mr usha sanglah
DESCRIPTION
MRTRANSCRIPT
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MORNING REPORT
August 22th 2015
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IDENTITAS PASIEN Name : F Umur : 21 Thn Jantina : Laki Kewarganegaraan : Indonesia Alamat : Denpasar Agama : Islam Pekerjaan : swasta Status Perkahwinan : Sudah menikah Tanggal MRS : August 21th, 2015
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ANAMNESIS
Nyeri pada tungkai dan badan
Ps datang sadar, rujukan dari RSUD Negara dengan Combustio gr II 72%, mengeluhkan nyeri pada tungkai dan badan setelah terkena air panas 5 jam SMRS. Pasien mengatakan terpeleset dan terjatuh di bak air panas.Pasien mengatakan merasakan saat nyeri dan merasakannya lebih sewaktu lukanya terpapar udara. Riwayat pingsan (-) mual (-) muntah (-).
KELUHAN UTAMA
RIWAYAT PENYAKIT SEKARANG
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MOI: pasien terpeleset dan jatuh ke bak air panas
ANAMNESISRIWAYAT PENYAKIT
SEKARANG
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Pasien sudah dipasang infus dan dikasi supratul dan dibalut dengan perban bersih. Pasien tidak mempunyai riwayat penyakit sistemik yang lain seperti diabetes mellitus, hipertensi dan sakit jantung.
ANAMNESISRIWAYAT PENGOBATAN
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PEMERIKSAAN FISIK
Keadaan Umum : Sakit Sedang
Tingkat Kesadaran : Compos mentis
GCS : E4V5M6
Vital Sign: • BP : 120/80 mmHg• RR : 22 x/min• PR : 90 x/min
• tax : 36,5°C
• Weight : 65kg
STATUS PRESENT
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PEMERIKSAAN FISIK
A : clear
B : spontan 22x/menit
C : Stabil, N : 90 x/mnt, T: 120/80 mmHg
D : alert
PRIMARY SURVEY
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MATA : anemis (-/-); ikterus (-/-); pupil reflex (+/+) isokor, oedema palpebra (-/-)
THT :Tonsils T1/T1; pharyngeal hyperemia (-); tongue normal; lip cyanosis (-)
LEHER : JVP PR + 0 cmH2O;
pembesaran kelenjar getah bening(-)
SECONDARY SURVEY
PEMERIKSAAN FISIK
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Thorax : SymetrisCor
Inspection : Ictus cordis tidak tampak Palpation : Ictus cordis tidak teraba Percussion :
• UB : ICS II• LB : MCL S ICS V• RB : PSL D
Auscultation : S1 S2 single regular, murmur (-)
PulmoInspection : SymetrisPalpation : Tactile Fremitus N/ NPercussion : sonor/sonorAuscultation : Vesicular + / + , Rh -/-, wh -/-
PEMERIKSAAN FISIKStatus
Generalis
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Punggung : Reg sacrum combustio 3%
Abdomen : Inspection : Distensi (-); ascites (-)Auscultation : Bunyi Usus (+) normalPercussion : shifting dullness (-)Palpation : liver & spleen not palpable
Extremitas : R. axilla D 1%; Brachialis D 2%;
Antebrachii D 3%; Femur D 3%; Femur S 4%; Cruris D 7%; Cruris S 5%; R. dorsum pedis D/S 1%/1%
PEMERIKSAAN FISIKStatus
Generalis
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Status lokalis:
R. axilla D 1%;
Brachialis D 2%; Antebrachii D 3%;
Femur D 3%; Femur S 4%;
Cruris D 7%; Cruris S 5%;
R. dorsum pedis D/S 1%/1%
STATUS LOKALIS
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Combutio Gr II AB 30 %
DIAGNOSIS
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Pemeriksaan Darah Lengkap
PEMERIKSAAN PENUNJANG
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Hasil Pemeriksaan Darah Lengkap
Na 133/ K 3,6/ pH 7,45/ pCo2 35/ pO2116/ Beecf 0,3/ HCO3 24,3
PPT 11,4/ INR 1,05/ APTT 35,2
WBC 17,67/ RBC 6,53/ HGB 15,76/ HCT 48,79/ PLT 247,4/ BT 2/ CT
9.3
SGOt 17,2/ SGPT 10,5/ Alb 4,6/ BS 98/ BUN 7/ Crea 0,85/ Cl 97,9
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MRSIVFD maintenance RL Paracetamol 3x1 gr IVVit C 2x200mg IVRanitidine 2x50 mg IVRawat luka dg Sufratulle + Sucralfate syr tiap
hariRawat Burn Unit Planning Debridement
Terapi
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Take care of YOUR BODY, it’s the only place you have to
LIVE in….
THANK YOU