bedah morep 12-10-15
DESCRIPTION
cuma cumaTRANSCRIPT
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