7/29/2019 21 januari 2013.ppt

1/17

MORNING REPORT

SURGERY DEPARTMENT

DM E-1721st January 2013

7/29/2019 21 januari 2013.ppt

2/17

Patients Identity

Name : Mrs. L

Age : 36 year

Sex : Girl ID : 082597

Religion : moslem

Address : Dsn Ringin Ds Payaman KecSolokuro

7/29/2019 21 januari 2013.ppt

3/17

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 (-).

7/29/2019 21 januari 2013.ppt

4/17

Past illness history: (-)

Family illness history: (-)

7/29/2019 21 januari 2013.ppt

5/17

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

7/29/2019 21 januari 2013.ppt

6/17

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-

7/29/2019 21 januari 2013.ppt

7/17

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 (-)

7/29/2019 21 januari 2013.ppt

8/17

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

7/29/2019 21 januari 2013.ppt

9/17

7/29/2019 21 januari 2013.ppt

10/17

7/29/2019 21 januari 2013.ppt

11/17

Clue and cue

Woman , 36 years

Abdominal discomfort

Bloated stomach

Flatus (-) Nausea

Vomit

Post bloody and slimy diarrhea

Consume anti diarrheal drug

7/29/2019 21 januari 2013.ppt

12/17

Problem List

Bloated stomach

Flatus (-)

Nausea Vomit

7/29/2019 21 januari 2013.ppt

13/17

Initial Diagnose

Ileus obstructive

7/29/2019 21 januari 2013.ppt

14/17

Planning of diagnose

CBC

BOF

SE

7/29/2019 21 januari 2013.ppt

15/17

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

7/29/2019 21 januari 2013.ppt

16/17

Monitoring

Vital signs

Patients complain

7/29/2019 21 januari 2013.ppt

17/17

Prognosis

Dubia ad bonam