mr bedah 29 april 2014
DESCRIPTION
Mr bedahTRANSCRIPT
![Page 1: MR Bedah 29 April 2014](https://reader034.vdocuments.mx/reader034/viewer/2022051519/577cc39c1a28aba7119690da/html5/thumbnails/1.jpg)
MORNING REPORTAPRIL 29TH 2013
Konsulen dr. Jean Pello, SpB
![Page 2: MR Bedah 29 April 2014](https://reader034.vdocuments.mx/reader034/viewer/2022051519/577cc39c1a28aba7119690da/html5/thumbnails/2.jpg)
1St Case
![Page 3: MR Bedah 29 April 2014](https://reader034.vdocuments.mx/reader034/viewer/2022051519/577cc39c1a28aba7119690da/html5/thumbnails/3.jpg)
BIODATA Name : MD Age : 4 years old Sex : Male Address : Sikumana
![Page 4: MR Bedah 29 April 2014](https://reader034.vdocuments.mx/reader034/viewer/2022051519/577cc39c1a28aba7119690da/html5/thumbnails/4.jpg)
Anamnesis
Chief Complaint : Fell from the carMOIpatient come to ER because of falling from the parked car several minutes ago. The child cry a lot and blood was over the face. There’s a wound at the right forehead. The kid didn’t loss the consciusness, no nausea, no vomit, but there’s headache presents. There’s no other wound or other complaints.
![Page 5: MR Bedah 29 April 2014](https://reader034.vdocuments.mx/reader034/viewer/2022051519/577cc39c1a28aba7119690da/html5/thumbnails/5.jpg)
Primary Survey A: Patent, clear B : RR: 24 times/min, spontan C : CRT : <2”, Pulse: 92 times/minute,
reguler. D : GCS E4V5M6 E : V. Laceration on region Frontal
dextra, 2cm
![Page 6: MR Bedah 29 April 2014](https://reader034.vdocuments.mx/reader034/viewer/2022051519/577cc39c1a28aba7119690da/html5/thumbnails/6.jpg)
Secondary Survey GCS : E4 V5 M6 Head : Normal eyes : anemic (-/-), light reflex (+/+),
icteric (-/-) , isokhor +/+ Ear : normal Nose : normal Neck: Normal
![Page 7: MR Bedah 29 April 2014](https://reader034.vdocuments.mx/reader034/viewer/2022051519/577cc39c1a28aba7119690da/html5/thumbnails/7.jpg)
Thorax Inspection : chest expansion simetrics,
reguler, abdominothoracal, Bruish (-) Palpation : vocal fremitus R=D, krepitasi
(-), Pain (-) Percusion: sonor (+/+) Auscultation : vesicular (+/+), ronchi
(-/-), wheezing (-/-)
![Page 8: MR Bedah 29 April 2014](https://reader034.vdocuments.mx/reader034/viewer/2022051519/577cc39c1a28aba7119690da/html5/thumbnails/8.jpg)
Abdomen Inspection : look flat, follow the chest
expansion Palpation : pain (-), mass (-), tenderness
(-) Percusion : timpany (+) Auscultation : peristaltics (+), normal
![Page 9: MR Bedah 29 April 2014](https://reader034.vdocuments.mx/reader034/viewer/2022051519/577cc39c1a28aba7119690da/html5/thumbnails/9.jpg)
Extremity
Look (normal)Feel normalpain (-)
Move ROM : normal
![Page 10: MR Bedah 29 April 2014](https://reader034.vdocuments.mx/reader034/viewer/2022051519/577cc39c1a28aba7119690da/html5/thumbnails/10.jpg)
Assessment Vulnus laceratum at regio frontal dextra
![Page 11: MR Bedah 29 April 2014](https://reader034.vdocuments.mx/reader034/viewer/2022051519/577cc39c1a28aba7119690da/html5/thumbnails/11.jpg)
Planning therapy Wound toilet and primary hecting Anti tetanus serum Paracetamol 250 mg 3x1 tab Amoxicillin 250 mg 3x1 tab
![Page 12: MR Bedah 29 April 2014](https://reader034.vdocuments.mx/reader034/viewer/2022051519/577cc39c1a28aba7119690da/html5/thumbnails/12.jpg)
Picture
![Page 13: MR Bedah 29 April 2014](https://reader034.vdocuments.mx/reader034/viewer/2022051519/577cc39c1a28aba7119690da/html5/thumbnails/13.jpg)
Patient Identity Name : Mrs. WN Sex : Female Age : 51 y.o Religion : Catholic Job : Housewife Adress : Soe
![Page 14: MR Bedah 29 April 2014](https://reader034.vdocuments.mx/reader034/viewer/2022051519/577cc39c1a28aba7119690da/html5/thumbnails/14.jpg)
History Chief complaint: shortness of breathe 2 days before
hospitalize MOI:
Shortness of breath has been felt for a long time, experienced again 2 days after patient received an introductory home from the hospital. Patients treated till date 21/03/14 04/26/14 26 with a diagnosis of ca. mammary sinistsra. Ca experienced since 2009, breast surgery. In 2012 appeared the bump, bump in 2013 turned into a wound. August 2013 appear small bumps around the left breast to the right spread to the neck and armpits. The bumps on the left side neck pain when touched. Because it is often shortness of breath, in 2014 the patient had 6 times the puncture lung fluid, four times in the left lung and right lung 2 times. Bumps that have become wound was cut then sent for examination, then the result is 2 weeks out. 2 months ago while being treated, the patient's legs and hands swelled. History urinating blood while being treated. unconsciousness (-), nausea (+), vomit (-), dizziness (-).
