Duty Report

Thursday, May 6
th
,

2014
Consultants on Duty
dr. Daan Khambri, SpB.(K)Onk
dr.Hermansyah, SpOT
dr. H. Syaiful Saanin, Sp BS
dr. Alvarino,Sp.B, SpU

Residents on duty
Islam, Arifianto, Rini, Irsyad, Rahmen, Achroma , Faris
Total patient : 3 patient
Patients underwent to surgery : - patient
In patient : 1 patient
Out patient : 1 patient
Refused to be threated : 1 patient

TC : 31 patient
HCU : 10 patient
CP : 34 patient
CW : 31 patient
CAA : 17 patient
BU : 4 patient



No patient underwent surgery
In patient
A female baby 4 days old was admitted to ER
with

Chief complaint :
Distended of abdomen for 2 days before
admission

Present Illness History :

Distended of abdomen for 2 days before admission
There is no defecation for 2 days.
Vomit (+)
Fever (-)
Micturation was normal.
History of delayed meconium (+) at 48 hours.
Patient spontaneous labour with midwife, aterm,
birthweight 3900 gram, length 49 cm.
There were no family history with delayed meconium.

PHYSICAL EXAMINATION

General Appearance :Moderately illness
Counciousness : Active
Heart Rate : 132 X/minute
Respiratory Rate : 34 X/minute
Temperature : 37, 2
O
C

Eyes : conjunctive was not anemic
Sclera was not icteric

Thorax was normal


LOCALLY STATE :

ABDOMINAL REGION

I : Distension (+) , visible contour (-), visible
peristaltic (-)
A : Bowel Sound (+) increase
P : Muscle rigidity(-), mass (-)


RE : Expulsion stool (+)

Clinical Pictures
X - Ray
LAB:
Hb : 13,2 gr/dl
Leukocyte : 9.000/ mm3



WD/ Susp. Hirschprungs disease


DD / Meconium Plug Syndrom






ICD X Q43.1
ICD X P76.0
For the patient we performed :
- OGT
- Urinary catheter
- Washout
Condition patient this morning :
Patient in the couvice
Spontaneus defecation ( + )
Abdomen : Distension ( - )
Planning : Barium Enema



REFUSED TO BE THREATED

A male patient, 38 years old was admitted to ER
with Diagnose
Closed fracture of left tibial plateau Schatzker
Type VI
Closed fracture of left fibular head

ICD X S82.1



Clinical Pictures
X- Ray