MORNING REPORT SURGERY DEPARTMENT DM E-17

21st

January 2013

Patients Identity
Name : Mrs. L Age : 36 year Sex : Girl ID : 082597 Religion : moslem Address : Dsn Ringin Ds Payaman Kec Solokuro

Summary of Database
Chief complaint : abdominal discomfort Present illness history: Patient complained abdominal discomfort since a day before hospitalized. Patient felt her stomach bloated. She couldnt flatulent. 3 days before hospitalized, patient got diarrhea for 2 days. The diarrhea was more than 8 times a day. It was bloody and slimy. Then, patient went to midwife and got anti-diarrheal drugs, but patient forgot the name. Her abdominal discomfort begun since the diarrhea stopped after consume the drugs. Patient also felt nausea and vomit. She vomitted more than 5 times a day. Even, she was getting vomit in emergency room of RSML. Her appetite was bad since she got sick. Shiver (-).

 Past illness history: (-) Family illness history: (-)

Patients Status
Vital signs General appearence, awareness, GCS Weak , CM, 456

Blood Pressure
Pulse Rate Temperature Respiratory Rate

102/60 mmHg
70x/mnt 37,0 C 24X/mnt

Phisical Examination
Head : An -/- ; Ict -/- ; Cya -/- ; Dysp Thorax
Symmetric -, retraction Pulmo : RR: 24x/m, Ves/ves, Rh-/-, Whz-/ Cor : HR: 70x/m, reg (+) S1S2 tunggal, M-

 Abdomen
Inspection : Slight distended Palpation : soefl, pain (+) in all quadran abdomen, H/L just palpable Auskultation : BU (+) Perkution : met (+)

Extremity : acral warm and dry Rectal toucher

Tonus of spinchter ani: good Mucosa: slick Painless The content of ampula recti was blank Feses (-), blood (-), slime (-)

LABORATORY FINDING
Diffcount Hct Hb Leukosit Trombosit Clorida Serum Kalium Serum Natrium Serum Urea Serum creatinin RBG : 0/0/61/33/6 : 36,2 % : 11.9 mg/dl : 8.300 : 200.000 : 105 : 4,0 : 135 : 19 : 0,8 : 95

Clue and cue

Woman , 36 years Abdominal discomfort Bloated stomach Flatus (-) Nausea Vomit Post bloody and slimy diarrhea Consume anti diarrheal drug

Problem List
Bloated stomach Flatus (-) Nausea Vomit

Initial Diagnose
Ileus obstructive

Planning of diagnose
CBC BOF SE

Planning of therapy
IVFD Asering 1500 cc/ 24 hour Inj. Metamizole 3x1 Inj ranitidin 2x1 Inj metoclopramid 3x1 prn Inj alinamin F 2x1 NGT Antibiotik

Monitoring
Vital signs Patients complain

Prognosis
Dubia ad bonam