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Bedah Umum
dr. Amrul Marpaung., Sp.B

DM Januardi dan DM Elsye

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Identity
Name : Mr. Tommy Banggu
Age : 38 Years Old
Admission date :
Room : Kelimutu
No. MR : 546303
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Anamnesis
Chief Complaint

Recent History of Disease

Anamnesis
History of past disease

History of medication
.

Family History Disease

No family member has ever been sick with similar symptoms.
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Physical Examination

• General Condition: Looks moderately ill

• Consciousness : Compos mentis (E4V5M6)
• Vital sign :
BP: 110/70 mmHg
Pulse: 88x/minute
Temperature: 36.7 C
RR : 20 x/minute
SpO2 : 99%
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General State
Skin: Jaundice (-), cyanosis (-), pale (-)
-Head: black and white hair, not easy to pull out
-Eyes: anemic conjunctiva (+), icteric sclera (-), pupil isocor 3mm/3mm, direct and
indirect light reflex (+/+)
- Nose: No deformity, discharge (-), septal deviation (-/-)
-Ears: Symmetrical, no deformity, otorrhoea (-), mastoid tenderness (-)
-Mouth: Dry lip mucosa, cyanosis (-), pale (+)
-Neck: no lymph node enlargement, no thyroid enlargement, no jugular venous
distention
Thorax
-Shape: symmetrical, use of accessory muscles to breathe (-), scar (-)
-Inspection: symmetrical when static and dynamic, accessory muscles of
respiration (-), widening of the intercostal space (-)
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General State

Abdomen
Inspection: flat
Auscultation: bowel sounds (+)
Palpation: distension (-), epigastric tenderness (-), liver and
spleen are not palpable under the costal arch
Percussion : Shifting dullness (-), abdominal mass (-)

Extremities:
- Warm palpable akral, CRT < 2 seconds, edema (-), joint
pain (-)
Laboratory Examination
24/08/2021
Hasil Lab
Pemeriksaan Hasil Nilai Rujukan
Hemoglobin 14.3 mg/dL 13.0-18.0 g/dL
Jumlah Eritrosit 6.38 x 10^6/µl 4.50-6.20 10^6/µl
Hematokrit 48.7% 40.0-54.0%
Jumlah Lekosit 9.17 10^3/µl 4.00-10.00 10^3/µl
Kalium Darah 4.72 mmol/L 3.50-4.50
Neutrofil 69% 50-70%
Calcium Ion 1.13 mmol/L 1.12-1.32
Total Calcium 2.48 mmol/L 2.20 – 2.55

*LOW
HIGH
Foto Radiologi
16/08/2021
Impression:
• Normal cast size
• Pneumonia
Impression:
• suspected peripheral
arterial disease with
atherosclerosis a. common
femoral, superficial
femoral and right popliteal
• right sided
lymphadenopathy
 Assessment
Sp. B
IDO post amputasi bellow knee dextra +
osteomyelitis os tibia dextra
DM Tipe II
Aterosclerosis a. coornarius
Anemia
 Planning
- Sp. B
• Treat wounds in the morning and evening
• Active mobilization
•IVFD RL 20 tpm
• Paracetamol 3 x 500 mg PO
• Amlodipin PO
• Ceftriaxone 1x10 PO
F.U Kelimutu 23/08/2021

S dry cough, dry lips, itchy neck, still pain in the legs, the patient vomited once in the
morning filled with fluid

O General condition : moderate illness

GCS : E4V5M6 – Compos Mentis

TD : 150/80
N : 84x/m
RR : 24x/m
S :  36.8 C
SpO2: 99%
O Skin: Jaundice (-), cyanosis (-), pale (-)
-Head: black and white hair, not easy to pull out
-Eyes: anemic conjunctiva (+), icteric sclera (-), pupil isocor 3mm/3mm, direct and indirect light reflex (+/+)
-)
-Mouth: Dry lip mucosa, cyanosis (-), pale (+)
-Neck: no lymph node enlargement, no thyroid enlargement, no jugular venous distention
Thorax
-Shape: symmetrical, use of accessory muscles to breathe (-), scar (-)
-Inspection: symmetrical when static and dynamic, accessory muscles of respiration (-), widening of the intercostal space (-)
Abdomen
Inspection: flat
Auscultation: bowel sounds (+)
Palpation: distension (-), epigastric tenderness (-), liver and spleen are not palpable under the costal arch
Percussion : Shifting dullness (-), abdominal mass (-)

Extremities:
- Warm palpable akral, CRT < 2 seconds, edema (-), joint pain (-)

A IDO (+) osteomyelitis os tibia and fibula dextra post amputatum bellow knee dextra, Anemia, DM type II, Artherosclerosis a.
Coronarius

P • Treat wounds in the morning and evening

• Active mobilization
• IVFD RL 20 tpm
• Omeprazole 2x1 IV
• Amlodipin PO
• Ondansentron 3x1gr IV
• Miconazole Cream
F.U Kelimutu 27/08/2021

S Pain in the surgical wound, Patient Vomited 3 times last night filled with fluid.
Haven't had a bowel movement since the operation finished

O General condition : moderate illness

GCS : E4V5M6 - compos mentis

TD : 130/70
N : 80x/m
RR : 20x/m
S :  36.7 C
SpO2: 97%
O Skin: Jaundice (-), cyanosis (-), pale (-)
-Head: black and white hair, not easy to pull out
-Eyes: anemic conjunctiva (+), icteric sclera (-), pupil isocor 3mm/3mm, direct and indirect light reflex (+/+)
-)
-Mouth: Dry lip mucosa, cyanosis (-), pale (+)
-Neck: no lymph node enlargement, no thyroid enlargement, no jugular venous distention
Thorax
-Shape: symmetrical, use of accessory muscles to breathe (-), scar (-)
-Inspection: symmetrical when static and dynamic, accessory muscles of respiration (-), widening of the intercostal
space (-)
Abdomen
Inspection: flat
Auscultation: bowel sounds (+)
Palpation: distension (-), epigastric tenderness (-), liver and spleen are not palpable under the costal arch
Percussion : Shifting dullness (-), abdominal mass (-)

A POD 2:
Osteotomy Os tibia and Fibula Dextra

P • Treat wounds in the morning and evening

• Active mobilization
• IVFD RL 20 tpm
• Amlodipin PO
• Ondansentron 3x1gr IV
• Miconazole Cream
• Ceftriaxone 1x150 mg PO
Thanks