MORNING REPORT

FAKULTAS KEDOKTERAN UNIVERSITAS MUHAMMADIYAH

MALANG
RUMAH SAKIT MUHAMMADIYAH LAMONGAN

Daftar OB Bedah
1. Ny. Arsy/ contusion muscle and tendon/ RJ
2. Tn. Suwito/ snake bite/ shofa 11
3. Tn. Mukhtar/ abses perianal/ shofa 12
4. Tn. Iksan/ Vulnus app manus/ shofa 9
5. Tn. Sarip/ peritonitis/ shofa 8
6. Hamam/ app/ shofa 15
7. Ny. Nimatul/ SDH+CKR+CF clavicula
D+Vulnus app kepala/ Shofa 10
8. Sdr. Khohar/ contusion muscle and tendon/ RJ

Status Pasien
Patient Identity
Name
: Tn. Suwito
Gender
: Male
Age
: 53 years
Address
: Lamongan
admission
: 4/07/2016 time: 16:11

Status Pasien
Anamnesis
Chief Complaint : Snake bite
Present illness : patient just got snake bite 1 hour before admitted
to the hospital when he was on the field for looking some grass.
He didnt know what kind of snake that was bite him. He got bite
at his left hand on index finger. After got snake bite, he went to
the nearest maidwife but she told him to go to RSML as soon as
possible. His hand got tied. His hand swelling + and warm +,
movement+, pain on the bite site+, bleeding active -. The patient
didnt complaint headache-, nausea -, vomiting-, fever-, short of
breath -.
Past ilness : DM and HT denial
Family History : -

Status Pasien
Physical
examination

Kesadaran : Composmentis
GCS
: 456
Vital sign
:Blood Pressure : 162/108 mmHg
Heart Rate
: 86 x/ mnt
Temp
: 36oC
RR
: 20 x/menit

Status Pasien

Physical
Examination

Head/ Neck : Inspeksi: anemia -, icterus -, cyanosis -,

dispsneu Thorax
: Simetris +, Retraction -/Lung:
I : Chest expansion simetris
P : Chest espansion simetris, krepitation P : Sonor | Sonor
A : vesikuler/vesikuler Rh -/-, Wh -/Cor:
I : ictus cordis (-), voussure cardiac (-)
P : thrill (-)
P : Batas jantung normal
A : S1S2 single, Murmur -, gallop Abdomen : I : distended
P : Soft, hepar dan lien unpalpable, tenderness
P : thympani
A : Bowel Sound decrease.
Extermity : Normal

Status lokalis
L: oedem manus sinistra +, snake
bite at dgiti 2 saO296 85%, pulsasi
teraba lemah
F: tenderness +

Status Pasien
Clue and Cue

Mrs. SUlaeni
Sanek bite
Oedem manus sinistra, pulsasi teraba lemah

Assesment
Snake bite

Planning Diagnosis
CBC

Laboratory Findings

GDA 489
Kalium serum 3.5
Natrium serum 136
Clorida serum 105
Urea 37
Creatinine 1.2
SGOT 50
SGPT 46
Lekosit 7.3
Neutrofil 50.5
Limfosit 37.7
Monosit 6.5
Eusinofil 4.8
Hematokrit 52.6

Basofil 1.1
Eritrosit 6.10
Hb 17.3
MCV: 86.10
MCH 28.30
MCHC 32.90
RDW 11
Trombosit 300
MPV 4
LED 1 9
LED 2 2
HbsAg negative
Metode 1 non reaktif
APTT 26.10
PT 13.60

Re-assesment
Snake bite
Terapi
Drip sabu 1 amp dalam
500cc pz 2x tiap 12 jam
Pasang bidai
Inf. Asering 1500cc/24jam
Inj. Ceftriaxone 2x1gr
Inj. Santagesik 3x1 gr iv
Inj. Acran 2x50 mg iv
Inj. Tetagram 250 iu im
Inj. Metilprednisolon
3x125 gr

Thankyou