Duty Report

th
Friday, April 4 2015
Consulent Onsite : dr. Simangungsong, Sp. B
Resident Onsite : dr. Odette, dr. Sari, dr. Stefanny
Koas
: Ferry - Anas - Yita

MELAPORKAN
Stagnant patient : 6 patient
New patient
: 9 patient
Operation
: 1 patient

Stagnant patient
1. Mr. taufik syarif/ 59yo/ ulcus DM pedis sinistra
with ascending infection pro debridement,
HCU (-)
2. Mr. entong/ 55yo/anemia gravis ec hemoroid
interna post transfusion, corection hcl
Hb=4,3
3. Mrs. Hahyanti/ 51yo/anemia on ca mamme
post tranfusion 750cc check laboratory
peripheral blood
4. Mr. sanusi/50yo/urin retension ec susp BPH
catheter, cystostomy guiding USG post
cystostomy evaluation on ER
5. Mr. Aca syanti/76yo/hernia scrotalis ireponible
conservative, home care
6. Mr. jawawi/18yo/Acute appendicitis pro
appendiktomy OK

New patient
1. Mr. Eko budi/20yo/illeus obstrutktif refused to insert
NGT and catheter forced home care
2. Mr. dafa/12yo/ VL regio dorsum pedis hecting +
wound toilet
3. Mr. Agustinus/34yo/VL regio pattela dx hecting +
wound toilet
4. Ms. Shana Adela/20yo/acute gastritis + chronic
appendisitis home care
5. Mr. Hendro/33yo/contusio tissue of thorax sinistra
home care. Assesment dr. Simangunsong, Sp. B
6. Mr. Daffal foat/13yo/ gastritis home care
7. Ms. Nurindah/17yo/VL labialis inferior ec got kicked by
her friend when karate wound toilet + hecting
8. Mr. Rohmani Ali/52yo/Abcess pedis sin abcess
insicion
9. Mr. Ilhamsyah/22yo/mild head injury + VL regio
frontalis wound toilet + hecting

Mr. dafa/12yo/ VL regio dorsum

pedis hecting + wound toilet

Ms. Nurindah/17yo/VL labialis inferior

ec got kicked by her friend when
karate wound toilet + hecting

Mr. Rohmani Ali/52yo/Abcess pedis sin

abcess insicion

Mr. Agustinus/34yo/VL regio pattela dx

hecting + wound toilet

Mr. Ilhamsyah/22yo/mild head injury +

VL regio frontalis wound toilet +
hecting

OPERATION

IDENTITY
Name
Age
Sex
Occupation

: Mr. Jawawi
: 18 yo
: Male
: Student

 Chief complaint:
lower right abdominal pain since 1 day befor hospital admission
History of Present Illness:
The patient came to the RSF on Friday 3 April 2015 with
complaints of lower right abdominal pain since 1 day befor
hospital admission. Abdominal pain is felt sharp, continuous,
reduced in sleeping position, localized to the right lower
stomach, appear suddenly. In addition to pain patients also
complain of fever since 2 days before hospital admission, said
the patient had a high fever but didnt measured it by
thermometer, but then fever gets down when the patient
comes to the ER. The patient also had nausea and vomiting,
frequency 2-3 times/day

Physical Examination

General state
: Moderate sickness
Awareness
: Compos mentis
Vital sign :
Temperature: 37C
Pulse: 88x/min
Respiration: 20x/min
Blood Pressure: 151/71 mmHg

Head
: normocephal, no deformity
Eyes
: conjungtiva pale -/-, icteric sclera -/Lungs
: normal breathing sound, rhonki -/-, wheezing -/Heart
: heart sound is normal, murmur (-), gallop (-)
Abdomen : tenderness in the right iliac fossa, local guarding
and rebound tenderness at the McBurney point, muscular
defense (-), psoas sign (-), rosving sign (+), obturator sign (-)
Extremitas: edema on joints or ankles are absent
DRE
: tone of the anal sphincter good, prostate non
palpable, tenderness (-), stool (-), mucous (-), blood (-)

Test
Hb
Haematocyrit
Leucocyte
Trombosit
GDS

Result

Normal value

15 gr/dl

11,7- 15,5

46 %

33-45

18.000

5000- 10000

371.000 ribu

150 ribu- 440 ribu

96 mg/dl

70-140

Natrium

138 mmol/l

135-147

Potassium

4,76 mmol/l

3,1-5,1

Chloride

103 mmol/l

95-108

Diff count

0/1/81/13/4

PT/APTT
Urinalysis

14,3/40,1
Albumin (Trace)
Blood/Hb (Trace)

11,3-14,7/ 27,4-39,3

Working Diagnosis
Acute Appendisitis

Treatment
Fasting
Appendectomy cito
Consultation
to
Interna,
anesthesi
Antibiotic Ceftriaxone 1x2 gr,
Ketorolac 3x30mg
IVFD RL 20 dpm

THANK YOU