Download - SNT
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LAPORAN PAGI
Michael Raja P. Sitorus
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• Laporan Jaga Pagi tanggal 10 Desember 2015 (15.00-05.00)
• Dokter jaga : dr. Rani Adi• Koass jaga : Michael Sitorus• Rawat Inap : Satu Pasien• Rawat Jalan : Satu Pasien
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• sakit badan
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Primary Survey
• A :Bersih, Hambatan Jalan Nafas (-)• B : Laju Pernafasan 25x/min• C : Denyut nadi 78x/min, regular• D : GCS E4V5M6• E : (-)
• Pasien Prioritas 4
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IDENTITAS PASIEN
• Nama : Nn. L• Umur : 20 tahun• Jenis kelamin : Perempuan• Alamat : Jln. Komp. Sui Jawi Permai
B.20
• Masuk UGD pada tanggal 7 Desember 2015 jam 18.00
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KELUHAN UTAMA
• Luka Post KLL.
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RIWAYAT PENYAKIT SEKARANG
• Pasien post KLL 30 mnt SMRS, kecelakaan motor dengan truk. Os dtg dalam keadaan sadar, pingsan (-), mual(-), muntah(-), pusing(+) mengingat peristiwa kejadian (+). Nyeri dada(+) karena dada terbentur aspal terdapat luka lecet pada kaki kanan dan patah pada gigi seri pertama bagian atas
• Pusing (-), mual (-), muntah (-), nyeri kepala (-)• Riwayat pemberian obat (-)
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RIWAYAT PENYAKIT DAHULU
• Riwayat keganasan (-)• Riwayat DM (-)• Riwayat HT (-)
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PEMERIKSAAN FISIK
• Status Generalis– Sakit Ringan– Level kesadaran : E4V5M6– Tanda vital :• RR : 25x/min• Temprature : 36.60 C
• HR : 78X/min
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PEMERIKSAAN FISIK
• Mata : Konjungtiva anemis (+/+), sklera ikterik (-/-), Refleks pupil (+/+) isokhor,
• THT : Tonsil T1/T1, Faring hiperemis(-), • Leher : Pembesaran kelenjar limpa (-)• Paru : – Bentuk dada simetris, retraksi dinding dada (-),
sonor di kedua lapang paru. – Suara vesicular di kedua lapang paru(+), Whz (-),
ronkhi (-).
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• Jantung:– S1/S2, regular, gallop (-), murmur (-), split (-)
• Extrimitas:— hangat, merah, kering, cap refill time < 2 sec, edema (-)— kekuatan motorik
5 5
5 5
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• Abdomen:— massa (-), Sikatriks(-), datar, supel— BU = 10x/ min.— nyeri epigastrium (-), nyeri tekan (-)
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Lokalis
Vulnus ekskoriatum, P= 4cm. L=2 cm cm, nyeri (+), eritem (+), debris (+)
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Pemeriksaan Penunjang
• Leukosit : 11.100• HB : 12,8 gr/dl• HCT : 36%• Plt : 279000
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Pemeriksaan Penunjang
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Cue and Clue
• Pusing (+)• Vulnus ekskoriatum a.r.
tibia anterior dextra
• Cedera kepala ringan e.c. post KLL
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RENCANA PEMERIKSAAN
• Rawat Inap
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TERAPI
• IVFD RL 16 TPM• IV Ondancentron 4 mg 2x1• IV Ranitidine 150 mg 2x1.• IV Paracetamol vial 2x1