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REPORT

 January, 6th 2016

Agustian Deny

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O Inpatient : 3 patient

O Outpatient : 1 patient

O Total : 4 patients

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OutpatientO Mr. , !ale, 16 yo. "# e$r %ollar e.&

rope 'ites. (T. Anti tetanus,

Analgeti&, Anti)ioti&.

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eatures

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1. %oli& *reter

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+ri!ary ur-eyO Airay : %lear

O /reathing : %lear, rate: 20$!in

O %ir&ulation : %lear, pulse rate:$!in, regular, /+: 110$0 !!g

O Disa)ility: Alert

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e&onary sur-ey

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IentityO 5a!e: Mr. A

O Age : 1 years ol

O eligion : Isla!O Aress : tuent

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%hie7 %o!plaint8e7t a)o!inal pain

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+resent Illness+stient &o!plaint o7 8e7t a)o!inal pain 7or 2 ays

)e7ore a!ission, the paint as 9rst 7elt in an' region

an raiates to le7t a)o!en, the pain as &onstant.

+atient also &o!plains pain at the en o7 urination 7or

one ee' )e7ore a!ission, urination as i;&ult 3

ays )e7ore a!ission, san <=>, )loo <=>, !uy <=>

De7e&ate an atus <=> sin&e 2 ays )e7ore a!ission,

the last at unay in e-ening, har <=>, )ron <?>

5ausea <=>, -o!iting <=>

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"ital ignO %on&iussness : %o!pos Mentis, @%

1

O +ulse : $ !inuteO espiratory ate : 20 $ !inute

O /+ : 110$0

O Te!perature : 36, O%

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+hysi&al #a!inations@eneral tatus

O ea : 5or!o&ephal

O #yes : %A <=$=>, I <=>O #5T : in nor!al range

O 5e&' : tenerness <?> illia&a sinistra

O %hest : sy!!etri&al

O %or : 1, 2 M <=> @ <=>O +ul!o : "/ <?$?>, (h <=$=>, h <=$=>

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O A)o!en :o Inspe&tion : at

o Aus&ultation: /oel soun <?> nor!al, !etali&

soun <=>,o +er&ution : ti!pani <?>

o +alpation : oepel, tenerness <?> ilia&a sinistra.#pigastriu!, !us&ular e7ense <=>, %"A <=$?>,)allote!ent <=$=>

O #tre!ity : ar! <?>, %T B 2 se&ons, ee!a<=>

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8o&alis status

O T: a!pula re&ti goo, tonus goo,!u&osa s!ooth, hans&oon: 7eses<?> )loo <=>

- Tenerness <?> iilia&asinistra.-= %"A <=$?>-= )allote!ent <=$=>

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(or'ing DiagnosisO %oli& ureter e.& susp. *rolithiasis

sinistra

O %onstipation

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Aitional #a!inationO %o!plete /loo %ount <8eu&o&yte

14,6 10C$l, #ritro&yte , 1012$l ,

g) 16, g$l, Tro!)o&yte C1 10C

$l>O /loo @lu&ose : !g$l

O *reu!: 6 !g$l

O %reatinin: 1, !g$l

O @OT: 1C u$lO @+T: 21 u$l

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=ay /5O

O I!pression:O OpaEue &on&ra!ent <=>

O Air istri)ution in )oel see!s nor!al

O "erte)ral align!ent nor!al,

osteophyte <=>

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*@

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DiagnosisO %oli& ureter e.& susp. *rolithiasis

sinistra

O %onstipationO O)ser-asi tro!)ositopenia

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 Treat!entO Mei&a!entosa

O I"D 8 20 tp!

O %e7otai!e 3 2 gr <I">O Fetorola& 3 30 !g <I">

O Opila 3 % II

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2. %oli& A)o!en

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+ri!ary ur-eyO Airay : %lear

O /reathing : %lear, rate: 24$!in

O %ir&ulation : %lear, pulse rate:4$!in, regular, /+: 10$C0 !!g

O Disa)ility: Alert

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e&onary

ur-ey

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IentityO 5a!e: Mr.

O Age : 36 years ol

O eligion : Isla!O Aress : el7 e!ployee

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%hie7 %o!plaint8e7t a)o!inal pain

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+resent Illness8e7t a)o!inal pain 7or 1 ay )e7orea!ission, persistent pain, nausea <?>,-o!iting <?>, -o!iting !ore than ti!es

e-er <=>, heart)urn <=>, *rinate <?> 5,

De7e&ate <?> 5, latus <=> sin&e last night.

