SURGERY WEEKLY REPORT

December, 10th 2019

Sari Asih Ar-Rahmah Hospital
Menu
1 Mr. H, 38 years old with hernia inguinalis dextra
2 F, 12 years old with abscess pedis sinistra
Case 1
Identity
• Name : Mr. A
• Gender : Male
• Age : 59 yo
• MR : 00083650
• Date of admission : December, 7th 2019
History / Anamnesis
Mr. H came to emergency unit with complaints contained
lump in the right groin. The lump only came out when he was
feeling tired and re-entered by itself but since 3 days ago the
lump couldn’t reenter. He cannot urination and defecation ,
nausea(+), vomiting(+) since 1 day ago with frequency 2 times a
day. History of the same disease(-), history of massage(+) 1 day
ago.
General Examination
• Compos Mentis, GCS 15
• Vital Sign :
BP : 130/90 mmHg
PR : 96x/i
RR : 20x/i
T : 36,6 ‘C
• General Examination :
Eyes : Ca -/-, SI -/-
lungs : SNV +/+, rh -/-, wh -/-
Cor : Heart sound regular +/+, murmur -/-, gallop -/-
Abdomen : bowel sounds (+) decreased
Extremities : warm, CRT < 2 seconds
ABDOMINAL X-RAY
IMAGING EXPERTISE
Result Of X-Ray
• High layout ileus obstruction
Laboratory Findings
• Hb : 12,3 g/dL
• Leu : 9.100 /uL
• Eri : 5,63 /uL
• Ht : 37 %
• Tr : 358.000 /uL
• Random Blood Glucose : 101 mg/dL
Diagnosis
• Hernia Inguinalis Dextra
Treatment
• IVFD RL 2 loading, next 20tpm
• Inj. Ketorolac 3x1
• Inj. Ondansetron 3x1
• Inj. Ceftriaxone 1x2gr
• NGT
• DC
• Pro herniorrhaphy
Case 2
Identity
• Name :F
• Gender : Female
• Age : 12 yo
• MR : 00083672
• Date of admission : December, 8th 2019
History / Anamnesis
She came to emergency unit of hospital with complaints of
swollen and there is a wound in the left leg since 1 week ago.
Previously she felt itchy skin and she scratch her leg for almost a
month. Produced the pus(+), fever(-), nausea(-), vomiting(-). She
had no complaint of urination and defecation.
General Examination
• Compos Mentis, GCS 15
• Vital Sign :
BP : 110/70 mmHg
PR : 86x/m
RR : 20x/m
T : 36,0 ‘C
BB : 40kg
• General Examination :
Eyes : Ca -/-, SI -/-
lungs : SNV +/+, rh -/-, wh -/-
Cor : Heart sound regular +/+, murmur -/-, gallop -/-
Abdomen : supple, bowel sounds (+)
Extremities : warm, CRT < 2 seconds
Laboratory Findings
• Hb : 9,3 g/dL
• Leu : 10.700 /uL
• Eri : 4,28 /uL
• Ht : 30 %
• Tr : 383.000 /uL
Diagnosis
• Abscess pedis sinistra + anemia
Treatment
• IVFD RL 12tpm
• Inj. Ceftriaxone 1x750mg
• PCT 3X1
• Pro debridement
THANK YOU