Laporan Jaga 6 november 2015.pptx
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Transcript of Laporan Jaga 6 november 2015.pptx
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Laporan Jaga 6 November 2015
Dokter onsite : dr. Yantoko Sp.BPDokter residen : dr. Sun & dr. Febriadi Co-ass : Aghis & Deviana
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Rekapitulasi pasienPasien Keterangan
Operasi (2) -An. FA/13thn /P/Dx. Apendisitis akut/Tx: Apendektomi-An. A/11thn /L/Dx.Ruptur arteri ulnaris sin/Tx: Repair arteri
Rawat Inap (1) -Tn. Y/ 60thn/ Dx. Batu ginjal sin + tumor ginjal dex + BPH
Rawat jalan (1) -Nn. A / 19 thn / ISK
Meninggal (0) Tidak ada
Sisa (7) -Tn. TA /20 thn/Appendisitis akut-Tn. MS/ 30 thn/ CKS + edema cerebri -Tn. BR/ 46 thn/ CKR-Tn. K/ 27 thn/ CKS + Multiple VE region fasialis + Fraktur Os nasal-Tn. MB/ 75 thn/ Hernia scrotalis dextra-Tn. S/ 54 thn/ Fraktur collum humerus dextra -Ny. Tjasih/ 65 thn Abses region axillaris sinintra
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Rekapitulasi pasien
Pasien Operasi : 2 Pasien Rawat jalan : 1 Pasien Rawat Inap : 1 Pasien Sisa : 7 Pasien Meninggal : 0
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Pasien 1
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An. FA (13 tahun) KU:
Nyeri perut kanan bagian bawah sejak 1 hari SMRS RPS:
Nyeri perut kanan bawah sejak 1 hari SMRS, nyeri dirasakan seperti ditusuk tusuk, terus menerus, bertambah nyeri, terutama saat berakivitas. Awalnya nyeri dirasakan di ulu hati lalu menetap perut kanan bawah. Pasien merasakaan mual (-), Muntah (-), demam (-). Gangguan BAK dan BAB disangkal, Siklus menstruasi normal.
RPDRiwayat nyeri seperti ini sebelumnya disangkal
RPK: kakak dan adik pasien memiliki riwayat usus buntu.
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Pemeriksaan fisik Keadaan umum: Tampak sakit sedang
Kesadaran : CM
Tanda vital :
TD: 107/68 mmHg N : 89x/ menit
PR: 20x/ menit S : 37oC
Kepala : Normocephal
Mata : Konjungtiva anemis-/-, Sklera ikterik -/-, pupil isokor
THT : Sekret -/-, darah -/-
Leher : KGB tak membesar
Thoraks : Simetris
Cor : BI-II reguler, Murmur (-), Gallop(-)
Pulmo : Vesikuler +/+, rhonki -/-, wheezing -/-
Ekstremitas : Akral hangat (+), edema (-), CRT < 2”
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Pemeriksaan fisik
Status lokalis abdomen: I : datar, lembut A : bising usus (+) normal P:
Mc Burney Sign (+), Rovsing Sign (-), Psoas Sign (+) Obturator sign (+), defans (-)
P : timpani
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Laboratorium
DPL : 13.1/38/11000/319000Diff Count:
Netrofil :58.0% Limfosit :31.9.6% Monosit : 6.0%Eosinofil : 3.7 %Basofil : 0.4 %
PT/APTT : 11.9/35.3 Kontrol : 13.7/34Ureum : 12 mg/dl Kreatinin : 0.4 mg/dl SGOT : 27 U/LSGPT : 11 U/LNa/Cl/K : 144/4.6/109
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Anestesi : Acc , ASA 1 , rencana: Spinal anestesi
Toleransi Operasi
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DIAGNOSIS PRE-OP
Appendisitis Akut
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Sikap
Pro appendektomi Informed consent Puasa IVFD RL 1500 ml / 24 jam Ceftazidim 2 x 1 gr IV Ketorolac 3 x 30 mg IV Ranitidin 3 x 50 mg IV
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Laporan Operasi Pasien terlentang diatas meja operasi dalam spinal anastesi Asepsis dan antisepsis daerah operasi Insisi transversal melewati titik McBurney, menembus kutis,
subkutis, fascia Otot dipisahkan secara tumpul Ketika peritoneum dibuka tidak keluar pus Identifikasi caecum, Appendiks dikenali, letak antesekal, tidak tampak perforasi,
hiperemis (+), fecalith (-), ukuran 5 x 1,0 cm Dilakukan appendektomi, Puntung Appendiks dibenamkan dalam
jahitan kantung tembakau Rongga abdomen dibersihkan dengan kassa lembab hingga bersih Luka operasi dibersihkan dan dijahit lapis demi lapis Operasi selesai
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DIAGNOSIS POST-OP
Appendisitis Akut
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PRE-OP
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INTRA-OP
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P0ST-OP
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Instruksi Post Operasi
Rawat inap: Bedah Kelas Awasi TNSP IFVD RL: D5 /24 jam Cefotaxime 2 x 1 gr IV Paracetanol 3 x 500 Ranitidin 2x 50 mg IV Diet bebas setelah bising usus (+) normal Follow up hasil PA