Duty Report

Tuesday, 1 November 2016

Interns:
Fahmi, Annisa, Teuku,
Finta
Consultants in Charge
Pediatric surgery : dr. Catur S Sutisna, Sp. B, Sp.
BA
Digestive surgery : dr. A. Hamid R, Sp. BD
Orthopedic surgery: dr. AB. Mulyanto, Sp. Ot,
MARS
Plastic surgery : dr. Denny Irwansyah, Sp.Bp-RE
Neuro surgery : dr. Agus Yunianto, Sp. Bs
Oncology surgery : dr. Taslim Mansoer,Sp.B(K)
Onk
Thoraco surgery : dr. Arif Widya Taufiq, Sp. Btkv
Urology surgery : dr. Mamur Sjafei, Sp. U
Patient's Resume
Outpatient 3
Inpatient 1
Operation 0
 Mr. A, 31 years old
Chief Complaint:
Patient complaint of painful bulge in the
scrotal sac region since yesterday.
History of present illness:
Patient felt the bulge was getting bigger and much
more painful.
There was no nausea and vomit
Last defecation was yesterday, flatus (+)

History of past illness :

HT(-), DM (-). Gastritis (-). Patient has history
of hernia since ten years ago but never felt
this painful like before
 General Examination
Conciousness : Compos Mentis
Hemodinamic stabile
BP: 127/75
HR: 72x/m
RR: 20x/m
Head: Pale conjungitva (-), icteric sclera (-)
Lungs: Vesicular on both lungs, ronchi (-),
wheezing (-).
Heart: HS I, II normal, no murmur or gallop.
Abdomen:
Inspection: Distended (+), Darm contour (-), Darm
steifung (-).
Auscultaion: Bowel sound normal
 Local state

Bulge at right scrotum , size 10 x

10 x 7, same colour as the skin
surround it
 Laboratory result October 31 2016

TBC 16,3/45/18110/244000
Ureum 15
Creatinine 0,8
SGOT 18
SGPT 15
Electrolite 141/3.8/105
PT/APTT 9.6/31.7
Blood sugar 96
Working Diagnosis
Hernia scrotalis dextra strangulate
Treatment
NGT
Foley Cathether
Fasting
IVFD RL + Tramadol 100gr/8 hours
Ketorolac 3 x 30 mg
Outpatient
1. Ny. G, Ankle Sprain Sinistra
2. Ny. S, Urinary Tract Infections
3. Ny. L, Vulnus Laceratum region occipitalis +
syok hemoragic