Consulent Onsite: dr. Simangungsong, Sp. BResident Onsite : dr. Odette, dr. Sari, dr. StefannyKoas : Ferry - Anas - YitaDuty Report Friday, April 4th 2015

MELAPORKANStagnant patient: 6 patientNew patient : 9 patientOperation : 1 patient

Stagnant patientMr. taufik syarif/ 59yo/ ulcus DM pedis sinistra with ascending infection pro debridement, HCU (-)Mr. entong/ 55yo/anemia gravis ec hemoroid interna post transfusion, corection hcl Hb=4,3Mrs. Hahyanti/ 51yo/anemia on ca mamme post tranfusion 750cc check laboratory peripheral bloodMr. sanusi/50yo/urin retension ec susp BPH catheter, cystostomy guiding USG post cystostomy evaluation on ERMr. Aca syanti/76yo/hernia scrotalis ireponible conservative, home careMr. jawawi/18yo/Acute appendicitis pro appendiktomy OK

New patientMr. Eko budi/20yo/illeus obstrutktif refused to insert NGT and catheter forced home careMr. dafa/12yo/ VL regio dorsum pedis hecting + wound toiletMr. Agustinus/34yo/VL regio pattela dx hecting + wound toiletMs. Shana Adela/20yo/acute gastritis + chronic appendisitis home careMr. Hendro/33yo/contusio tissue of thorax sinistra home care. Assesment dr. Simangunsong, Sp. BMr. Daffal foat/13yo/ gastritis home careMs. Nurindah/17yo/VL labialis inferior ec got kicked by her friend when karate wound toilet + hectingMr. Rohmani Ali/52yo/Abcess pedis sin abcess insicionMr. Ilhamsyah/22yo/mild head injury + VL regio frontalis wound toilet + hecting

Mr. dafa/12yo/ VL regio dorsum pedis hecting + wound toilet

Ms. Nurindah/17yo/VL labialis inferior ec got kicked by her friend when karate wound toilet + hecting

Mr. Rohmani Ali/52yo/Abcess pedis sin abcess insicion

Mr. Agustinus/34yo/VL regio pattela dx hecting + wound toilet

Mr. Ilhamsyah/22yo/mild head injury + VL regio frontalis wound toilet + hecting

OPERATION

IDENTITYName: Mr. JawawiAge: 18 yoSex: MaleOccupation: Student

Chief complaint:lower right abdominal pain since 1 day befor hospital admission

History of Present Illness:The patient came to the RSF on Friday 3 April 2015 with complaints of lower right abdominal pain since 1 day befor hospital admission. Abdominal pain is felt sharp, continuous, reduced in sleeping position, localized to the right lower stomach, appear suddenly. In addition to pain patients also complain of fever since 2 days before hospital admission, said the patient had a high fever but didnt measured it by thermometer, but then fever gets down when the patient comes to the ER. The patient also had nausea and vomiting, frequency 2-3 times/day

Physical ExaminationGeneral state: Moderate sicknessAwareness: Compos mentisVital sign :Temperature: 37CPulse: 88x/minRespiration: 20x/minBlood Pressure: 151/71 mmHgHead: normocephal, no deformityEyes: conjungtiva pale -/-, icteric sclera -/-Lungs: normal breathing sound, rhonki -/-, wheezing -/-Heart: heart sound is normal, murmur (-), gallop (-)Abdomen: tenderness in the right iliac fossa, local guarding and rebound tenderness at the McBurney point, muscular defense (-), psoas sign (-), rosving sign (+), obturator sign (-)Extremitas: edema on joints or ankles are absentDRE: tone of the anal sphincter good, prostate non palpable, tenderness (-), stool (-), mucous (-), blood (-)

TestResultNormal valueHb15 gr/dl11,7- 15,5Haematocyrit 46 %33-45Leucocyte18.0005000- 10000Trombosit 371.000 ribu150 ribu- 440 ribuGDS96 mg/dl70-140Natrium 138 mmol/l135-147Potassium4,76 mmol/l3,1-5,1Chloride103 mmol/l95-108Diff count0/1/81/13/4PT/APTT14,3/40,111,3-14,7/ 27,4-39,3UrinalysisAlbumin (Trace)Blood/Hb (Trace)

Working Diagnosis

Acute Appendisitis

TreatmentFastingAppendectomy citoConsultation to Interna, anesthesiAntibiotic Ceftriaxone 1x2 gr, Ketorolac 3x30mgIVFD RL 20 dpm

THANK YOU

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