Morning Report CFR 1/3 Distal Os Fibula D

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  MR PASIEN IGD Rabu, 14februari 2018 1  IDENTITAS ■ Nama : Nn. K ■ Umur :21tahun ■ Jenis Kelamin : Perempuan ■ Agama : Islam ■ Alamat :- ■ Jam datang : 16/02/201818.43 ■ Jam pemeriksaan: 13/02/2018 18.45   KU:Jatuhdaritangga  RPS:PasiendatangkeIGDdengankeluhanjatuhdaritangga sejaka2hariyanglalu.Awalnya,pasienturundaritangga,kemudianterpelesetpadatigatanggaterakhir.Lukatanpadisertaipendarahan,pasientidakmengeluhmual,muntah,  pusing,pingsan,panas,mengantuk.  RPD:keluhanyangsama(-)  Riw.alergiobat:(-)  RPK:keluhanyangsama(-) 3 Anamnesis   Airway dan C-spine immobilization : bebas  Breathing : spontan RR=20x/mnt  Circulation : Baik Nadi : 90x/menit CRT < 2 detik  Disability : kesadaran/GCS : CM/ 4-5-6Pupil : bulat isokor +/+, reflek cahaya +/+  Exposure : Suhu : 35.6 0 C 4 Primary Survey
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