Morning Report

Departement of Surgery
February 15rd 2017
List OB Bedah 17/2/2017

1. Ny. Nafiah /50 th DOA

2. Tn marlan / 60 th DOA
3. Sumiyani / 55th peritonitis, hyponatremia, hiperglikemia shofa 11
4. Sdr yusuf/ 14th CF ulna 1/3 proksimal sin type transfers arofah 1
5. An Hanafi / 15th ilius obstruktif shofa 12
6. An ines / 14th CF humerus 1/3 proksimal dex, type obliq shofa 14
7. Tn. Lucito / 27 th OF tibia 1/3 medial dex type buterfly, OF fibula 1/3
medial type segmental.
Identity

Name : Ny S
Age : 55years old
Occupation : -
Address :paciran , Lamongan
Admission : February 17nd, 2017 at 20.00 PM
Anamnesis

Chief Complain:
abdominal pain
Present History:

Patient came to emergency room RSML with chief complaint of

abdominal pain since yesterday. The patient felt persistent pain in the all
abdominal area. The pain was not relieved with rest. Shifting abdominal
pain denial. The patient also had nausea, vomiting twice a day contain
yellowish clear fluid. . The Last defecation yesterday with mushy
consistency. Patient also can not flatus since yesterday . urinate was
normal limit. Loss of appetite +. Fever -
 Past Illness History:
Alergi DM ? HT ?
Family History:
-
Vital Signs

BP
139/71mmHg
Pulse
130x/min
Temp
36.8C
RR
25x/min
Primary Survey

A: clear, gargling (-), snoring (-), speak fluently (-), potential obstruction (- )
B: spontaneous, RR 28x/min, ves / ves, rh -/-, wh -/-, SaO2 100% without O2
support.
C: extremity WDR, CRT <2, N 130x/min, BP 139/71 mmHg
D: GCS 456, lat-, PBI 3mm/ 3mm, LP +/+
E: temp 36,8 C
 GENERAL STATUS
General condition : weak
GCS : 456
H/N : a -/i-/c-/d-
lymph node enlargement at neck (-)
JVP within normal limit
Thorax
Inspection
Symmetrical, retraction -
Palpation
Thrill -, fremitus WNL
Percussion
Lungs: sonor / sonor
Cor: N
Auscultation
Lungs: ves /ves, rh -/-, wh -/-
Cor: S1S2 single, M -, gallop -
Abdomen
Inspection
Distended , abdominal breathing.
Auscultation
Met -, decrease bowel sound
Palpation
Pain (+ )all regio abdomen . Defans muscular + Liver/Spleen within normal
limit
Percussion
Tymphany.
Extremities
Inspection
Clubbing fingers (-), icteric (-), cyanosis (-), edema (-)
Palpation
Acral: warm dry red, CRT <2
CLUE AND CUE

female , 55y.o.
abdominal pain
All abdominal area
Distended
Pain (+ )all regio abdomen
decrease bowel sound
Defans muscular +
 Initial Diagnose
Susp. Peritonittis

Planning diagnose
BOF LLD
USG
DL
GDA
Elektrolit
Thorax
Laboratory Examination
GDA 713
Complete Blood
K5
Count
Leukosit 12,2 Na 126
Neutrofil 36 Cl 93
Limposit 1,7
Monosit 9,0
Eosi 0,2
Basofil 2,9
Eritrosit 4,5
Hb 11,2 g/dL
Hematokrit 35,5%
Mcv 78,9
Mch 24,9
Mchc 31,50
Trombosit 329.000
LED 1/ 2 = 100/110
Thorax USG- BOF LLD
Diagnose

Peritonitis
Hyponatremi
Hiperglikemia
 Planning Therapy
O2 nasal 2 lpm
Pasang DK- NGT
Inf. PZ Loading 1000cc 1500cc/24 jam
Inj. Terfacef 2x1 gr
Inj metronidazol 3x500mg
Inj. Na. Metamizole 3x1gr iv
Inj. Ranitidine 2x50 amp iv
Inj. Ceteron 8 mg prn
Insulin bolus 4iu / jam ceek GDA tiap 4 jam
Consul Surgeon