bakterial vaginitis
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Morning Report11th 12thof September
2014
Co-ast : Dwi Permana Putra
Doctor in charge
1 !r Ratih
2 !r "i#i!
$ !r Rio
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%!entit& '1(
)ame : Ms )ur*ae*a
Se+ : ,ema*e
ge : .$ &o
Re*igion : mos*em
/ccupation : housewife
!!ress : Parit Mamur St Siantan i*ir ospita*ie! : 11thof /ctober 201.3 at
1000 pm
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Primar& Sur#e&
irwa& : 5oo : agitation '-(3 sianotic '-(3 retraction '-(3
musc*e use! on breathing '-(
5isten : snoring '-(3 gurg*ing '-(3 crowingsoun! '-( 6 stri!or '-(
,ee* : 7rachea !e#iation'-(
8reathing : respiration rate 24+9menit3 t&pe of
breathing ab!ominothoraca*3 7hora+s&mmetrica**& e+pansion '(3 chest pain whi*ebreathing '(3 percussion sonor '(3 5ung soun!#esicu*ar '9(
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Circu*ation : b*ee!ing '-(3 pu*se;;+9min regu*ar3 pa*e of the sin '-(3b*oo! pressure 1n#ironment : -
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Chief comp*aint Pain on the be*ow *eft *eg when mo#ing
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istor& of present i**nesses
Patient came to the emergenc& !epartment at1000 pm accompanie! b& her fami*& with usingcar 12 hours before arri#ing in hospita* 8eforethat3 the patient ha! an se*f-acci!ent !ue to s*ip
of her motorc&c*e tire when she wante! to turn tothe *eft er *eft *eg was struc !own a coup*e ofminutes an! su!!en*& she fe*t her be*ow *eft *egrea**& painfu* an! !i?cu*t to mo#e it nother
comp*aint such as hea!ache '-(3 !iiness '-(3nausea '-(3 #omitting '-( Me!ica* histories such ashipertension '-(3 !iabetes me**itus '-(3 uric aci! '-(3an! cho*estero* '-(
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**erg& : asthma '-(3 a**ergic onme!ications '-(
Me!ication :there was no me!icationafter in@ur&
Past %**ness: trauma '-(3 surger& '-(
5ast Mea* : - >#ent : -
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Ph&sica* >+amination
"ita* Signs : Aenera* con!itions : fe*t pain
wareness : Compos Mentis
8*oo! Pressure : 1
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ea! to 7oe >+amination
ea! 6 ma+i*ofacia*
%nspection : *aceration '-(3 b*ee!ing '-(3 contusio '-(3fracture '-(3 hematoma '-(
Pa*pate : crepitation '-(3 ten!erness '-( !e+tra
>&e: b*ee!ing '-(3 penetrating in@ur& '-(3 soft*enseuse! '-(3 optic ner#e !amage '-(3 anemia '-(3 icteric'-(
)>7 : 8*ee!ing '-(3 unstea!& teeth '-(3 !entures
use! '-(3 batt*e sign '-( )ec : h&peremia '-(3 !eformit& '-(3 swo**en '-(3
subcutaneous emph&sema '-(3 trachea !e#iation'-(3musc*e use breathing assistance '-(3ten!erness '-(
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Chest : s&mmetric '-(3 !eformit& '-(3h&peremia '-(3 scar '-(3 musc*e use breathingassistance '-(3
Cor %nspection : ictus cor!is is in#isib*e
Pa*pasi : %ctus cor!is fee* at S%C 4 mi!c*a#iu*asinistra *ine
Perusi : upper site S%C 2 Mi!*a#iu*as sinistra*ine3 right site at S%C 4 Parasterna* sinistra *ine3*eft site @antung S%C 4 Mi!c*au*a sinistra *ine
uscu*tation : Murmur '-(3 Aa**op '-(
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Paru %nspection : e+pansion of chest '(3
breathing pattern thoracoab!omina*3 scar
'-(3 musc*e use breathing assistance '-( Pa*pation : subcutaneous emph&sema '-(3
ten!erness '-(3 crepitation '-(
Percussion : sonor '(
uscu*tation : #esicu*ar '9(3 crac*es'-(3 wheeing '-(
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b!omina* : %nspection : =at 3 scar '-(3 h&peremic '-(3
tumor '-(
Pa*pation : ten!erness'-(3 hepar !an *ien'-(3 tumor '-(
Percussion : t&mpanic '(
usu*tasi: meta**ic soun! '-( norma* Aenita* : unperforme!
nus : unperforme!
