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  • Morning Report Oct 12, 2015: Group B22

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    tara mandiricha
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    This document summarizes an 80-year-old male farmer's morning report from the hospital on October 12th, 2015. He presented with right abdominal pain since the previous day along with difficulty passing gas and stool for two days. His examination found pressing pain in the right upper abdominal quadrant with increased bowel sounds. Laboratory tests and abdominal x-rays revealed partial small bowel obstruction with increased gas and fecal material in the intestines. He was diagnosed with partial low intestinal obstruction and uncontrolled hypertension. His treatment plan included intravenous antibiotics, pain medication, and fluid resuscitation.

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    cuma cuma

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    Bedah Morep 12-10-15

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    This document summarizes an 80-year-old male farmer's morning report from the hospital on October 12th, 2015. He presented with right abdominal pain since the previous day along with difficulty passing gas and stool for two days. His examination found pressing pain in the right upper abdominal quadrant with increased bowel sounds. Laboratory tests and abdominal x-rays revealed partial small bowel obstruction with increased gas and fecal material in the intestines. He was diagnosed with partial low intestinal obstruction and uncontrolled hypertension. His treatment plan included intravenous antibiotics, pain medication, and fluid resuscitation.

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    © All Rights Reserved
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    7 views20 pages

    Morning Report Oct 12, 2015: Group B22

    Uploaded by

    tara mandiricha
    This document summarizes an 80-year-old male farmer's morning report from the hospital on October 12th, 2015. He presented with right abdominal pain since the previous day along with difficulty passing gas and stool for two days. His examination found pressing pain in the right upper abdominal quadrant with increased bowel sounds. Laboratory tests and abdominal x-rays revealed partial small bowel obstruction with increased gas and fecal material in the intestines. He was diagnosed with partial low intestinal obstruction and uncontrolled hypertension. His treatment plan included intravenous antibiotics, pain medication, and fluid resuscitation.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
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    of 20

    MORNING REPORT

    Oct 12th, 2015


    Group B22

    Name

    : Tn. S
    Gender : Male
    Age : 80 y.o
    Address : wonokromo tikung Lamongan
    Occupation : farmer
    Religion : Moeslem
    Ethnic : Javanese
    Status : Married
    Entry Date : oct 11th, 2015

    Identity

    Chief

    complain: right abdominal

    pain
    Present illnes history :
    Patients complaint right abdominal pain
    since yesterday morning. Pain is felt as in
    knead , intermittent . Previous since two
    days ago patient complained of difficulty to
    fart and defecate. Now stomach felt sebah
    so that patients complaining of nausea +,
    but not vomiting . febris -

    History

    of past illness:

    DM (-), HT (+) uncontrolled


    History

    of family:

    HT (-)
    DM (-)
    no family who complain like this
    R.

    Sos : work as a farmer

    Vital

    Sign:

    GCS : 456
    BP : 172/68 mmHg
    HR: x/58min
    RR : 25x/min
    Temp : 36,5 C

    PHYSICAL EXAMINATION

    GENERAL STATUS
    K/L

    : A/I/C/D : -/-/-/-

    Lymphe gland
    thyroid gland

    : no enlargement
    : no enlargement

    Thorax :
    Pulmo
    :
    Inspection :
    Palpation :
    Percussion :
    Auscultation
    Cor
    :
    Inspection :
    Palpation :
    Auscultation

    Simetris, Retraction (-)


    Fremitus N/N
    Sonor/Sonor
    : Ves/Ves ; rh -/-, wh -/Ictus cordis (-)
    Ictus cordis strong lifting (-)
    : S1S2 single, murmur (-) , gallop (-)

    Abdomen

    Inspection : flat
    Palpation : Soepel, pressing pain (+) et regio
    RUQ, H / L not palpable, mc burney sign -,
    psoas sign Percussion : hiperthympani, pekak hepar
    menghilang
    Auskultation : Met - , BU (-)

    EXTREMITY :
    warm, edema (-), cyanosis (-)

    Susp ileus obstruksi

    Clinical ASSESSMENT

    GDA acak : 117


    Kalium serum: 3.8
    Natrium serum: 136
    Clorida: 103
    Urea 30
    SC: 0,8
    SGOT 52
    SGPT: 74
    Waktu perdarahan: 2.00
    Waktu pembekuan: 9.30
    Leukosit 12.4
    Neutropil: 84.6
    Limposit 6.3
    Monisit 6.1

    Eosinofil: 0,7
    Basofil: 2,3
    Eritrosit: 5,45
    Hb: 15,7
    Hct: 48,4
    MCV 88.80
    MCH 28.80
    MCHC: 32.40
    RDW: 12
    Trombosit: 126
    LED 1: 22
    LED 2: 42

    LAB. EXAMINATION

    COR

    : bentuk dan ukuran kesan


    membesar
    PULMO :
    Tampak nampak fibroinfiltrat
    Sudut prenicocostalis tajam
    Soft

    tissue dan tulang dbn


    Kesimpulan : kesan cardiomegali

    Radiologi

    Bayangan

    gas usus meningkat + fecal material


    dan dilatasi sebagian colon dan usus halus.
    Hepar dan lien tidak membesar
    Tak tampak adanya batu radioopaq
    Psoas shadow simetris
    Tulang- tulang tak tampak kelainan
    LLD:

    tak tampak udara bebas, tak tampak step


    lader patologis

    Kesimpulan:

    partial ileus obstruktif letak rendah

    RUQ

    abdominal pain
    Colic pain
    Susah kentut dan buang air besar sejak 2 hari ini
    Takypneu
    Hipertimpani + BU menghilang
    Radiologist Bayangan gas usus meningkat + fecal
    material dan dilatasi sebagian colon dan usus halus.
    Leukositosis

    Clue & cue

    Ileus obstruktif partial letak rendah


    Hypertension stg II

    RE-ASSESSMENT

    Inf.
    Inj
    Inj
    Inj
    Inj
    Inj

    Asering 1500/24 jam


    ondancetron 3x1 prn
    ranitidin 2x1
    santagesic 3x1
    ceftriaxon 2x1 gr iv
    metronidazole 3x500 mg

    Consult

    Sp.B

    PLANNING THERAPY

    Patient

    complaints
    Vital Sign

    MONITORING

    Explain

    the patient and family about the illness


    Explain the planning therapy and possible side
    effects
    Explain the diagnosis
    Explain to take drugs properly
    Explain to always take proper food with balance
    nutrients
    Explain to always take good care for self
    hygiene and environment
    Explain to always thinking positively and use
    the rest of her time for a good deed

    EDUCATION

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