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  • Morning Report

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    Adinda Ariestha Rgukguk
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    This document summarizes a 68-year-old male patient's morning report from the hospital. The patient presented with abdominal pain for two days that started in the epigastric region and spread throughout the abdomen. He has a history of dyspepsia and smoking. On examination, the patient showed abdominal rigidity, hypertympany, and decreased bowel sounds. Laboratory tests and abdominal drainage produced abnormal results. The working diagnosis is diffuse peritonitis due to a hollow organ perforation, and the treatment plan includes fasting, IV fluids, antibiotics, and an emergency exploratory laparotomy.

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    This document summarizes a 68-year-old male patient's morning report from the hospital. The patient presented with abdominal pain for two days that started in the epigastric region and spread throughout the abdomen. He has a history of dyspepsia and smoking. On examination, the patient showed abdominal rigidity, hypertympany, and decreased bowel sounds. Laboratory tests and abdominal drainage produced abnormal results. The working diagnosis is diffuse peritonitis due to a hollow organ perforation, and the treatment plan includes fasting, IV fluids, antibiotics, and an emergency exploratory laparotomy.

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    © All Rights Reserved
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    15 views13 pages

    Morning Report

    Uploaded by

    Adinda Ariestha Rgukguk
    This document summarizes a 68-year-old male patient's morning report from the hospital. The patient presented with abdominal pain for two days that started in the epigastric region and spread throughout the abdomen. He has a history of dyspepsia and smoking. On examination, the patient showed abdominal rigidity, hypertympany, and decreased bowel sounds. Laboratory tests and abdominal drainage produced abnormal results. The working diagnosis is diffuse peritonitis due to a hollow organ perforation, and the treatment plan includes fasting, IV fluids, antibiotics, and an emergency exploratory laparotomy.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
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    of 13

    Morning Report

    17 november 2017
    M/Male/ 68 y.o
    • CHIEF COMPLAINTS: pain on the whole abdomen
    It has been suferred since 2 days before he came
    to the hospital, initially the pain was found at
    epigastric, than the pain spread to the whole
    abdoment. History drinking coffee every morning
    was found, history of active smooker was
    found,dyspepsia (+). The patient was refered
    from the district hospital
    History of previous illnes : dyspepsia
    History of drug use: antaside
    Localize State
    • ABDOMEN
    • I : Simetris
    • P : abdominal rigidity (+)
    • P : hypertympani
    • A : peristaltic (+) decreased
    Laboratory
    • Hb/Ht/Leu/PLT : 13.9/41.1/18.72/221
    • Ur/Cr: 49/1,06
    • Na/K/Cl:142/4,60/110
    Treatment :
    - Fasting
    - NGT came out vol. +/- 80 cc (greenish fluid)
    Catheter folley comeout +/- 200cc (darkyellow)
    urine
    - Double IVFD RL  4 flsh
    - Antibiotic injection
    - Analgesic injection
    P/ emergency laparatomy exploration
    Working diagnose:
    Diffuse peritonitis d/t hollow organ
    perforation.

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