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>+tremities : a9r ma*eo*us me!ia*issinistra 5oo :Deformit& '( on the *eft *eg3
bone e+posure '( of *eft tibia
,ee* : crepitation '(3 ten!erness '(
Mo#e : R/M of an*e @oint was
*imite! !ue to pain
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>+remities : a9r !igiti . manussinistra
5oo : !eformit& '(3 boneexposure '-(3 b*ee!ing'(3 #u*nusamputatun !ista* '(
,ee* : 7en!erness'(3 crepitation '-(
Mo#e : =e+ion '(3 e+tension '(
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Resume
Patient came to the emergenc&!epartment at 1000 pm accompanie! b&her fami*& with using car 12 hours before
arri#ing in hospita* 8efore that3 thepatient ha! an se*f-acci!ent !ue to s*ip ofher motorc&c*e tire when she wante! toturn to the *eft er *eft *eg was struc
!own a coup*e of minutes an! su!!en*&she fe*t her be*ow *eft *eg rea**& painfu*an! !i?cu*t to mo#e it
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,rom #ita* sign3 genera* con!ition wasfe*t pain3 wareness was composmentis3 8*oo! pressure 1
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Ph&sica* e+amination number .thofthe nger
Deformit& '(3 b*ee!ing '(3amputation on the !ista* of number.thof the nger3 ten!erness '(
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oring !iagnose!
/pen fracture Ara!e %%% a9r 19$ !ista*tibia sinistra
#u*nus amputatum a9r !ista*pha*angea* !igiti " manus sinistra
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orup
Comp*ete b*oo! count
8C : 10;00
A8: 1$2 P57 : 1;
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Rontgen photo of an*e @oint P 6
5eft *atera*
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Rontgen photo of *eft han! P 6
*atera*
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7reatment
Rencana operasi !ebri!ement /R%,
Persiapan operasi persetu@uan tin!aan3onsu* anestesi3 *apor /E3 puasa < @am
sebe*um operasi3 e*astic #erban sufratu**e Me!iamentosa:
%F,D Ringer 5atat 20 tpm
/pimer 1 gr912 @am %" 'sin test(
Eetoro*ac $0 mg9; @am %"
Raniti!ine 2. mg912 @am %"
7S 03. mg %M
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7han &ou
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%!entitas
)ama : 7n DE
Genis Ee*amin : 5ai-*ai
Fsia :1. tahun
gama :%s*am
Peer@aan : Pe*a@ar
*amat : G*n Ehatu*istiwa Ag Darma
Putra Ma@u )o 1stremitas : e!ema '-(3 CR7 H 2I3sianosis '-(
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Resume
Pasien !atang e %AD RFME%7 pa!a puu*22$0 !iantar o*eh a&ahn&a !enganmenggunaan motor serta !a*am ea!aan!igen!ong o*eh a&ahn&a pa!a saat masu %AD!iarenaan merasa n&eri pa!a perut bagiantengah wa*n&a3 pasien menga*amiece*aaan motor !imana menga*amitabraan !engan motor *ain !ari arah !epanPasien ti!a memaai he*m3 !an ter@atuhtersungur earah !epan sehingga bagianperut pasien membentur stang motor
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Pasien sempat pingsan H 10 menit3 mua* '(3muntah 2+ isi maanan !an berwarna se!iitemerahan Pasien @uga merasaan *emah3 sertamengantu3 88 '( norma*3 8E '( norma* Pa!a
pemerisaan si !itemuan teanan !arah1209
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Diagnosis Eer@a
7rauma 7umpu* b!omen
"u*nus esoriatum a9r suprapubic
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Pemerisaan Penun@ang
Darah 5engap
Frina*isis
FSA b!omen
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Darah 5engap
8C : 1;400
A8: 1$0
P57 : 2J;000
R8C : 4B.
ADS: 110 mg9!*
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Frina*isis
arna : uning eruh
Ph : B30
Protein : '-(
Re!usi : '-(
8i*irubin : '-(
Frobi*in : '-(
>ritrosit : '(95P80-1
5eu : '( '$-.(0-.
>pite* : '( '(
Si*in!er : '-( '-(
Erista* : '-( '-(
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FSA b!omen
epatorena* : epar ti!a membesar3 parenim homogen&3apsu* inta3 !utus bi*iaris !an estrahepar ti!a me*ebar3ti!a tampa massa 7i!a tampa o*esi cairan !i seiatarn&a
Sp*enorena* : *ien ti!a membesar3 apsu* inta3 parenimhomogen
Ain@a* anan iri: ti!a membesar3 parenim homogen&3apsu* inta3 batas parenim !engan centra* echo comp*e+
@e*as Sistem pe*#oa*ises ti!a me*ebar 7i!a tampa o*esicairan
"esia urinaria : ti!a terisi penuh3 !in!ing ti!a meneba*3
regu*ar3 batu '-(3 ti!a tampa o*esi cairan Eesan : 7i!a tampa o*esi cairan !i hepatorena*3 sp*enorena*
retro#esia 6 scanning hepar3 *ien3 e!ua gin@a* gin@a* !an #esiaurinaria ta tampa e*ainan
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Diagnosis
