LAPORAN JAGA

Senin, 13 Januari 2014

 REKAP KUNJUNGAN IGD
Rawat Inap
No Identitas Diagnosis Tindakan

1
 REKAP KUNJUNGAN IGD
Rawat Inap
No Identitas Diagnosis Tindakan
2
 REKAP KUNJUNGAN IGD
Rawat Inap
No Identitas Diagnosis Tindakan

4
Paviliun
No Identitas Diagnosis Tindakan

1 Tn.Ks Burst Fr acture VL 1 Frenkel A MRS Paviliun

54 thn neglected
01238940
2 Tn.Sk Post MRS Paviliun
68 th
01238942
Rawat Jalan

No Identitas Diagnosis Keterangan

1 Medikasi
Analgetik
Antibiotik
2 Observasi
Analgetik
3.
Konsulan
No Identitas Diagnosis Tindakan
- - - -

Meninggal

No Identitas Diagnosis Keterangan

- - - -

APS

No Identitas Diagnosis Keterangan

- - - -
NAME : Tn.Nr
AGE : 41 thn
MR : 01238939
Keluhan Utama :
Unconsiousness and wound at shoulder dan feet region after
being hit by electrical wire

RPS :
4 hours prior to admission, the patient was standing in the
back of a truck loaded with glass. The patient inadvertent
being hit by electrical wire. The patient was shocked and hit
the glass in front of him and then fell from the truck. After that
the patient was unconsious, vomit (-), seizure (-). By the
helper, the patient brought to Maguan Husada hospital. The
patient then injected with some medications, got IV line.
Because off lack of facilities, the patient then being brought to
RSDM with mild brain injury E3V3M2
 Primary Survey

A : Clear with collar brace

B : I : Thoracoabdominal R=L, RR : 20x/mnt
P : Crepitation (-/-)
P : Sonor - sonor
A : Vesiculer sound (+/+), Additional sound (-/-)
C : HR: 84 x/mnt BP : 138/72 mmHg
D : GCS E3V2M5, isocore pupils(3 mm/3 mm), light reflexes
(+ /+), lateralization(-)
E : T : 36.7 C, lesion (+) look at the physical examination
 Secondary Survey
Head : lesion (+) look the localized examination
Eyes : hematome (-/-)
Nose : rhinorhhea (-)
Mouth : malocclusion (-)
Ear : otorrhea (-)
Neck : collar brace (+)
Chest : no abnormality
Stomach : no abnormality
Extremity : lesion (+) look the localized examination
 STATUS LOKALIS
R.Scapula (S) :
I : electrical wound(+), bulae (-),
white, wound degree 0,5 %

R.Frontal :
I : lacerated wound (+) size
4x3x1,5 cm and 3x2 cm

R.Supralabialis :
I : lacerated wound (+) through
and through size 5x2x2 cm

R.Pedis (D) :
I : electrical wound grade II, bulae
(+) wound degree 1 %

R.Pedis (S) :
I : lacerated wound digiti I +
excoriated wound
ASS I :
Electrical burn grd II wound degree 1,5%
Mild brain injury GCS E3V2M5
Lacerated wound Frontalis region + Pedis region (S)
Lacerated wound Supralabialis region

PLAN I :
- O2 3 Lpm
- IVFD NaCl 0,9% 2000 cc/24 hours
- Ceftriaxon inj 1 g/12 jam
- Metamizol Inj.1 g/8 jam
- Ranitidin Inj.50 mg/12 jam
- Routine blood examination
- Head CT Scan
- Cervikal X-Ray AP/Lat, Thorax X-Ray
LAB
ASS II :
Comotio cerebri GCS E3V5M6
Electrical burn grd II wound degree 1,5%
Lacerated wound Frontalis region + Pedis region (S)
Lacerated wound Supralabialis region

PLAN II :
Neurosurgery :
Inward HCU
Monitoring og VS/GCS/Lateralization signs

Plastic Surgery :
Inward HCU
Monitoring heart rhythm disturbances
Monitoring urine product
 Arrival time 14.25
Triage time 14.25
Surgery Dept.time 14.30
Laboratory time 14.35 15.10
X-Ray time 14.40 15.20
Diagnose time 15.25
Operation time -
Inward time 15.40