Laporan Jaga IGD P1 1 JULI 2020 Fix
Laporan Jaga IGD P1 1 JULI 2020 Fix
Laporan Jaga IGD P1 1 JULI 2020 Fix
1 Juli2020
Team Jaga:
REV/GAS/MET/AND-SAR/BAR/BAY/ZII
Supervisor:
dr. Isngadi, M.Kes, SpAn KAO
identity Budi Suryono/Lk/51th/11486990
Entry Diagnosis Acute chest pain
Exit Diagnosis Acute Myocardial infarction dt STEMI Inferior
Management Airway : Paten, Suara nafas tambahan -
Breathing : Nafas Spontan on o2 10lpm NRBM, Pengembangan
dada kanan = kiri
Circulation : Akral Hangat A. Radialis teraba, TD 140/100 mmHg
Dissability : Alert
Exposure : -
Entry P1 1/7/2020 jam 19.28
Exit P1 2/7/2020 jam 04.22
Transfer to: Cardio
duration in P1 9 jam
Problems Menunggu hasil eclia dan hasil konsul paru
department Cardio
involved Anestesi
identity Jumari/L/51th/11486992
Entry Diagnosis Acute Chest pain dt susp STEMI Anteroseptal
Exit Diagnosis STEMI Anteroseptal
Management Airway : paten,suara nafas tambahan -
Breathing : pengembangan dada kanan = kiri
Circulation : Akral dingin, CRT 2”, TD 110/76 nadi 90x/min
Dissability : alert
Exposure : -
Entry P1 1/7/2020 jam 20.20
Exit P1 1/7/2020 jam
Transfer to: CVCU
duration in P1 9 jam
Problems Tertunda hasil eclia dan hasil konsul paru
department Cardio
involved Anestesi
identity Moch soetedjo/Lk/70th/11486991
Entry Diagnosis Acute chest pain
Exit Diagnosis Acute Myocardial infarction dt STEMI Inferior
Management Airway : tidak paten, Suara nafas -
Breathing : pengembangan dada-
Circulation : Akral dingin, nadi tidak teraba, TD tidak terdeteksi
Dissability : unrespon
Exposure : -
Entry P1 1/7/2020 jam 19.05
Exit P1 1/7/2020 jam 19.25
Transfer to: -
duration in P1 15 menit
Problems Pasien meninggal dunia 19.20
department
involved Anestesi
identity Zakiyah/P/48th/11487001
Entry Diagnosis DOC dt hypovolemic shock ec hematemesis melena dd septic shock
Exit Diagnosis DOC dt hypovolemic shock ec hematemesis melena dd septic shock
Management Airway : paten,suara nafas tambahan -
Breathing : pengembangan dada kanan = kiri
Circulation : Akral dingin, CRT 2”, TD 124/72 nadi 100x/min
Dissability : respon to pain
Exposure : -
Entry P1 1/7/2020 jam 23.30
Exit P1 1/7/2020 jam
Transfer to: 26 HCU IPD
duration in P1 5 jam
Problems Tertunda transfuse prc 1 labu
department IPD
involved Anestesi
identity Musnandwi/L/36th/11487002
Entry Diagnosis CKS 225+Facial bleeding+alcohol ingestion
Exit Diagnosis CKS 225+Facial bleeding+alcohol ingestion
Management Airway : paten on ett no 7,5,nafas on ventilator mode psimv, p supp
12, flow trigger 2, rate 14, peep 5, oxygen 60%><rate 17, ppeak 16,
vte 380-410, Sp. O2 90-95%, vesikuler, Rh-, Wh-
Breathing : pengembangan dada kanan = kiri
Circulation : Akral dingin, CRT 2”, TD 109/75 nadi 120x/min
Dissability : unrespond
Exposure : jejas di kepala, dan kaki kiri
Entry P1 2/7/2020 jam 00.30
Exit P1 2/7/2020 jam
Transfer to: ICU
duration in P1 4 jam
Problems Tertunda menunggu hasil konsul dpjp bedah
department Bedah
involved Anestesi
identity Muari/L/56th/11487000
Entry Diagnosis CKS 225
Exit Diagnosis CKS 225
Management Airway : paten on OPA,
Breathing : pengembangan dada kanan = kiri, Sp. O2 90-95%,
vesikuler, Rh-, Wh-
Circulation : Akral dingin, CRT 2”, TD 180/100 nadi 100x/min
Dissability : respond to pain
Exposure : jejas di kepala, dan lutut kiri
Entry P1 2/7/2020 jam 00.25
Exit P1 2/7/2020 jam
Transfer to: 13 HCU
duration in P1 4 jam
Problems Tertunda menunggu hasil konsul dpjp bedah
department Bedah
involved Anestesi
identity Tumini/P/51th/11487007
Entry Diagnosis Cardiogenic dd Septic Shock
Exit Diagnosis Cardiogenic dd Septic Shock
Management Airway : paten ,vesikuler, Rh+ di apeks paru, Wh-
Breathing : pengembangan dada kanan = kiri
Circulation : Akral dingin, CRT 2”, TD 94/60on NE0,05
mcg/kgbb/min+dobutamine 5 mcg/kgbb/min nadi 99x/min
Dissability : alert
Exposure : -
Entry P1 2/7/2020 jam 02.00
Exit P1 2/7/2020 jam
Transfer to: 26 HCU
duration in P1 3 jam
Problems Tertunda menunggu hasil konsul dpjp crdio dan IPD
department Cardio
involved IPD
Anestesi