mmr 16 feb
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Transcript of mmr 16 feb
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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#%