LAPORAN KASUS DIVISI BEDAH

ANAK OFFLINE
2 November 2020
I. PATIENT IDENTITY

 Name :R
 MR : 1804950
 Age : 54 y.o
 Sex : Male
 Religion : Islam
 Status : Married
 Address : Jln Pulau Galang, Denpasar
 Date Of Arrival : November 9th 2018 at 19.52 WITA
II. ANAMNESIS

Chief Complaint : Nausea and Vomiting

Present Illness
 Patient came to the hospital conscious with chief complaint of
nausea and vomiting. Patient experienced nausea and vomiting since
3 days before admission. Complaint appear after patient taken
medicine (metronidazol, cefixime and paracetamol). Patient vomited
every time after eating. Patient vomited the food that he had
consumed previously. History of bloody vomit was denied.
II. ANAMNESIS

Signs of fever, cough and shortness of breath was

denied.
Urination is normal, pain during urination was
denied.
II. ANAMNESIS

Past History
 History of same complain was denied. Patient diagnosed with DM since 13
years ago and not routinely treated. On August, patient got wound on plantar
area of left pedis. Patient said that the wound looked redness and there was
dry black crustae on his toes. He complained of tingling sensation and also
decreasing of sensation on the left plantar. Patient’s digiti II, III, IV have been
amputated on 28 Oktober 2018. After operation, patient prescribed with
metronidazol 3x500 mg, cefixime 2x100 mg, paracetamol 3x500 mg.
Family History
His Grandmother has history of DM. History of hypertension, heart disease
and other systemic diseases in family members were denied.
Social History
There is no other people in the patients environment that have similar
complaint. Now Patient is jobless.
 III. PHYSICAL EXAMINATION
Appereance : Moderate ill
Consciousness : Compos mentis (GCS E4V5M6)
Blood Pressure : 130/80mmHg
Pulse Rate : 84x/mnt
Respiration Rate : 20x/mnt
Temperatur axilla : 36 0 C
SpO2 : 99% (room air)
 Height : 160 cm
Weight : 55 kg
General State
Eyes : anemis (-/-), ict (-/-), Pupil reflex (+/+)
ENT : tonsils T1/T1; pharyngeal hyperemia (-); nasal
mucus (-)
 Neck : JVP PR 0 cmH2O, Lymph Node enlragement (-)
Thorax : Symetrical
Cor :
Inspection: Ictus cordis unseen
Palpation : Ictus cordis palpable
Percussion : Right Border : PSL Dextra
Left Border : MCL Sinistra
Upper border : ICS II Sinistra
Auscultation: S1 S2 normal, Reguler, murmur (-)
Pulmo
Inspection : Symmetric
Palpation : Focal fremitus normal
Percussion : Sonor|Sonor
Auscultation : Vesikular+|+ Ronchi -|-Wheezing -|-
+|+ -|- -|-
+|+ -|- -|-
 Abdomen
Inspection : Distention (-)
Auscultation : Bowel Sound (+) normal
Palpation : Abdominal pain (-), Liver
unpalpable,Spleen upalpable
Percussion : Thympany (+), Undulation(-)
Extremity : Warm +|+ Edema -|-
-|- -|-
IV LABORATORY EXAMINATION
09/11/2018
Parameter Result Unit Reference range

WBC 15,77 (H) 103/μL 4,10 – 11,00

-Neu 72,16% 11,38 (H) % 103/μL 47-80 2,50 – 7,50
-Lym 18,61% 2,93 % 103/μL 13-40 1,00 – 4,00
-Mono 6,79% 1,07 % 103/μL 2-11 0,10 – 1,20
-Eo 0,97% 0,15 % 103/μL 0,0-5,0 0,00 – 0,50
-Ba 1,48% 0,23 (H) % 103/μL 0,0-2,0 0,00 – 0,10
RBC 3,69 (L) 106/μL 4,50 – 5,90
HGB 9,30 (L) g/dL 13,50 – 17,50
HCT 32,21 (L) % 41,00 – 53,00
MCV 87,39 fL 80,00 – 100,00
MCH 25,22 (L) pg 26,0 – 34,0
MCHC 28,86 (L) g/dL 31,00 – 36,00
RDW 15,88 (H) % 11,60 – 14,80
PLT 651,70 (H) 103/μL 150,00 – 440,00
 IV LABORATORY EXAMINATION
Parameter Result Unit Reference range

AST/SGOT 14,6 U/l 11,00 – 33,00

ALT/SGPT 6,80 (L) U/l 11-50
BUN 3,30 (L) Mg/dl 8-23
Creatinin 0,74 Mg/dL 0,70-1,20
Albumin 3,20 g/dL 3,40-4,80
Natrium 138 Mmol/L 136-145
Kalium 3,5 Mmol/L 3,50-5,10
Glukosa Darah Sewaktu 184 (H) Mg/dL 70-140
Foto Thoraks
 Cor : besar dan bentuk kesan normal
 Pulmo : tak tampak infiltrat/nodul.
Corakan bronkovaskular normal
 Sinus pleura kanan dan kiri tajam
 Diaphragma kanan dan kiri normal
 Tulang-tulang : tidak tampak kelainan

Kesan :
Cor dan pulmo tak tampak kelainan
 EKG
V. ASSESSMENT

1. DM Type II
-DM DF Wagner V Pedis Sinistra post
Amputasi digiti II-IV
- Anemia ringan Normokromik
Normositer ec ACD
2. Obs Nausea-vomiting ec suspect drug
induced (cefixime/metronidazol)
 VI. PLANNING
Therapy
 IVFD NaCl 0,9% 20 tpm Monitoring
 Lansoprazole 30 mg every 24 hours IV • Vital sign
• Complaint
 Domperidone 10 mg every 8 hours IO
 Sucralfat 15 ml every 8 hours IO
 Insulin Aspart 4 unit every 8 hours SC
 Insulin Glargine 6 unit every 24 hours SC
 Cefoperazon 1 gram every 12 hours IO

Planning
Consult to Vascular Surgery Department
TERIMA KASIH