![Page 15: MR Bedah 29 April 2014](https://reader034.vdocuments.mx/reader034/viewer/2022051519/577cc39c1a28aba7119690da/html5/thumbnails/15.jpg)
Habit history: smoke five to six cigarettes / day since the age of 21 years and drank alcohol
![Page 16: MR Bedah 29 April 2014](https://reader034.vdocuments.mx/reader034/viewer/2022051519/577cc39c1a28aba7119690da/html5/thumbnails/16.jpg)
Primary Survey Airway: clear Breathing: 36 x/min• Circulation:
Pulse: 97x/min Disability: E4V5M6 Exposure : covered with gauze
![Page 17: MR Bedah 29 April 2014](https://reader034.vdocuments.mx/reader034/viewer/2022051519/577cc39c1a28aba7119690da/html5/thumbnails/17.jpg)
Secondary Survey GCS E4V5M6 Head: simetric, normocephal Eye : anemic (-/-), light reflex (+/+), icteric
(-/-), isokor (+/+) Ear : Normal Nose : Normal Mouth : Normal Neck: enlarged lymph nodes (+), multiple,
cervical region, axilla region, chest region. Size: 1cm, elastic, immobile, tenderness (+)
Throat : Normal
![Page 18: MR Bedah 29 April 2014](https://reader034.vdocuments.mx/reader034/viewer/2022051519/577cc39c1a28aba7119690da/html5/thumbnails/18.jpg)
Thorax Inspection : chest expansion simetrics, reguler, Palpation : edema (-), crepitation (-), tenderness (-) Percusion : sonor (+/+) Auscultation : vesicular (+/+), ronchi (+/+), wheezing(-/-)
![Page 19: MR Bedah 29 April 2014](https://reader034.vdocuments.mx/reader034/viewer/2022051519/577cc39c1a28aba7119690da/html5/thumbnails/19.jpg)
Abdomen Inspection : flat, mass (-), wound (-) Auscultation : peristaltics (N) Palpation : tenderness pain (-) Percussion : timpanic sound (+)
![Page 20: MR Bedah 29 April 2014](https://reader034.vdocuments.mx/reader034/viewer/2022051519/577cc39c1a28aba7119690da/html5/thumbnails/20.jpg)
Extremity Look
Deformitas (-), shortening (-), lengthening (-), swelling (+)
Feel CRT <2’, warm, pulsation of a. Dorsalis pedis
sinistra and dextra (+), Sensoris (+), crepitation (-)
Move Normal
![Page 21: MR Bedah 29 April 2014](https://reader034.vdocuments.mx/reader034/viewer/2022051519/577cc39c1a28aba7119690da/html5/thumbnails/21.jpg)
Workup Chest X-ray CBC Complete urine count
![Page 22: MR Bedah 29 April 2014](https://reader034.vdocuments.mx/reader034/viewer/2022051519/577cc39c1a28aba7119690da/html5/thumbnails/22.jpg)
Asessment Ca mammae sinistra Dyspnoe e.c metastasis pleura Limfodenitis
![Page 23: MR Bedah 29 April 2014](https://reader034.vdocuments.mx/reader034/viewer/2022051519/577cc39c1a28aba7119690da/html5/thumbnails/23.jpg)
Management O2 4 lpm IVFD RL 10 tpm If leucocytosis Ceftriaxon 2x1gr iv
![Page 24: MR Bedah 29 April 2014](https://reader034.vdocuments.mx/reader034/viewer/2022051519/577cc39c1a28aba7119690da/html5/thumbnails/24.jpg)
Picture
![Page 25: MR Bedah 29 April 2014](https://reader034.vdocuments.mx/reader034/viewer/2022051519/577cc39c1a28aba7119690da/html5/thumbnails/25.jpg)
![Page 26: MR Bedah 29 April 2014](https://reader034.vdocuments.mx/reader034/viewer/2022051519/577cc39c1a28aba7119690da/html5/thumbnails/26.jpg)
Case 3
![Page 27: MR Bedah 29 April 2014](https://reader034.vdocuments.mx/reader034/viewer/2022051519/577cc39c1a28aba7119690da/html5/thumbnails/27.jpg)
Identity Name : Mr. TB Age : 22 y.o Sex : Male Address : Camplong
![Page 28: MR Bedah 29 April 2014](https://reader034.vdocuments.mx/reader034/viewer/2022051519/577cc39c1a28aba7119690da/html5/thumbnails/28.jpg)
History Taking Chief Complaint: Burn wound
Present Complaint: Patient presented w/ painful burn wound existed from a day ago, resulted from falling on top of a flaming cooking stone stove while squatting in front of it. Toothpaste was applied on his burn wound before he was admitted at RS Naibonat.
