21 januari 2013.ppt
TRANSCRIPT
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MORNING REPORT
SURGERY DEPARTMENT
DM E-1721st January 2013
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Patients Identity
Name : Mrs. L
Age : 36 year
Sex : Girl ID : 082597
Religion : moslem
Address : Dsn Ringin Ds Payaman KecSolokuro
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Summary of Database
Chief complaint : abdominal discomfort
Present illness history:
Patient complained abdominal discomfort since a day before
hospitalized. Patient felt her stomach bloated. She couldnt
flatulent. 3 days before hospitalized, patient got diarrhea for 2
days. The diarrhea was more than 8 times a day. It was bloodyand slimy. Then, patient went to midwife and got anti-diarrheal
drugs, but patient forgot the name. Her abdominal discomfort
begun since the diarrhea stopped after consume the drugs. Patient
also felt nausea and vomit. She vomitted more than 5 times a day.Even, she was getting vomit in emergency room of RSML. Her
appetite was bad since she got sick. Shiver (-).
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Past illness history: (-)
Family illness history: (-)
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Patients Status
Vital signs
General appearence, awareness,
GCS
Weak , CM, 456
Blood Pressure 102/60 mmHg
Pulse Rate 70x/mnt
Temperature 37,0 C
Respiratory Rate 24X/mnt
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Phisical Examination
Head :
An -/- ; Ict -/- ; Cya -/- ; Dysp
Thorax
Symmetric -, retraction -
Pulmo : RR: 24x/m, Ves/ves, Rh-/-, Whz-/-
Cor : HR: 70x/m, reg (+) S1S2 tunggal, M-
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Abdomen
Inspection : Slight distended
Palpation : soefl, pain (+) in all quadranabdomen, H/L just palpable
Auskultation : BU (+)
Perkution : met (+)
Extremity : acral warm and dry Rectal toucher
Tonus of spinchter ani: good
Mucosa: slick
Painless
The content of ampula recti was blank
Feses (-), blood (-), slime (-)
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LABORATORY FINDING Diffcount : 0/0/61/33/6
Hct : 36,2 % Hb : 11.9 mg/dl
Leukosit : 8.300
Trombosit : 200.000
Clorida Serum : 105
Kalium Serum : 4,0
Natrium Serum : 135
Urea : 19
Serum creatinin : 0,8
RBG : 95
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Clue and cue
Woman , 36 years
Abdominal discomfort
Bloated stomach
Flatus (-) Nausea
Vomit
Post bloody and slimy diarrhea
Consume anti diarrheal drug
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Problem List
Bloated stomach
Flatus (-)
Nausea Vomit
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Initial Diagnose
Ileus obstructive
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Planning of diagnose
CBC
BOF
SE
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Planning of therapy
IVFD Asering 1500 cc/ 24 hour
Inj. Metamizole 3x1
Inj ranitidin 2x1 Inj metoclopramid 3x1 prn
Inj alinamin F 2x1
NGT
Antibiotik
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Monitoring
Vital signs
Patients complain
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Prognosis
Dubia ad bonam