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PATIENT IDENTITY
Name
Gender
Age
Occupation
Address
Ethnic
Religion
Marriage st.
: An APS
: Female
: 4 y.o
:: Bluluk, Lamongan
: Javanesse
: Moslem
: Single
SUMMARY OF DATABASE
Chief of complaint:
Bloody diarrhea
PHYSICAL EXAMINATION
Vital Sign:
Blood Pressure
Pulse Rate
Respiration Rate
Temperature
: 0/0 mmHg
: 114 x/minutes
: 24 x/minutes
: 38 C
Generalis Examination:
Head/Neck: anemis -/-, jaundice -/-, cyanosis -/-,
dyspnoe -/-. Dry mouth mucose +, sunken eye -|-.
Chest:
Inspection: symmetrical, retraction -/-,
Cor:
Inspection: Ictus cordis(-)
Palpation: ictus (-), thrill (-)
Percussion: the normal size of heart
Auscultation: S1/S2 single and reguler, murmur -, gallop
Abdomen:
Inspection: Flat,
Palpation: soepel, some masses + on the RLQ long like sausage, solid,
reguler, tenderness -, mobile. hepar and lien not palpable, tenderness -,
Mc Burney sign (-), Rovsing sign, blumberg sign (-), turgor slowly ,
Percussion: tymphani
Auscultation: bowel sound (+), metallic sound (+)
Extrimity :
PROBLEM LIST
Susp ileus obstruktif
PLANNING DIAGNOSIS
DL
USG
Colon in loop
LABORATORIUM
Hb
: 11.5
Lekosit
: 25.000
Erytrocyte : 4.48
Hematocrete : 34.4
Platelets : 414.000
Eosinophyl : 2.2
Basofil
: 1.7
Neutrophyle : 89.1
Lymphocyte : 3.4
Monocyte : 3.6
K
NA
Cl
GDA
: 4.4
: 131
: 99
: 51
USG
Re- assessment
Intususepsi
PLANNING THERAPY
Ivfd Kaen 3B loading 300cc status dehidrasi
terkoreksi maintananance 1200cc/24
jam
Inj. Ceftriaxon 2 x 1 gr IV
Inj. Ondansetron 2 x 2 mg IV
Drip D40 1 fl cek GDA
Pro laparotomy
EDUCATION