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
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