7rauma tumpu* ab!omen SuspRuptur Ge@unum
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Diagnosis 8an!ing
Ruptur i*eum
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Penata*asanaan
Persiapan *aparotom& %nforme! consent
Persetu@uan tin!aan
Puasa ; @am sebe*um operasi pasang )A7
%n@esi Ceftria+one 2 gram Metroni!ao*e infuse .00 mg'$0 menit sebe*um !i*auan operasi(
7ata*asana !i ruangan : Pantau tan!a-tan!a #ita*
Diet cair
%nfuse R5 24 tpm %n@ Cefota+ime $ + 2 gr
%n@ 7oramin $ + $0mg
%nf Metroni!ao*e $ + .00 mg
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7erima Easih
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%!entitas
)ama : 7n nggiawan
Genis Ee*amin: 5ai- *ai
Fsia : 24 tahun
gama : %s*am
Peer@aan : 7)% D
*amat : G*n !i Sucipto EM< SuiRa&a
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)M)>S%S 'utoanamnesis pa!atangga*: 11 /tober 201.3 puu*:11.$ %8(
E>5F) F7M : su*it 8E
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R%K7 P>)KE%7 S>ER)A
7n nggiawan3 24 tahun Datang !engane*uhan su*it 8E se@a 1 hr smrs3 Su*it 8E
!irasaan tiba-tiba 8E !irasaan ti!atuntas3 seperti menetes3 8E ber!arah '-(38E berpasir '-(3 8E !irasaan se!iitin&eri Demam '-(3 mua* '-(3 muntah '-(3
ma9mi '9( norma*3 88 norma* Riwa&atDM '-(3 o*estero* '-(3 asam urat '-(3 7 '-(3riwa&at e*uhan serupa sebe*umn&a '-(
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R%K7 E>8%S) Pasien men&anga* mengonsumsi a*coho*
!an meroo '(
R%K7 S/S%5 >E/)/M%: Pasien sehari-hari merupaan seorang
tentara 7)% D
R%K7 E>5FRA:7i!a a!a anggota e*uarga &ang memi*ii
e*uhan &ang sama !engan pasien
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P>M>R%ES) ,%S%E
7an!a "ita*: Eea!aan Fmum : 7ampa tenang
Eesa!aran : Compos Mentis '>4MB".(
7eanan Darah: 1209J0 mmg ,reuensi )a!i :
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Status Aenera*is
Eepa*a: )ormocepha*i '(3Mirocepha*i '-(3Marocepha*i '-(
Mata : Eon@ungti#a anemis '-9-(3
S*era iteri '-9-( 77 : De#iasi septum '-(3 secret '-9-(3
tonsi* 71971 '(3 ,aring iperemis '-(
5eher : Pembengaan EA8 '-( )&eripa!a EA8 '-(
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DD
Gantung : %tus or!is ter*ihat !i S%C . *inea
mi!c*a#icu*a sinistra 8atas @antung anan !i S%C 4 *inea
parasterna*is !e+tra
8atas @antung iri !i S%C . *inea
mi!c*a#icu*a sinistra
Pinggang @antung !i S%C 2 *ineaparasterna*is sinistra
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Paru: 8entu !a!a norma* '(3 barre* chest '-(3
pectus esa#atum '-( pectus
escarinatum '-( Pergeraan !a!a simetris '(3 !a!a
tertingga* '-(
Perusi sonor '(3 n&eri eto '-(
S)D : "es '9(3 Rh '-9-(3 h '-9-(
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b!omen %nspesi : !atar '-(3 cembung '-(3
ceung '-(3 *ua beas operasi '-(3 massa'-
usu*tasi: 8ising usus '( 10 +9menit3bruit '-(
Pa*pasi : )&eri tean '( a9rsuprapubic3 Soepe* '(3 hangat3 b*asspenuh
Perusi : )&eri eto C" '-9-(
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Aenita* : Penis norma*3pembesaran srotum '-(3 hiperemis'-(
nus : !i*auan R73 hasi*hemoroi! '-(3 sngter ani uat3muosa *icin3 no!u* '-(3 pembesaran
prostat '-( >stremitas : ra* hangat3 CR7
H2I3 e!ema '-9-(
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Resume
7n nggiawan3 24 tahun Datang!engan e*uhan su*it 8E se@a 1 hrsmrs3 Su*it 8E !irasaan tiba-tiba
8E !irasaan ti!a tuntas3 sepertimenetes3 ma9mi '9( norma*3 88norma* Pemerisaaan si
!itemuan teanan !arah 1209J03na!i
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Diagnosis Eer@a
Retensio urin ec susp 8atu sa*uranemih
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Pemerisaan Penun@ang
asi* 5aboratorium
Darah 5engap
5eucoc&te :
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FSA b!omen
Ain@a* anan iri: ti!a membesar3 parenimhomogen&3 apsu* inta3 batas parenim!engan centra* echo comp*e+ @e*as Sistempe*#oa*ises ti!a me*ebar ti!a tampa o*esi
cairan "esia urinaria : ti!a terisi penuh3 !in!ing
ti!a meneba*3 regu*ar3 batu '-(3 ti!a tampao*esi cairan
Prostat : ti!a membesar3 parenim homogen&
Eesan : Scanning kedua ginjal, vesikaurinaria dan prostat tak tampak kelainan
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Diagnosis
Retensio urin ec Susp 8atu Fretra
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Diagnosis 8an!ing
8atu ureter
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Penata*asanaan
%nfus R5 20 tpm
%n@ etoro*ac $ + $0 mg
%n@ Cefota+ime 2 + 1 gr
arna* tab*et 1 + 034 mg
Frinter apsu* 1 + 400 mg
Pasang DC