1 friday 25 july 2014 pu dr wahyu
DESCRIPTION
contoh laporan jagaTRANSCRIPT
Consultant in charge
Digestive surgery : Dr. Tan Suhardi SpB
Urology surgery : Dr. Nindra P., SpU.
Neuro surgery : Dr. Agus Yunianto SpBS
Oncology surgery : Dr. Taslim M. SpB(K)Onk
Orthopaedic surgery : Dr. Jursal H, SpOT
Pediatric surgery : Dr. Yessy SpBA
Plastic surgery : Dr Budiman, SpBP
Cardiothoracic surgery : Dr. AW Taufik, SpBTKV
Mrs. Buniah, 55 y.o. (MR: 43 98 90)
CC : Pain on her whole abdomen
HPI : Since 3 days before admission patient felt pain on her abdomen. She felt
pain on her epigastric, then the pain spread to the whole of her abdomen. Patients also felt that she had nausea and vomited. There was no disturbance on urinated and defecated.
Patient brought to clinic in Cibitung City, she got 2 days hospitalized there, but she felt no improvement and she felt more pain on her whole abdomen.
Patient referred to Gatot Subroto Hospital. Patien had history of chronic gastritis and often to ate rheumatic drugs.
Physical examinations : Compos mentis, vital signs T:99/70 mmHg, HR
110x/mt, RR:28x/mt sat 99%. T; 36,5 C, Pain score : 6 General Status : within normal limits Local status, abdominal region :
I : distended P : tender pain with muscular rigidity on whole area of
abdomen, P : tympanic, absence of liver dullnes A : decreased bowel sound
DRE : anal sphincter tone was good , no palpable mass, anal mucous was smooth, pain on 9-15 o’clock projection. Glove: faeces (+), blood (-)
Mrs. Buniah, 55 y.o. (MR: 43 98 90)
Laboratory Findings : Haemoglobins : 10,9 mg/dL Haematocrits : 39% White blood couts: 20.100 mg/dl Platelets count : 257.000 mg/dl
Chemical blood : Ur/Cr : 104/2.2
Other Chemical blood within normal limits
Mrs. Buniah, 55 y.o. (MR: 43 98 90)
Working diagnosed : General Peritonitis ec suspect Perforated of Peptic Ulcer
(Boey score II) Treatment : IVFD Cateter/ NGT Antibiotic Analgetic Laparatomy - exploration cito
Mrs. Buniah, 55 y.o. (MR: 43 98 90)
Intraoperative findings : When peritoneum was
opened, air was came out and found 500 cc of pus.
Gaster perforated on anterior site of antrum piloricum, diameter 1 cm.
primary suture and omental patch
Mrs. Buniah, 55 y.o. (MR: 43 98 90)
Post operative diagnosed : Perforated of peptic ulcer Laparatomy - exploration,
primary suture and omental patch
Follow up this morning:Stable condition, no pain, general status within normal limitPlan to discharge
Mrs. Buniah, 55 y.o. (MR: 43 98 90)