morning report departement of surgery 27 feb

7/28/2019 Morning Report Departement of Surgery 27 Feb

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Departement of SURGERYPavilion shofa, 6th march 2013(14.00- 07.00 am)


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Identity

Name : Mr. RH Age : 37 YO

Address : Andanwangi street,

Sukomulyo Lamongan Occupation : Enterpreneur

Religion : Moeslim

Date : 06 March 2013 at 09.00 am

No. MR : 19.81.59


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Anamnesis

Chief complaint: abdominal pain Present illnes: Patient complained about his

abdominal pain in Right Upper Quadrant since 7

days before hospitalized. The pain was reffered to

his back. The pain was relaps in last one year. He feltNausea (-), vomit (-). This pain could reduce by

analgesic but about this 7 days its still pain.

Defecation and urination within normal limit. Fever(-).


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History or past illness :

- He had history of cholelithiasis about one year ago.

- Hypercholesterol denial

- Diabetes & hypertension denial

- History of liver disease (-)

History of family:

- History of cholelithiasis (-)

History of sociality:

- High cholsterol Food consumption (+)


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Physical Examinations

General Appearance : weak

GCS : 456

Vital sign :

BP : 127/89 mmHg

Pulse : 80 bpm

RR : 22x/minutes

T : 36,8 C


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Physic Examinations

General appearance : weak

Head and neck :

Anemic -/icteric-/cyanosis-/dyspneu-

Thorax :

I : simetric bilaterally+

P : ICS normal

P : sonor/sonorA : ves/ves, rh-/-, whz-/-

RR : 20x/minute, spontan

Cor : S1 S2 single, M-, G-


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Abdomen :

I : Flat, mass (-)

P : Soefl, tenderness (+) RUQ, Murphy sign (+)P: Tymphani (+)

A : Bowel Sound (+) Nomal, Met (-)

Extremity :Dry and warm to touch

CRT< 2 detik


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Laboratory Findings

Diff count: 0/0/66/10/4

Hematocrite: 43,9 %

Hb 14,7 mg/dl

LED : 11/23

Leukocytes : 8.600

Thrombocyte : 266.000

Alkali phospatase : 203 U/L

Bilirubin direk : 0,22 mg% Bilirubin total 0,43 mg%

SGOT/SGPT : 15/15 U/L

Urea 19 mg/dl

Serum creatinin 1 mg/dl

Cholesterol 219 LDL Cholesterol 147, 1 mg/dl

HDL Cholesterol 44,6 mg/dl

Trigliserida 154 mg/dl

BRG : 101


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USG Abdomen


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Cholelithiasis

Assessment


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Planning Dx : -

Planning Tx : Infus Asering 1500cc/24h

Inj.Ketorolac

Inj cefotaxim 3x1 g i.v

Inj pantoprazole 2x1 i.v

Inj ondansentron 3x8mg i.v

Inj ranitidin 2x50 mg i.v

c/ surgery pro

cholesistecthomy


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Prognosis

Dubia ad bonam


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Education

Explain to the family about the condition of this

patient now, its disease, about itsexaminations, theraphy and intervention will

be done, and also about complication and

prognosis.


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morning report departement of surgery 27 feb

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