bedah morep 12-10-15

MORNING REPORTOct 12th, 2015

Group B22

Identity

Name : Tn. SGender : MaleAge : 80 y.oAddress : wonokromo tikung

LamonganOccupation : farmerReligion : MoeslemEthnic : JavaneseStatus : MarriedEntry Date : oct 11th, 2015

Patients complaint right abdominal pain since yesterday morning. Pain is felt as in knead , intermittent . Previous since two days ago patient complained of difficulty to fart and defecate. Now stomach felt sebah so that patients complaining of nausea +, but not vomiting . febris -

Chief complain: right abdominal pain

Present illnes history :

History of past illness:◦DM (-), HT (+) uncontrolled

History of family:◦HT (-)◦DM (-)◦no family who complain like this

R. Sos : work as a farmer

PHYSICAL EXAMINATION

Vital Sign: ◦GCS : 456◦BP : 172/68 mmHg◦HR : x/58min◦RR : 25x/min◦Temp : 36,5 C

GENERAL STATUS◦K/L : A/I/C/D : -/-/-/-◦ Lymphe gland : no enlargement◦ thyroid gland : no enlargement

◦Thorax : Pulmo :

◦ Inspection : Simetris, Retraction (-)◦Palpation : Fremitus N/N◦Percussion : Sonor/Sonor◦Auscultation : Ves/Ves ; rh -/-, wh -/-

Cor : ◦ Inspection : Ictus cordis (-) ◦Palpation : Ictus cordis strong lifting (-)◦Auscultation : S1S2 single, murmur (-) , gallop (-)

◦Abdomen : Inspection : flat Palpation : Soepel, pressing pain (+) et regio

RUQ, H / L not palpable, mc burney sign -, psoas sign -

Percussion : hiperthympani, pekak hepar menghilang

Auskultation : Met - , BU (-)◦EXTREMITY :

warm, edema (-), cyanosis (-)

Clinical ASSESSMENT

Susp ileus obstruksi

LAB. EXAMINATION

GDA acak : 117 Kalium serum: 3.8 Natrium serum: 136 Clorida: 103 Urea 30 SC: 0,8 SGOT 52 SGPT: 74 Waktu perdarahan: 2.00 Waktu pembekuan: 9.30 Leukosit 12.4 Neutropil: 84.6 Limposit 6.3 Monisit 6.1

Eosinofil: 0,7 Basofil: 2,3 Eritrosit: 5,45 Hb: 15,7 Hct: 48,4 MCV 88.80 MCH 28.80 MCHC: 32.40 RDW: 12 Trombosit: 126 LED 1: 22 LED 2: 42

Radiologi

COR : bentuk dan ukuran kesan membesar

PULMO : ◦Tampak nampak fibroinfiltrat◦Sudut prenicocostalis tajam

Soft tissue dan tulang dbnKesimpulan : kesan cardiomegali

Bayangan gas usus meningkat + fecal material dan dilatasi sebagian colon dan usus halus.

Hepar dan lien tidak membesarTak tampak adanya batu radioopaqPsoas shadow simetrisTulang- tulang tak tampak kelainan

LLD: tak tampak udara bebas, tak tampak step lader patologis

Kesimpulan: partial ileus obstruktif letak rendah

Clue & cue

RUQ abdominal painColic painSusah kentut dan buang air besar sejak 2 hari iniTakypneu Hipertimpani + BU menghilangRadiologist Bayangan gas usus meningkat +

fecal material dan dilatasi sebagian colon dan usus halus.

Leukositosis

RE-ASSESSMENT

Ileus obstruktif partial letak rendahHypertension stg II

PLANNING THERAPY

Inf. Asering 1500/24 jamInj ondancetron 3x1 prnInj ranitidin 2x1Inj santagesic 3x1Inj ceftriaxon 2x1 gr ivInj metronidazole 3x500 mg

Consult Sp.B

MONITORING

Patient complaintsVital Sign

EDUCATION

Explain the patient and family about the illnessExplain the planning therapy and possible side

effectsExplain the diagnosisExplain to take drugs properlyExplain to always take proper food with

balance nutrientsExplain to always take good care for self

hygiene and environmentExplain to always thinking positively and use

the rest of her time for a good deed