Doctors on duty:

On Site Consultant : Irfansyah, MD, SpB

Members : Endang Syuhada
Mutiara Ayu Putri Anjela Pratiwi
Sintya Lestari
Siti Haryati
Syalfa Luthfira Nugroho
Wulan Mulyani
Yeyen Satriyani
Trauma patients : patients
Non trauma patients : patients
Total patients : patients
 NON TRAUMA CASES(1)
• Joni Aryo Raharjo/ ♂ / 60 tahun
Dx: Post Ileustomi
• Joni Aryo Raharjo/ ♂ / 60 y.o
Admitted on Monday, September 13th 2021 at 15.16

Pain (-). Vomit (-). Flatus (+), defecate (+) in the stoma
Past medical history peritonitis ec ileum perforation and colostomy surgery 8
months ago.

VITAL SIGN
Sense : CM
BP : 113/73 mmHg
HR : 83 x/m
RR : 20 x/m
T : 36,5ºC
PHYSICAL EXAMINATION

On the abdominal region

I : stoma in the right iliaca region and post-op
wounds in the suprapubic region
P : Tenderness (-)
P : Tympani
A : Bowel sound (+)
 LABORATORY FINDINGS
Hb : 11,7 gr/dl (14 – 18 g/dl)
Ht : 37,6 vol% (40 – 48 vol%)

DIAGNOSIS
Post Ileustomi

THERAPY
- Anastomosis ileum at September 15th, 2021

Patient was treated in the ward

• PONINTEN / Female / 51 y.o
follow up on Tuesday, September 14th 2021 at 05.30

Pain on post op laparotomi (+). Nausea (+). Vomit (+). Flatus

(+), defecate (+) in the drain on abdomen
Past medical history Ca Colon Descendant and history of
and laparotomy and colostomy

VITAL SIGN
Sense : CM
BP: 107/73 mmHg
HR : 107 x/m
RR : 20 x/m
T : 37,1ºC
PHYSICAL EXAMINATION

On the abdominal region

I : stoma in the left .......... region and post-op
wounds in the epigastrium until suprapubic region
P : Tenderness (+)
P : Tympani
A : Bowel sound (+)
• Katiyo / Male / 56 y.o
follow up on Tuesday, September 14th 2021 at 05.30

Pain on post op appendectomy (+). Nausea (-). Vomit (-).

Flatus (+), defecate (-)
Past medical history Appendicitis Chronic and history of
appendectomy

VITAL SIGN
Sense : CM
BP: 137/75 mmHg
HR : 52 x/m
RR : 20 x/m
T : 37,1ºC
PHYSICAL EXAMINATION

On the abdominal region

I : post-op wounds in the right iliaca region
P : Tenderness (+)
P : Tympani
A : Bowel sound (+)
• Sriyatin / famale / 36 y.o
follow up on Tuesday, September 14th 2021 at 05.30

Pain on post op laparascopy (+). Nausea (+). Vomit (+). Flatus (+),
defecate (-)
Past medical history cholelithiasis and history of laparascopy

VITAL SIGN
Sense : CM
BP: 121/79 mmHg
HR : 99 x/m
RR : 20 x/m
T : 36,5ºC
PHYSICAL EXAMINATION

On the abdominal region

I : post-op wounds in the right hypochondriac,
epigastric, right lumbar region
P : Tenderness (+)
P : Tympani
A : Bowel sound (+)
• M Farid Hisam/ ♂ / 53 y.o
Admitted on thrusday, September 16th 2021 at 12.42

right side abdominal pain, limp since 2 days,

flatus(-), poop 2 days ago

VITAL SIGN
Sense : CM
BP: 121/99 mmHg
HR : 105 x/m
RR : 21 x/m
T : 36,7ºC
PHYSICAL EXAMINATION

On the abdominal region

I : Flat, Hematom (+)
P : Tenderness in right side of abdomen (+)
P : Faint
A : Increased Bowel Sounds (+)
• Beryl Raizel Khanri/ ♂ / 13 y.o
Admitted on thrusday, September 16th 2021 at 19.51

was bitten by a snake after caming home from the

mosque after being bitten the patient said it was sore
and painful in the right leg

VITAL SIGN
Sense : CM
BP: 106/64 mmHg
HR : 77 x/m
RR : 20 x/m
T : 36,2ºC
PHYSICAL EXAMINATION

On the abdominal region

I : Abdominal wall at chest level
P : Tenderness (-), liver and spleen not palpable
P : Tympani
A : Bowel sounds (+) normal
• Afriyana/ Female / 59 y.o
Admitted on thrusday, September 16th 2021 at 15.20

wound on left leg since 1 week not healing,DM (+)

VITAL SIGN
Sense : CM
BP: 140/100 mmHg
HR : 130 x/m
RR : 20 x/m
T : 36,2ºC
PHYSICAL EXAMINATION

On the abdominal region

I : Abdominal wall at chest level
P : Tenderness (-), liver and spleen not palpable
P : Tympani
A : Bowel sounds (+) normal
• Suprapti/ ♂ / y.o
Admitted on thrusday, September 16th 2021 at

VITAL SIGN
Sense : CM
BP: 140/80 mmHg
HR : 95 x/m
RR : 20 x/m
T : 36,9ºC
PHYSICAL EXAMINATION

On the abdominal region

I :
P:
P:
A: