru %nspection : e+pansion of chest '(3

breathing pattern thoracoab!omina*3 scar

'-(3 musc*e use breathing assistance '-( Pa*pation : subcutaneous emph&sema '-(3

ten!erness '-(3 crepitation '-(

Percussion : sonor '(

uscu*tation : #esicu*ar '9(3 crac*es'-(3 wheeing '-(


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b!omina* : %nspection : =at 3 scar '-(3 h&peremic '-(3

tumor '-(

Pa*pation : ten!erness'-(3 hepar !an *ien'-(3 tumor '-(

Percussion : t&mpanic '(

usu*tasi: meta**ic soun! '-( norma* Aenita* : unperforme!

nus : unperforme!


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>+tremities : a9r ma*eo*us me!ia*issinistra 5oo :Deformit& '( on the *eft *eg3

bone e+posure '( of *eft tibia

,ee* : crepitation '(3 ten!erness '(

Mo#e : R/M of an*e @oint was

*imite! !ue to pain


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>+remities : a9r !igiti . manussinistra

5oo : !eformit& '(3 boneexposure '-(3 b*ee!ing'(3 #u*nusamputatun !ista* '(

,ee* : 7en!erness'(3 crepitation '-(

Mo#e : =e+ion '(3 e+tension '(


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Resume

Patient came to the emergenc&!epartment at 1000 pm accompanie! b&her fami*& with using car 12 hours before

arri#ing in hospita* 8efore that3 thepatient ha! an se*f-acci!ent !ue to s*ip ofher motorc&c*e tire when she wante! toturn to the *eft er *eft *eg was struc

!own a coup*e of minutes an! su!!en*&she fe*t her be*ow *eft *eg rea**& painfu*an! !i?cu*t to mo#e it


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,rom #ita* sign3 genera* con!ition wasfe*t pain3 wareness was composmentis3 8*oo! pressure 1


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Ph&sica* e+amination number .thofthe nger

Deformit& '(3 b*ee!ing '(3amputation on the !ista* of number.thof the nger3 ten!erness '(


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oring !iagnose!

/pen fracture Ara!e %%% a9r 19$ !ista*tibia sinistra

#u*nus amputatum a9r !ista*pha*angea* !igiti " manus sinistra


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orup

Comp*ete b*oo! count

8C : 10;00

A8: 1$2 P57 : 1;


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Rontgen photo of an*e @oint P 6

5eft *atera*


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Rontgen photo of *eft han! P 6

*atera*


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7reatment

Rencana operasi !ebri!ement /R%,

Persiapan operasi persetu@uan tin!aan3onsu* anestesi3 *apor /E3 puasa < @am

sebe*um operasi3 e*astic #erban sufratu**e Me!iamentosa:

%F,D Ringer 5atat 20 tpm

/pimer 1 gr912 @am %" 'sin test(

Eetoro*ac $0 mg9; @am %"

Raniti!ine 2. mg912 @am %"

7S 03. mg %M


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7han &ou


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%!entitas

)ama : 7n DE

Genis Ee*amin : 5ai-*ai

Fsia :1. tahun

gama :%s*am

Peer@aan : Pe*a@ar

*amat : G*n Ehatu*istiwa Ag Darma

Putra Ma@u )o 1stremitas : e!ema '-(3 CR7 H 2I3sianosis '-(


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Resume

Pasien !atang e %AD RFME%7 pa!a puu*22$0 !iantar o*eh a&ahn&a !enganmenggunaan motor serta !a*am ea!aan!igen!ong o*eh a&ahn&a pa!a saat masu %AD!iarenaan merasa n&eri pa!a perut bagiantengah wa*n&a3 pasien menga*amiece*aaan motor !imana menga*amitabraan !engan motor *ain !ari arah !epanPasien ti!a memaai he*m3 !an ter@atuhtersungur earah !epan sehingga bagianperut pasien membentur stang motor


