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MORNING REPORTFEBRUARY 16th 2016

Surgery clerksh!

I"#y#hAr$#"sy#h

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P#te"t I$e"tty

N#%e & Mr' Y (

Age & )6 y'*'

Se+ & Me" Relg*" & Isl#%

A$$ress & R#s#u ,#y#

A$%ss*" $#te & Fe-ru#ry 16th.2016

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/he /*%!l#"t

u%! " the let scr*tu%

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Prese"t Ill"es (st*ry

P#te"t c#%e t* the e%erge"cy $e!#rt%e"t3th !#" " the let scr*tu%' The lu%! s elt#-*ut 1 ye#r #g*' The lu%! #!!e#re$

!#te"t $*"g he#4y #ct4ty' (e 3*rke$ #s #c#r!e"ter' The lu%! stll c#" -e e"tere$' Buts"ce ths %*r""g 5 h*ur -e*re #$%ss*"* the h*s!t#l7. the lu%! c#"8t !ut -#ck'

l#st $e#c#te #"$ 9#tus " ths %*r""g' Fe4er5:7. "#use# 5;7. 4*%t"g 5:7' The !#te"t stll$r"k"g'

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P#st Ill"es (st*ry

1' Str*ke hst*ry 5;7

ye#rs #g*2' (T 5:7

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Physc#l E+#%"#t*"

Ge"er#l c*"$t*" & %*$er#te !#"

A3#re"ess & /*%!*s Me"ts

>t#l sg"&

Bl**$ Pressure & 160?@0 %%(g

Pulse !ressure & @2 +?% Res!r#t*ry R#te & 2 +?%

Te%! &

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Eyes & /*"u"gt4# #"e%s 5:7. scler#kterk 5:7

ENT & Ph#ry"g h!ere%s 5:7. Neck & GB 5:7

/hest & S%etrs

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u"g& Percuss*"& S*"*r

Auscult#t*"& >eskuler 5;?;7. Ch

5:?:7.Rh5:?:7

/*r& S1?S2 reguler. g#l*! 5:7. %ur%ur

5:7 A-$*%e" & s*e!el. -*3el s*u"$

N*r%#l. te"$er"ess 5:7

E+tre%ty& "*r%#l. *e$e% 5:7

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*c#l St#tus

D

#?r scr*tu% s"str#

u%! 5$#%eter 10 c%7

Re$"ess P#" 5;7

rre!*"-le

B*3el s*u"$ " scr*tu% 5;7

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/l"c#l I%#ge

10

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#-*r#t*ry Test(- & 10.6 gr 51 167

euc*cytes & 1

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=#g"*ss

I"gu"#l (er"# #ter#l "c#rser#t#

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Ther#!y

Consul to dr. Romidon Sp.B Pr* *! her"*r#!hy

F#st"g *r 6 h*urs NGT

R 0 $!%

B*+*" 5cetr#+*"e7 1 #%!

R#"t$" 1 #%!

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Pr*g"*ss

A$ >t#% & -*"#%

A$ u"ct*"#% & -*"#%

A$ S#"#ct*"#% & -*"#%

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P#te"t8s $e"tty

N#%e & T"' M

Age & 2) ye#rs *l$

Se+ & M#le A$$ress & R#s#u ,#y#

A$%ss*" $#te & 16th Fe-ru#ry 2016.

16'

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/(IEF /OMPAINT

C*u"$ " the %$$le "ger * rghth#"$

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Prese"t ll"ess hst*ry

P#te"t c#%e t* the h*s!t#l 3th #ct4e-lee$"g " the %$$le "ger' O"e h*urs

-e*re #$%tte$ t* h*s!t#l he 3#s *"$uty *r ch*!!"g 3**$ " ur"turec*%!#"y' Chle he 3#s 3*rk"g.su$$e"ly hs h#"$ e"tere$ t* the 3**$

cutt"g %#ch"e' Ths %#ch"e s!"Juckly'

P#te"t %%e$#tely t#ke" t* theh*s!t#l'

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Physc#l E+#%"#t*"

General: compos mentis

Vital sign:

- BP: 110/80 mmHg

- HR: 82 times/min

- RR: 20 times/min

- T : 36,3C per axilla

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Physc#l E+#%"#t*"

A-$*%e"&

I"s!ect*" &Fl#t

Auscult#t*" &-*3el s*u"$s 5;7. Percuss*" &ty%!#" *" !ercuss*"

P#l!#t*" &!#" *" !#l!#t*" 5:7'

E+tre%tes &

*e$e%# 5:7

/RT2 sec*"$s

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*c#l St#tus

#?r $gt III %#"us $e+tr#&

**k

O!e" 3*u"$ L < c% + 1 c%

S3ell"g & 5;7

=e*r%ty & 5;7

C*u"$ e$ge &

A!!e#r#"ce * -*"e& 5;7

Act4e -lee$"g & 5;7

N#l l*ss & 5;7

Feel

Te"$er"ess & 5;7

Se"s-lty & g**$

/RT & 2 sec*"$

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*c#l St#tus

#?r $gt III %#"us $e+tr#&

M*4e

R#"ge * %*4e%e"t #ct4e !#ss4e l%te$ ""ter!h#l#"g *"t #$" %et#c#r!*!h#l#"ge#l

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#-*r#t*ry Test

euk*cyte& 10'00?%%< 5)'000:10'000?%%

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R*"tge" e+#%"#t*"M#""us $e+tr# AP?OBIUE

=c*"t"uty "!h#l#"g $st#l$gt III 5;7

=c*"t"uty "!h#l#"g%e$#l $gtIII 5;7

S*t tssues3ell"g 5;7

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=#g"*ss

O!e" r#cture gr#$e < c*%!lete$s!l#ce$ c*%%"ute$ $gt III *s

!h#l#"g $st#l %#""us $e+tr# O!e" r#cture gr#$e < c*%!lete

$s!l#ce$ $gt III 1?< !r*+%#l *s!h#l#"g %e$#l %#""us $e+tr#

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Tre#t%e"t

C*u"$ t*let

A!!ly r% !ressure #"$ sterle -#"$#ge

I%%*-l#t*" 3th s!#lk

/*"sult t* $r' R*%$*". S!'B FINA/S& Pr* #%!ut#tu%

6 h*urs * !re:surgery #st"g

R"ger l#ct#te "us*" 20 $r*!s !er %" Pr*l#+s #"t-*tc ce*t#+% 1 gr#% I>

I"ect*" ket*r*l#c 1 #%!*ule

Sucr#l#te )00 %g

20'00 2 t#-le s!**"s

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Pr*g"*ss

A$ 4t#% & -*"#%

A$ u"ct*"#% & $u-# #$ %#l#%

A$ s#"#ct*"#% & $u-# #$ %#l#%