Professional Documents
Culture Documents
Digestive Surgery : -
Urology Surgery : -
Neuro Surgery : -
Oncology Surgery : -
Orthopaedy : 1
Total : 2
Patient List
No Identity Admission to ER Diagnose Treatment
1. Tn. Sarinoe /50 y.o./ Jan 01th 2019 Vulnus Sclopetorum VS Obs
RM. 31.12.88 14.30 Regio Thoracal (S) IVFD RL
Pneumotorax (S) Cek DL
Emfisema Subkutis Analgetic
Thorax x-ray
Co to Sp.B :
-Pro WSD Rujuk ke
Banjarmasin.
- Inj Tramadol 100mg
- Inj Ceftriaxone 1gr
- Inj Tetagam 250 IU
Patient List
No Identity Admission to ER Diagnose Treatment
2. NY. Silvia/ 31 y.o Jan 01th 2019 Close Fracture Tibia (D) VS Obs
RM 31.12.96 16.20 WIB Vulnus Excoriasi IVFD RL
Analgetic
xray
Consult to orthopedic
- Spalk
- Kompres
- Inj. Ketorolac
3x30mg
NY. Silvia/ 31 y.o
RM 31.12.96
Chief Complain:
Nyeri dan bengkak pada kaki kanan.
Secondary survey
A = Allergy (-)
M = Medication (-)
P = Past illness (-)
L = Last meal 2 hours before accident
E = Environment on the street.
• Head : brill haematoma( -/-), hematoma (-)
• Eye : Anemic conj. (-/-), icteric sclera (-/-),
Head • Mouth : moist mucous membrane,
• Neck : Increasion level of JVP (-)
General Status
• I : symmetric respiratory movement, no retraction, bruises (-)
• P : symmetric VF
Chest • P : sonor at all lung fields
• A : symmetric VBS, right =left, rhonchi (-), wheezing (-)
•Consult to orthopedic
- Spalk
- Kompres
- Inj. Ketorolac 3x30mg
Tn. Sarinoe /50 y.o./
RM. 31.12.88
Chief Complain:
Tertembak Senapan angin.
Secondary survey
A = Allergy (-)
M = Medication (-)
P = Past illness (-)
L = Last meal 4 hours before accident
E = Environment on the home.
• Head : brill haematoma( -/-), hematoma (-)
• Eye : Anemic conj. (-/-), icteric sclera (-/-),
Head • Mouth : moist mucous membrane,
• Neck : Increasion level of JVP (-)
•Co to Sp.B :
•-Pro WSD Rujuk ke Banjarmasin.
- Inj Tramadol 100mg
- Inj Ceftriaxone 1gr
- Inj Tetagam 250 IU