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Pasien sempat pingsan H 10 menit3 mua* '(3muntah 2+ isi maanan !an berwarna se!iitemerahan Pasien @uga merasaan *emah3 sertamengantu3 88 '( norma*3 8E '( norma* Pa!a

pemerisaan si !itemuan teanan !arah1209


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Diagnosis Eer@a

7rauma 7umpu* b!omen

"u*nus esoriatum a9r suprapubic


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Pemerisaan Penun@ang

Darah 5engap

Frina*isis

FSA b!omen


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Darah 5engap

8C : 1;400

A8: 1$0

P57 : 2J;000

R8C : 4B.

ADS: 110 mg9!*


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Frina*isis

arna : uning eruh

Ph : B30

Protein : '-(

Re!usi : '-(

8i*irubin : '-(

Frobi*in : '-(

>ritrosit : '(95P80-1

5eu : '( '$-.(0-.

>pite* : '( '(

Si*in!er : '-( '-(

Erista* : '-( '-(


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FSA b!omen

epatorena* : epar ti!a membesar3 parenim homogen&3apsu* inta3 !utus bi*iaris !an estrahepar ti!a me*ebar3ti!a tampa massa 7i!a tampa o*esi cairan !i seiatarn&a

Sp*enorena* : *ien ti!a membesar3 apsu* inta3 parenimhomogen

Ain@a* anan iri: ti!a membesar3 parenim homogen&3apsu* inta3 batas parenim !engan centra* echo comp*e+

@e*as Sistem pe*#oa*ises ti!a me*ebar 7i!a tampa o*esicairan

"esia urinaria : ti!a terisi penuh3 !in!ing ti!a meneba*3

regu*ar3 batu '-(3 ti!a tampa o*esi cairan Eesan : 7i!a tampa o*esi cairan !i hepatorena*3 sp*enorena*

retro#esia 6 scanning hepar3 *ien3 e!ua gin@a* gin@a* !an #esiaurinaria ta tampa e*ainan


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Diagnosis

7rauma tumpu* ab!omen SuspRuptur Ge@unum


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Diagnosis 8an!ing

Ruptur i*eum


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Penata*asanaan

Persiapan *aparotom& %nforme! consent

Persetu@uan tin!aan

Puasa ; @am sebe*um operasi pasang )A7

%n@esi Ceftria+one 2 gram Metroni!ao*e infuse .00 mg'$0 menit sebe*um !i*auan operasi(

7ata*asana !i ruangan : Pantau tan!a-tan!a #ita*

Diet cair

%nfuse R5 24 tpm %n@ Cefota+ime $ + 2 gr

%n@ 7oramin $ + $0mg

%nf Metroni!ao*e $ + .00 mg


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7erima Easih


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%!entitas

)ama : 7n nggiawan

Genis Ee*amin: 5ai- *ai

Fsia : 24 tahun

gama : %s*am

Peer@aan : 7)% D

*amat : G*n !i Sucipto EM< SuiRa&a


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)M)>S%S 'utoanamnesis pa!atangga*: 11 /tober 201.3 puu*:11.$ %8(

E>5F) F7M : su*it 8E


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R%K7 P>)KE%7 S>ER)A

7n nggiawan3 24 tahun Datang !engane*uhan su*it 8E se@a 1 hr smrs3 Su*it 8E

!irasaan tiba-tiba 8E !irasaan ti!atuntas3 seperti menetes3 8E ber!arah '-(38E berpasir '-(3 8E !irasaan se!iitin&eri Demam '-(3 mua* '-(3 muntah '-(3

ma9mi '9( norma*3 88 norma* Riwa&atDM '-(3 o*estero* '-(3 asam urat '-(3 7 '-(3riwa&at e*uhan serupa sebe*umn&a '-(


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R%K7 E>8%S) Pasien men&anga* mengonsumsi a*coho*

