Laporan jaga Bedah

21-28 Mei 2018

Identity
• Name : Mrs. Eni (38 y.o)
• Admission : 24/5/18
History
• Chief complain: there was a wound in the right foot since 1 month
before admission to the hospital.
• The wound is pain, with pus discharging lesions. The patient also felt
decreasing sensation of pain, tingling and numbness over 3 months
ago in the extremity.
• The patient have controlled diabetes mellitus type 2 with unstable
level of glucose and hypertension over 1 year. The patient have not
treated the chief complain before.
Physical Examination
• Vital signs:
HR: 100x/min
RR: 22x/min
T: 36.6 °c
TD: 100/60

• General exam:
Ca-/-, SI -/-
SNV +/+, rh-/-, wh-/-
Heart sound regular +/+, murmur -/-, gallop -/-

• Abdominal examination
I: flat, lump (-), hyperpigmentation (-)
P: warm, tenderness (-), rovsing sign (-)
P: tympanic, shifting dullness (-)
A: abdominal sound (+) normal
I: there is open wound in sole of
right foot, the size is about 8x5 cm,
pus (+), blood (+), gangrene (+),
clean base
Status connective
lokalis : tissue.

P:tenderness, pulsation of artery

dorsalis pedis (+), palpable warm
fingertips.

Lab = Hb 7.3 leucocyte: 24600, trombocyte:

493000
GDS 274
• Diagnose:
Diabetic foot pedis dextra
DM type 2 uncontrolled

• Treatment:
Ceftriaxone 1x2 gr
Ketorolac 3x1
Excision drainage
Consul to the internist

Prepare for transfusion PRC

Identity
• Name: Mr Riman (62 y.o)
• Admision: 27/5/2018
History
• Chief Complain : pain when urinating since 1 week before admision
• Patient denying about blood and sand/stone when urinating, patient denied
fever, nausea.
• Therfore, patient complaining that a lump in the both scrotum since 2 years ago,
initially the lump from the right inguinal then the lump to the scrotum, then the
left. The lump can shrinking but lately the lump can’t shrinking anymore.
• Patient feeling the lump size is bigger when patient stand up and getting smaller
when sleeping
• Patient denied difficulty in defecating, flatus (+)
• Hypertension (-), DM (-)
General examination
• Vital signs:
• HR: 80x/min
• RR: 20x/min
• T: 37.5 °c
• TD: 110/80 mmHg

• General exam:
• Ca-/-, SI -/-
• SNV +/+, rh-/-, wh-/-
• Heart sound regular +/+, murmur -/-, gallop -/-
• Abdominal examination
• I: flat, lump (-), hyperpigmentation (-)
• P: warm, tenderness (-), rovsing sign (-)
• P: tympanic, shifting dullness (-)
Local Examination (regio inguinalis)
• Inspeksi : lump ini both regional
inguinalis, color same with the skin,
diameter 10cm,
• Auskultasi : BU (+)

• Laboratory:
• Hb 14.3
• Leu 17.800
• Tr 236
• GDS 126
Diagnosis
• Hernia scrotalis bilateral
Treatment
• DC
• inj. Ranitidin 2×1
• Inj. Ceftriaxone 1×2 gr
• Paracetamol tab 3×1
• Herniorapy