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"ital ignO %on&ioussness : %o!pos Mentis, @% 1

O +ulse : 4 $ !inute

O /+ : 10$C0 !!gO espiratory ate : 24 $ !inute

O Te!perature : 36 O%

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+hysi&al #a!inations@eneral tatus

O ea : 5or!o&ephal

O #yes : %A <=$=>, I <=>O #5T : in nor!al range

O 5e&' : 5o &o!plain

O %hest : sy!!etri&al

O %or : 1, 2 M <=> @ <=>O +ul!o : "/ <?$?>, (h <=$=>, h <=$=>

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O A)o!en :o Inspe&tion : at

o Aus&ultation: /oel soun <?> in&rease, !etali&

soun <=>,o +er&ution : ti!pani <?>

o +alpation : oepel, tenerness <?> epigastriu! etlu!)al sinistra. #pigastriu!, !us&ular e7ense <=>,%"A <=$?>, )allote!ent <=$=>

O #tre!ity : ar! <?>, %T B 2 se&ons, ee!a<=>

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8o&alis tatus

-  Tenerness <?>

lu!)ar sinistra.-= %"A <=$=>-= )allote!ent <=$=>

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(or'ing DiagnosisO %oli& ureter etra

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Aitional #a!ination

O %o!plete /loo %ount <8eu&o&yte1, 10C$l, #ritro&yte ,1 1012$l ,g) 16,1 g$l, Tro!)o&yte 202 10C$l>

O/loo @lu&ose : 126 !g$l

O *ri& a&i : 4,C4 !g$l

O *reu!: 32 !g$l

O %reatinin: 0,C !g$l

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/5O =ayO I!pression :O OpaEue &on&ra!ent <=>

O Air istri)ution in )oel see!s nor!al

O "erte)ral align!ent nor!al,osteophyte <=>

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Diagnosis

O %oli& ureter etra

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 Treat!entO Mei&a!entosa

O I"D 8 20 tp!

O%e7triaone 1 2 gr <I">

O Fetorola& 3 30 !g <I">

O anitiin 2 1 <I">

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= Mil hea inGury

= Open 7ra&ture &o!!inutephalang !eial igiti "

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+ri!ary ur-ey

O Airay : %lear

O /reathing : pontan, 20$!inute

O %ir&ulation : /+: $ !!g, +ulse: C$!inute, %T B 2H

O Disa)ility : Alert

O #-ent: it )y a &ar hen ri-ing

!otor&yle

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e&onary ur-eyO Allergy : <=>

O Mei&ation : <=>

O +ast Illness : Asth!a <=>, DM <=>, T<=>

O 8ast !eal : 11.00 a!

O #-ent : it )y a &ar hen ri-ing

!otor&yle.

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Ana!nesisO +atient &o!plaint o7 open oun inle7t 7oot an her 97th 9nger posttra;& a&&ient. patient also

&o!plaining a)out selling an painin hea. +atient as 7ainte righta7ter the in&ient an the +atientas una)le to re&all the in&ient.5eusea <=>, -o!itting <=>.

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#a!ination ea to

 ToeO ea : 5or!o&ephal, inGury <?>, pain <=>

O #yes: +upil iso&hor 3!!$3!!, 8ight ee <?$?>

O #5T : /leeing <=>

O 5e&' : InGury <=>, +ain <=>O %hest: +ain <=>, Dispnea <=>

O %or : 1,2 regular, M<=>, @<=>

O +ul!o : "/ <?$?>, (h <=$=>, h <=$=>

O A)o!en : oepel, tenerness <=>, /oel soun <?>5.

O epar an 8ien: 5or!al

O #tre!ity: -ulnus la&eratu! e$r orsu! peissinistra, !ultiple -ulnus e&oriatu!

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8o&al tatus: 8e7t oot

O 8oo' : -ulnus la&eratu! e$r igiti!ini!i orsu! peis sinistra, )ase:)one, a&ti-e )leeing <?>, e7or!ity

<?>O eel : sollen <=>, tenerness <?>,

%T B2H, ensory <?>

O Mo-e : =

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O 8o&al tatus: Multiple "ulnus#&oriatu! an he!ato! e$rrontalis

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(or'ing iagnosisO Mil hea inGury

O Open 7ra'ture e$r igiti " peis

sinistra grae III)

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Aitional #a!inationO %o!plete /loo %ount <8eu&o&yte

14,6 10C$l, #ritro&yte , 1012$l ,

g) 16, g$l, Tro!)o&yte C1 10C$l>O /loo @lu&ose : !g$l

O *reu!: 6 !g$l

O %reatinin: 1, !g$l

O @OT: 1C u$lO @+T: 21 u$l

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=ay: A+$8ateral o7 +eisDetra

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DiagnosisO Mil hea inGury

O Open 7ra&ture &o!!inute phalang

proi!al igiti " peis sinistraO %lose 7ra&ture &o!!inute

!etatarsal igiti I" peis sinistra

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 Treat!entO (oun Toilet

O Anti Tetanus eru! inGe&tion

O /ioon 1 2 grO Fetorola& 3 30 !g

O +re. Operation

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THANK YOU