!an meroo '(

R%K7 S/S%5 >E/)/M%: Pasien sehari-hari merupaan seorang

tentara 7)% D

R%K7 E>5FRA:7i!a a!a anggota e*uarga &ang memi*ii

e*uhan &ang sama !engan pasien


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P>M>R%ES) ,%S%E

7an!a "ita*: Eea!aan Fmum : 7ampa tenang

Eesa!aran : Compos Mentis '>4MB".(

7eanan Darah: 1209J0 mmg ,reuensi )a!i :


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Status Aenera*is

Eepa*a: )ormocepha*i '(3Mirocepha*i '-(3Marocepha*i '-(

Mata : Eon@ungti#a anemis '-9-(3

S*era iteri '-9-( 77 : De#iasi septum '-(3 secret '-9-(3

tonsi* 71971 '(3 ,aring iperemis '-(

5eher : Pembengaan EA8 '-( )&eripa!a EA8 '-(


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DD

Gantung : %tus or!is ter*ihat !i S%C . *inea

mi!c*a#icu*a sinistra 8atas @antung anan !i S%C 4 *inea

parasterna*is !e+tra

8atas @antung iri !i S%C . *inea

mi!c*a#icu*a sinistra

Pinggang @antung !i S%C 2 *ineaparasterna*is sinistra


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Paru: 8entu !a!a norma* '(3 barre* chest '-(3

pectus esa#atum '-( pectus

escarinatum '-( Pergeraan !a!a simetris '(3 !a!a

tertingga* '-(

Perusi sonor '(3 n&eri eto '-(

S)D : "es '9(3 Rh '-9-(3 h '-9-(


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b!omen %nspesi : !atar '-(3 cembung '-(3

ceung '-(3 *ua beas operasi '-(3 massa'-

usu*tasi: 8ising usus '( 10 +9menit3bruit '-(

Pa*pasi : )&eri tean '( a9rsuprapubic3 Soepe* '(3 hangat3 b*asspenuh

Perusi : )&eri eto C" '-9-(


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Aenita* : Penis norma*3pembesaran srotum '-(3 hiperemis'-(

nus : !i*auan R73 hasi*hemoroi! '-(3 sngter ani uat3muosa *icin3 no!u* '-(3 pembesaran

prostat '-( >stremitas : ra* hangat3 CR7

H2I3 e!ema '-9-(


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Resume

7n nggiawan3 24 tahun Datang!engan e*uhan su*it 8E se@a 1 hrsmrs3 Su*it 8E !irasaan tiba-tiba

8E !irasaan ti!a tuntas3 sepertimenetes3 ma9mi '9( norma*3 88norma* Pemerisaaan si

!itemuan teanan !arah 1209J03na!i


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Diagnosis Eer@a

Retensio urin ec susp 8atu sa*uranemih


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Pemerisaan Penun@ang

asi* 5aboratorium

Darah 5engap

5eucoc&te :


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FSA b!omen

Ain@a* anan iri: ti!a membesar3 parenimhomogen&3 apsu* inta3 batas parenim!engan centra* echo comp*e+ @e*as Sistempe*#oa*ises ti!a me*ebar ti!a tampa o*esi

cairan "esia urinaria : ti!a terisi penuh3 !in!ing

ti!a meneba*3 regu*ar3 batu '-(3 ti!a tampao*esi cairan

Prostat : ti!a membesar3 parenim homogen&

Eesan : Scanning kedua ginjal, vesikaurinaria dan prostat tak tampak kelainan


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Diagnosis

Retensio urin ec Susp 8atu Fretra


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Diagnosis 8an!ing

8atu ureter


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Penata*asanaan

%nfus R5 20 tpm

%n@ etoro*ac $ + $0 mg

%n@ Cefota+ime 2 + 1 gr

arna* tab*et 1 + 034 mg

Frinter apsu* 1 + 400 mg

Pasang DC

bakterial vaginitis

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