1 Friday 25 July 2014 PU Dr Wahyu

Duty ReportFriday, July 25th, 2014Resident in charge :

Dr. Wahyu R Wibowo

Consultant in charge

Digestive surgery : Dr. Tan Suhardi SpB

Urology surgery : Dr. Nindra P., SpU.

Neuro surgery : Dr. Agus Yunianto SpBS

Oncology surgery : Dr. Taslim M. SpB(K)Onk

Orthopaedic surgery : Dr. Jursal H, SpOT

Pediatric surgery : Dr. Yessy SpBA

Plastic surgery : Dr Budiman, SpBP

Cardiothoracic surgery : Dr. AW Taufik, SpBTKV

Resume Outpatient : 1 patient Operations : 1 patient Hospitalized : 0 patient

Outpatients 1. Mr. S. / 27 yo

WD : Hematom of the right temporal Analgetic

Mrs. Buniah, 55 y.o. (MR: 43 98 90)

CC : Pain on her whole abdomen

HPI : Since 3 days before admission patient felt pain on her abdomen. She felt

pain on her epigastric, then the pain spread to the whole of her abdomen. Patients also felt that she had nausea and vomited. There was no disturbance on urinated and defecated.

Patient brought to clinic in Cibitung City, she got 2 days hospitalized there, but she felt no improvement and she felt more pain on her whole abdomen.

Patient referred to Gatot Subroto Hospital. Patien had history of chronic gastritis and often to ate rheumatic drugs.

Physical examinations : Compos mentis, vital signs T:99/70 mmHg, HR

110x/mt, RR:28x/mt sat 99%. T; 36,5 C, Pain score : 6 General Status : within normal limits Local status, abdominal region :

I : distended P : tender pain with muscular rigidity on whole area of

abdomen, P : tympanic, absence of liver dullnes A : decreased bowel sound

DRE : anal sphincter tone was good , no palpable mass, anal mucous was smooth, pain on 9-15 o’clock projection. Glove: faeces (+), blood (-)

Mrs. Buniah, 55 y.o. (MR: 43 98 90)

Laboratory Findings : Haemoglobins : 10,9 mg/dL Haematocrits : 39% White blood couts: 20.100 mg/dl Platelets count : 257.000 mg/dl

Chemical blood : Ur/Cr : 104/2.2

Other Chemical blood within normal limits

Mrs. Buniah, 55 y.o. (MR: 43 98 90)

Chest and abdominal X-Rays free air sub diafragma / pneumoperitoneum

Working diagnosed : General Peritonitis ec suspect Perforated of Peptic Ulcer

(Boey score II) Treatment : IVFD Cateter/ NGT Antibiotic Analgetic Laparatomy - exploration cito

Mrs. Buniah, 55 y.o. (MR: 43 98 90)

Intraoperative findings : When peritoneum was

opened, air was came out and found 500 cc of pus.

Gaster perforated on anterior site of antrum piloricum, diameter 1 cm.

primary suture and omental patch

Mrs. Buniah, 55 y.o. (MR: 43 98 90)

Post operative diagnosed : Perforated of peptic ulcer Laparatomy - exploration,

primary suture and omental patch

Follow up this morning:Stable condition, no pain, general status within normal limitPlan to discharge

Mrs. Buniah, 55 y.o. (MR: 43 98 90)

Thank you