![Page 29: MR Bedah 29 April 2014](https://reader034.vdocuments.mx/reader034/viewer/2022051519/577cc39c1a28aba7119690da/html5/thumbnails/29.jpg)
Physical Examination Primary Survey
A: Clear B: spontaneous breathing with RR of 20 C: Pulse rate: 88 D: Alert (GCS: E4V5M6)
Secondary Survey Hair : Black, Allopecia (-) Eyes : Conjungtiva : Anemic (-/-) Sclera : Icteric (-/-) Ears : Normal Nose : Normal Mouth : Normal Neck : Lymphadenopathy (-)
![Page 30: MR Bedah 29 April 2014](https://reader034.vdocuments.mx/reader034/viewer/2022051519/577cc39c1a28aba7119690da/html5/thumbnails/30.jpg)
Physical Examination PULMO
Inspection: symmetrical chest expansion Palpation : Vocal fremitus (d=s), mass (-),
crepitation (-) Percussion: sonor (+/+) Auscultation : Vesiculer (+/+),Ronchi (-/-),
Wheezing (-/-) COR
S1/2 single, murmur (-), gallop (-)
![Page 31: MR Bedah 29 April 2014](https://reader034.vdocuments.mx/reader034/viewer/2022051519/577cc39c1a28aba7119690da/html5/thumbnails/31.jpg)
Physical Examination ABDOMEN
Inspection : Flat, suitable with breathing Auscultation : normal peristaltic sound Palpation : Tenderness (-) Percussion : Tympanic sound
![Page 32: MR Bedah 29 April 2014](https://reader034.vdocuments.mx/reader034/viewer/2022051519/577cc39c1a28aba7119690da/html5/thumbnails/32.jpg)
Local status Location; face, neck, distal 2/3 of the left
arm, medial 1/3 of right upper arm.
![Page 33: MR Bedah 29 April 2014](https://reader034.vdocuments.mx/reader034/viewer/2022051519/577cc39c1a28aba7119690da/html5/thumbnails/33.jpg)
![Page 34: MR Bedah 29 April 2014](https://reader034.vdocuments.mx/reader034/viewer/2022051519/577cc39c1a28aba7119690da/html5/thumbnails/34.jpg)
![Page 35: MR Bedah 29 April 2014](https://reader034.vdocuments.mx/reader034/viewer/2022051519/577cc39c1a28aba7119690da/html5/thumbnails/35.jpg)
![Page 36: MR Bedah 29 April 2014](https://reader034.vdocuments.mx/reader034/viewer/2022051519/577cc39c1a28aba7119690da/html5/thumbnails/36.jpg)
![Page 37: MR Bedah 29 April 2014](https://reader034.vdocuments.mx/reader034/viewer/2022051519/577cc39c1a28aba7119690da/html5/thumbnails/37.jpg)
Lab ResultsDL
WBC: 24,64 Lymph: 1,84 Mono:1,48 Eo:0,52 Baso: 0,03 Neut:20,77 RBC13,56 HGB 14,9 HCT 43,6 MCV 78,4 MCH 26,8 MCHC 34,2 PLT 206
UL BJ: 1.020 pH 6,0 Lekosit +3 Nitrit (-) Glukosa N Protein N Urobilinogen N Keton (-) Bilirubin (-) Eritrosit +3
Sedimen•Lekosit penuh•Eritrosit 15-20/lp•Epitel 15-20/lp•Silinder (-)•Kristal (-)•Bakteri (-)
![Page 38: MR Bedah 29 April 2014](https://reader034.vdocuments.mx/reader034/viewer/2022051519/577cc39c1a28aba7119690da/html5/thumbnails/38.jpg)
Lab Results Ureum 16,1 Creatinin 0,3 GDS 133 Na 137 K 4,2 Cl 104
![Page 39: MR Bedah 29 April 2014](https://reader034.vdocuments.mx/reader034/viewer/2022051519/577cc39c1a28aba7119690da/html5/thumbnails/39.jpg)
Planning Plasma Albumin
![Page 40: MR Bedah 29 April 2014](https://reader034.vdocuments.mx/reader034/viewer/2022051519/577cc39c1a28aba7119690da/html5/thumbnails/40.jpg)
Assessment Grade 2 burns with 17% body area
involvement
![Page 41: MR Bedah 29 April 2014](https://reader034.vdocuments.mx/reader034/viewer/2022051519/577cc39c1a28aba7119690da/html5/thumbnails/41.jpg)
Planning Therapy Wound Toilet Burnazine zalf Inj ATS 1 amp IM IVFD RL 20 tpm Inj. Omeprazole 1 amp IV Inj. Cefotaxime 2x1 gr IV