DUTY REPORT

Monday, December 24th 2017

Residents on duty :
AWI
DAN/DHI
DED

Consultant in charge :
dr. Krisna Yuarno P. Sp.OT (K)
Herry S/M /66 yo/10183331 ISS : 1
ToAcc : 3 days ago RTS : 7.841
ToArr : 10.30 PS :98.3 %
ProcStart : 12.00
ProcEnd : 13.00 MORNING ADMISSIONS
Working Problem Solving /
Time General Status Problem Final Diagnosis
Diagnosis Management
10.30 A : Patent Open wound dorsal Infected wound dorsal Analgetics Infected wound dorsal
B : spontaneous side L index finger side L index finger Antibiotics side L index finger
symmetrical Human Antitetanus (MT1 NV1)
RR= 18x/min Immunoglobulin
C : BP= 120/70
mmHg MOI: injured by circle
HR= 74 x/min Wound toilet
D:
GCS= 456 Secondary closure
isocoric pupils
Herry S/M /66 yo
Herry S/M /66 yo
Herry S/M /66 yo
Ari Kiki/M /17 yo/11372219 ISS : 4
ToAcc : 10.00 WIB RTS : 7.841
ToArr : 10.50 WIB PS :99.3 %
ProcStart : 15.00 WIB
ProcEnd : 16.30 WIB MORNING ADMISSIONS
Working Problem Solving /
Time General Status Problem Final Diagnosis
Diagnosis Management

10.50 A : Patent Open wound on Open wound Analgetic Open wound

B : spontaneous the R hand extensor zone VI R Antibiotics extensor zone VI R
symmetrical hand + rupture EDC Human Antitetanus hand + total
RR= 16x/min I,II & EIP tendon Immunoglobulin rupture EDC I,II &
C : BP= 130/80 EIP tendon
mmHg MOI: cut by knife (MT5 NV1)
HR= 94 x/min Debridement
D: Explore
GCS= 456 Repair
isocoric pupils Splint
Ari Kiki/M /17 yo
Ari Kiki/M /17 yo
Ari Kiki/M /17 yo
Ari Kiki/M /17 yo
Ari Kiki/M /17 yo
Ari Kiki/M /17 yo
Mistiani /F /35 yo/11372242 ISS : 22
ToAcc : 17.00 WIB RTS : 7.841
ToArr : 20.30 WIB PS :98.3 %
ProcStart : 23.00 WIB
ProcEnd : 23.30 WIB EVENING ADMISSIONS
Working Problem Solving /
Time General Status Problem Final Diagnosis
Diagnosis Management
20.30 A : Patent Decrease of Mild hhead injury Neurosurgery : Mild hhead injury
B : spontaneous consciousness 356 debridement 356
symmetrical primary hecting
RR= 20x/min Pain and open wound edema cerebri edema cerebri
C : BP= 115/80 mmHg on the head region Digest :
HR= 98 x/min open wound regio parietal non operatif manajement open wound regio parietal
D: Pain on the chest and
GCS= 356 stomach internal bleeding HD Stable TKV : internal bleeding HD
isocoric pupils non operatif manajement Stable
Haematuria Fr costae 2,3,4 posterior S
Urology : Fr costae 2,3,4 posterior
Contusio pulmonum CT Scan Abdomen with S
S contrast
Contusio pulmonum S
Moderate ARDS
MOI: single Motorcycle Moderate ARDS
acident fall to cliff Susp. Trauma Ren S
Susp. Trauma Ren S
Susp. Trauma Buli
Susp. Trauma Buli

Pain and bruise on the Pelvic Ring injury APC II Pelvic binder Pelvic Ring injury APC II
hip region (AO 61-A2.2 IC1 MT1 NV1
CF os cocygeus Doughnut pillow )

CF os cocygeus
(AO 61-A3 IC1 MT1 NV1 )
Mistiani /F /35 yo
Mistiani /F /35 yo
Mistiani /F /35 yo
Naniek Hariati /F /66 yo/10378209 ISS : 4
ToAcc : 18.00 WIB RTS : 7.841
ToArr : 00.01 WIB PS :91 %
ProcStart : 01.00 WIB
ProcEnd : 01.30 WIB EVENING ADMISSIONS
Working Problem Solving /
Time General Status Problem Final Diagnosis
Diagnosis Management

00.01 A : Patent Pain and swelling CF middle third L Analgetics CF middle third L
B : spontaneous on the L forearm radius ulna radius ulna
symmetrical Back slab (AO 22-A3 IC1 MT1
RR= 14x/min NV1)
C : BP= 120/80 ORIF planned
mmHg MOI : sliped on
HR= 90 x/min the floor
D:
GCS= 456
isocoric pupils
Naniek Hariati /F /66 yo
Naniek Hariati /F /66 yo
M Reza / M /14 yo/11372255 ISS : 8
ToAcc : 15.00 WIB RTS : 7.841
ToArr : 23.57 WIB PS : 99.5 %
ProcStart : 01.45 WIB
ProcEnd : 01.15 WIB EVENING ADMISSIONS
Working Problem Solving /
Time General Status Problem Final Diagnosis
Diagnosis Management

23.57 A : Patent Headache Mild head injury NS : Mild head injury

B : spontaneous 456 Non operative 456
symmetrical Pain on the chest management
RR= 18x/min region Blunt chest trauma Blunt chest trauma
C : BP= 130/80 TKV : Non operative
mmHg Pain and bruise Blunt abdominal management Blunt abdominal
HR= 86 x/min on the abdominal trauma trauma
D: region Digestive :
GCS= 456 Non operative
isocoric pupils MOI : single management
motorcycle
accident
Pain and swelling CF distal third R Back slab CF distal third R
on the R forearm radius ulna ORIF planned radius ulna
(AO 22-A3 IC1 MT1
NV1)
M Reza / M /14 yo
M Reza / M /14 yo
M Reza / M /14 yo
Mega /F /22 yo/11372257 ISS : 4
ToAcc : 01.30 WIB RTS : 7.841
ToArr : 01.50 WIB PS :99.1 %
ProcStart : 02.30 WIB
ProcEnd : 02.15 WIB EVENING ADMISSIONS
Working Problem Solving /
Time General Status Problem Final Diagnosis
Diagnosis Management

01.50 A : Patent pain and open Open wound volar Analgetics Open wound volar
B : spontaneous wound on the L side L index finger Antibiotics side L index finger
symmetrical index finger Human anti tetanus (MT1 NV1)
RR= 16x/min imunoglobulin
C : BP= 130/70
mmHg Debridement
HR= 86 x/min MOI : injured by
D: knife Primary closure
GCS= 456
isocoric pupils
Mega /F /22 yo
Mega /F /22 yo
Mega /F /22 yo
THANK YOU