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Morning Report

Departement of Surgery
F24
21 Nov 2016
Patient List
Nn. Damayanti post KLL RJ
Tn. Abdul Kholiq colic abdomen RJ
Ny. Nur Laily vulnus laceratum at digiti II manus dextra RJ
An. Aqilla susp. Teratoma SHOFA
Sdr. Fakhruddin sprain RJ
Nn. Amaliatus obs. Abdominal pain & obs. Vomit SHOFA
Ny. Kasmunah peritonitis
Sdr. Gading close fracture antebrachii sinistra SHOFA
Ny. Siti Nur hematoschezia, susp. Hemorroid
Tn. Zainul vulnus laceratum digiti II manus dextra PLP
Ny. Siti COB
Hatta fraktur klavikula SAKINAH
Patient Identity
Name : Mr. KK
Gender : Male
Age : 44 y.o
Occupation :-
Address : Lamongan
Ethnic : Javanesse
Religion : Moeslem
Chief complain
Flatulance

Present illnes history


Patient complain of flatulance since 5 days ago,
increasingly become heavy two days. Nausea +, vomiting
of food 3 days ago, defecation and fart last 2 days ago.
Sometimes felt pain in his stomach. Fever -.
History of past illness:
Intestinal tumor surgery at 2013, PA report missing,
allergy
DM & HT denied
History of family:
- Cancer denied
Social History
- Smoking denied
PHYSICAL EXAMINATION
Vital Sign:
GCS : 456
BP : 148/61 mmHg
HR : 68 x/min
RR : 21x/min
Temp : 36 C
GENERAL STATUS

Head/Neck: anemis -/-, jaundice -/-


cyanosis -/-, dyspneu-/-

Chest:
Inspection: symmetrical, retraction -/-, Palpation: normal/
normal
Percussion: sonor/sonor
Auscultation: vesicular/vesicular, Rh -/-, Wh -/-
Cor:
Inspection: Vussorue cardiac (-), Ictus cordis(-)
Palpation: ictus (-), thrill (-)
Percussion: WNL
Auscultation: S1/S2 single murmur (-) gallop (-)

Abdomen:
Inspection: distended, scar operation +, mid line, darm steifung (-), darm
contour (-)
Palpation: soefl, H/L not palpable, hepatic deaf (+), pain (-)
Percussion: hypertymphani
Auscultation: bowel sound (+) increase

Extremity :
warm, dry, red, CRT < 2
LABORATORIUM
Hb : 17.3 Erytrocyte : 5.92
Lekosit : 9.8 Hematocrete : 51.9
Platelet : 310
Lymphocyte : 17.7
Urea : 26
Neutrophyle : 65.3 Serum creatinine: 0.8
Monocyte: 9.1 SGOT : 16
Eosinophyl : 6,8 SGPT : 19
Basofil : 1.1 K serum : 3.7
Na serum :132
Cl serum : 99
CLUE AND CUE

Male, 44 yo
Flatulance
Nausea
Vomit
Bowel sound (+) increase
BOF
Assesment
Ileus
Partial bowel obstruction
Planning therapy
Consult Sp.B:
NGT & DK
Inf. Ringer Asetat 1500 cc/ 24 h
Inj. Na Metamizole 3x1 amp prn
Inj. Pantoprazole 1x1 amp
Inj. Cefotaxim 3x1 g
MONITORING
Patient complaints
Vital Sign
EDUCATION
Explain patient and family about the illness
Explain planning therapy, intervention, and possible side
effects
Explain to take drugs properly
Explain to consult SpB
TERIMA KASIH