Você está na página 1de 34

Duty report

Sunday, 1st March 2015


19.00-05.00

Consulent : dr. Toni SpB


Resident : dr. Adrian, dr. Rifki, dr. Budi
Coass : Ratu, Nilam, Putra, Icha, Yitta,
Anas
Stagnant patient : 7 patient
New patient : patient
Operation : patient
Stagnant patient
1. Mrs. Ratih/ 74 yo/ 486380/ abcess ulcus diabetic right
leg/ incision
2. Mr. Wirasto/54 yo/ 1352350/ selulitis pedis dextra, CHF,
AKI/ wound dressing
3. Mr. Ishak Ahmad/ 17 yo/ 1352371/ acute appendicitis/
appendictomy cito
4. Vicha/ 3 yo/ 1352398/ vulnus laceratum superior labium
and maxillary + fracture dentoalveolar/ wound toilet +
consultation to plastic surgery
5. Mr. Mintra/ 62 yo/ 1352392/ right hernia scrotalis
irreponible/ herniotomy cito
6. Sahila/ 2 yo/ 1352398/ combustio grade II A TBSA 15%/
wound dressing
New patient
1. Mr. H. Mamat/ 59 yo/313210/ multiple
complete fracture os costae 5,6,7
posterior dextra/ conservative, home care
2. Mr. Djuhari Mamat/ 55 yo/1352414/
Vulnus laceratum pedis dextra/ WT,
hecting
3. Mr. Nasrullah/34 yo/1248890/ suspect
Acute Appendicitis, DHF/ Conservative,
consultation to internist for DHF
treatment
Mr. Djuhari Mamat/ 55 yo/1352414/
Vulnus laceratum pedis dextra
OPERATION
Case Illustration
IDENTITY
Name : IA
Age : 17 yo
Sex : Male
Occupation : Student
Anamnesis
Auto anamnesis was done on 1st of March, 2015

Chief Complaint

Lower right abdominal pain since 2


days before hospital admission
History of present illness
Patient complaints of acute abdominal pain which started from 2 days
before hospital admission. The pain felt continously until he feel to
twining. Nausea (-), vomitting (-), abdomen bloating (+), fever (-),
diarrhea (+) from 2 days ago, frequency 2-3 times every day. Urinate
normal.
Past medical history Surgical history (-)
Allergy (-)
Asthma (-)

Family medical history

Allergy (-)
Asthma (-)
Physical Examination
General state : Moderate sickness
Awareness : Compos mentis
Vital sign :
Temperature: 37C
Pulse: 106x/min
Respiration: 20x/min
Blood Pressure: 126/74
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 (-)
Preoperative
Laboratory (1/3/2015)
Test Result Normal value

Hb 15 gr/dl 11,7- 15,5


Haematocyrit 46 % 33-45
Leucocyte 18.000 5000- 10000
Trombosit 371.000 ribu 150 ribu- 440 ribu
GDS 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 14,3/40,1 11,3-14,7/ 27,4-39,3


Urinalysis Albumin (Trace)
Blood/Hb (Trace)
Chest
Rontgen

Normal heart
Lungs :
infiltrates in left
and right lungs,
especially in
both apex.
Sugestive TBC
Working Diagnosis

Acute Appendicitis

Treatment
Appendectomy cito
Consultation to Pediatric
Antibiotic Ceftriaxone 2x1 gr,
Metronidazole 3x500 mg
Fasting
Operation Report

1.Patient lay in spinal anesthesia on operation table in supine


position.
2.Aseptic and antisepsis procedure was done at the operation field
and the surrounding area
3.Oblique incision perpendicular to McBurneys into cutaneous,
subcutaneous, fascia, muscle separated by blunt
4.When the peritoneum was opened, nothing came out from it
5.Identification of the cecum, appendix located retrocecal
intraperitoneal, hyperemia (+), fecalith (-), perforation (-),
appendix size 5x1x1 cm
6.Appendectomy was done, appendix stump embedded in the
cecum with tobacco sacc suture
7.The abdominal cavity was being cleansed using a sterilized
saline
8.Control bleeding
9.The surgical wound were sutured layer by layer
Operation finished
10.
Intra operative
Post operative
Post-operation Instruction
Observe vital signs
Normal diet when fully awake
IVFD RL : D5 = 2 : 1 / 24 hours
Ceftriaxone 2x1 gr i.v
Ketorolac 3x30 mg i.v
Ranitidine 2x50 mg i.v
Hernia scrotalis
PATIENTs IDENTITY
Name : Tn. Mintra
Age : 62 yo
MR : 1352392
Address :

Anamnesis was done on 1st march


2015
History of Present illness
Chief complaint :
Theres a lump in the right scrotum that have
been 5 years. The lump appears all of sudden when
patient doing an activity and vanish by it self by
rest, there was no pain when the lump appears
back then. But now, the lump dont want to back by
it self by rest and by patient force, and feeling of
heaviness and aching. The other complaint, theres
an abdominal pain. Nausea and vomiting are
present. Also feeling heavy when inhale. Defecation
normal in the morning, mixtion spontan, clear.
Past medical history Surgical history (-)
Allergy (-)
Asthma (-)

Family medical history

Allergy (-)
Asthma (-)
Physical Examination
General state : Moderate sickness
Awareness : Compos mentis
Vital sign :
Temperature: 37C
Pulse: 92x/min
Respiration: 20x/min
Blood Pressure: 90/70
Head : normocephal, no deformity
Eyes : conjungtiva pale -/-, icteric sclera -/-
Lungs : normal breathing sound, rhonki -/-, wheezing -/-
Heart : heart sound is normal, murmur (-), gallop (-)
Abdomen : flat, bowel sound (+) normal, palpable pain (-),
hepar lien non palpable
Extremitas : edema on joints or ankles are absent
DRE : tone of the anal sphincter good, prostate non
palpable, tenderness (-), stool (-), mucous (-), blood (-)
Local State
Standart value Result

Darah rutin
Hemoglobin 13,2-17,3 15 g/dL
Hematokrit 33-45 44 %
Leukosit 5.000-10.000 11800/uL
Trombosit 150.000- 267.000/uL
440.000
Fungsi Ginjal
Ureum darah 20-40 34 mg/dL
Creatinin darah 0,6-1,5 0.9 mg/dl

Diabetes
Gula darah Puasa 80-100 95 g/dL
Standart value Result

Fungsi Hati
SGOT 0-34 19 mg/dL
SGPT 0-40 19 mg/dl

Elektrolit
Na 135 147 133
K 3.1-5.1 4.8
Cl 95-108 103
Hemostasis
APTT / control 28.8/31.5 =
0.89
PT / control
12.1/13.5 =
INR
0.89
0.87
Chest
Rontgen

Sight
cardiomegali
Lungs :
infiltrates in
basal right
lungs. Sugestive
Pneumonia
Diagnosis
Hernia scrotalis dextra irreponible
Treatment
Pro herniotomy cito
Ceftriaxon 1x2 gr
Ketorolac 3 x 30mg
Omeperazole 2 x 40 mg
Operation Report
Patient lay in spinal anesthesia
Aseptic and antisepsis eprocedure
was done at the operation field and
the surrounding area
Intruction post op