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    Duty Report Tuesday, January 23 2018

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    fitra wati
    - The duty report summarizes the consultants, residents, patients and ward status at a hospital on January 23rd 2018. There were 3 total patients with 1 undergoing a procedure in the operating theatre. - An 83-year-old male patient presented with abdominal pain for 3 days and was diagnosed with diffuse peritonitis likely due to a suspected gastric perforation based on examination and labs. - He underwent a mini laparotomy with diagnostic peritoneal lavage which found enteric contents, confirming the diagnosis. His condition was stable on morning rounds after surgery.

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    Duty Report Tuesday, January 23 2018

    Uploaded by

    fitra wati
    17 views15 pages
    - The duty report summarizes the consultants, residents, patients and ward status at a hospital on January 23rd 2018. There were 3 total patients with 1 undergoing a procedure in the operating theatre. - An 83-year-old male patient presented with abdominal pain for 3 days and was diagnosed with diffuse peritonitis likely due to a suspected gastric perforation based on examination and labs. - He underwent a mini laparotomy with diagnostic peritoneal lavage which found enteric contents, confirming the diagnosis. His condition was stable on morning rounds after surgery.

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    - The duty report summarizes the consultants, residents, patients and ward status at a hospital on January 23rd 2018. There were 3 total patients with 1 undergoing a procedure in the operating theatre. - An 83-year-old male patient presented with abdominal pain for 3 days and was diagnosed with diffuse peritonitis likely due to a suspected gastric perforation based on examination and labs. - He underwent a mini laparotomy with diagnostic peritoneal lavage which found enteric contents, confirming the diagnosis. His condition was stable on morning rounds after surgery.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    17 views15 pages

    Duty Report Tuesday, January 23 2018

    Uploaded by

    fitra wati
    - The duty report summarizes the consultants, residents, patients and ward status at a hospital on January 23rd 2018. There were 3 total patients with 1 undergoing a procedure in the operating theatre. - An 83-year-old male patient presented with abdominal pain for 3 days and was diagnosed with diffuse peritonitis likely due to a suspected gastric perforation based on examination and labs. - He underwent a mini laparotomy with diagnostic peritoneal lavage which found enteric contents, confirming the diagnosis. His condition was stable on morning rounds after surgery.

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    Duty Report

    Tuesday, January 23rd 2018

    Consultants on duty
    dr. Juni Mitra, Sp.B (K) BD
    dr. Hermansyah, Sp.OT
    dr. Dody Efmansyah, Sp.B, Sp.U
    dr. Hesty Lydia Ningsih, Sp.BS

    Residents on duty
    Indra, Amrizal, Danus, Ishak, Defri, Richard, Iqbal, Gilang,
    Meri, Deno, Ryan
    Total patient : 3 patients
    Patient Underwent To Operative Theatre : 1 patient
    In Patient : - patient
    Out Patient : 2 patients
    Refused to treated : - patient

    Ward report :
    • CP : 24 Patients
    • CW : 24 Patients
    • CAA : 10 Patients
    • TC : 28 Patients
    • BR : 3 Patients
    • RR : 10 Patients
    Patient
    A male patient, 83 years old was admitted to
    emergency room with

    Chief complaint :
    Pain at the whole abdomen for 3 days before
    admission
    Present Illness History :
    • Pain at the whole abdomen for 3 days before
    admission
    • Previously pain was began at epigastrium suddenly
    pain shift to the whole abdomen
    • Pain was felt continuously and increased by
    movement
    • Anorexia (+), nausea (+), vomited (+)
    • Fever (-)
    • History of epigastric pain (+)
    • History of NSAID consumption (+) for 1 year
    Physical Examination :
    General Appearance : Moderately Illness
    BP : 110/80 mmHg
    Heart rate : 100 X/minute
    Respiratory rate : 24 X/minute
    Temperature : 37OC
    VAS :6

    Eyes : Conjunctive was not anemic


    Sclera was not Icteric

    Thorax : was normal


    Locally state
    Abdominal Region :
    Ins : Distended (+)
    Aus : Bowel Sound (+) decreased
    Per : Liver dullness was disappear
    Pal : Muscle rigidity (+), tenderness (+), rebound
    tenderness (+) at the whole abdomen

    DRE : anal spincter tone was weakness


    Glove : feses (+), blood (-)
    Clinical Picture
    Working Diagnose :
    Diffused peritonitis caused by susp gaster
    perforation

    Laboratory
    Hb : 11,6 gr/dL
    WBC : 24.190/ mm3
    Platelet : 329.000/mm3
    Ureum : 170 mg/dl
    Creatinin : 1,7 mg/dl
    Natrium : 152Mmol/L
    Kalium : 4,7 Mmol/L
    Glucose : 170 mg/dL
    X - Ray
    Patient was prepared at the pre operative room :
    Informed consent
    NPO
    NGT and urine catheter
    IVFD
    Rehidration
    Antibiotic

    Planning :

    Mini Laparotomy Diagnostic Peritoneal Lavage


    Operative Report
     Supine position under local anesthesia
     Desinfection of the operating field
     Midline Incision lower umbilical, opened cutis, subcutis,
    fascia and peritoneum, came out air.
     Insert threeway catheter 24F into abdominal cavity and
    fixation
     Irigate with normal saline, came out enteric content
     Closed operative wound layer by layer
    Diagnosed :
    Diffused peritonitis caused by susp gaster
    perforation
    Patient’s Condition this morning
    Patient is in the HCU
    S : Fever (-), pain (-), flatus (+)
    O:
    BP : 110/80 mmHg
    Heart rate : 88 X/minute
    Respiratory rate : 20 X/minute
    Temperature : 36,8OC
    Abdomen
    Ins : Distended (-)
    Aus : Bowel sound (+)
    Pal : Muscel rigidity (-), tenderness (+), rebound
    tenderness (+) at the whole abdomen

    A : Post mini laparotomy POD 3


    P : Antibiotic
    planning Laparatomy Explorasi

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