MORNING REPORT

IDENTITY

Name : Mrs. K D
Age : 51 years old
Sex : Female
Address : Rambutan street
DPJP : dr. Tedjo Arianto, Sp.B-KBD
Admission : November 25th 2018
 HISTORY TAKING
Chief complain : abdominal pain
Anamnesis :
Patient present with complaints of abdominal pain felt since 3 months ago, pain
relief. This complaint is accompanied by discharge in the suture of the open
surgery. Vomiting (+) reduced appetite (+) insomnia (+). Urination within
normal limits.
History of same complaint (-).
History of other disease (+) post mastektomi total dextra agustus 2018 and in
2017 november laparatomy operation
History of some disease in the family (-)
History of medication (+)
PHYSICAL EXAMINATION

General state :
Being sick, composmentis, malnutrition
Vital sign :
BP = 90/60mmHg
HR = 104x/m, regular, strong
RR = 18x/m, regular
Temperature = 36oC
 STATUS PRESENT

Head : Within Normal Limit

Face : Within Normal Limit
Eye : Within Normal Limit
Nose : Within Normal Limit
Ear : Within Normal Limit
Neck : Within Normal Limit
Chest : Within Normal Limit
Abdomen : localized state
Extremity
Superior : Within Normal Limit
Inferior : Within Normal Limit
 LOCALIZED STATE
ABDOMEN
I : convex, distention abdomen (-),take a breath, redness on a surgical scar
(+)
A : Peristaltic (+)
P : Tenderness (-) mass (-) defans muscullar (-)
P : tymphani(+)
Rectal toucher :
- Sphincter ani : less strangulate
- Ampulla : feces (-)
- Mucosa : smooth
- Handschoen : there is brown feces, blood (-), mucus (-)
CLINICAL FINDINGS
 PLANNING

• Routine Blood
• Injury care
Lab. Finding
 DIAGNOSIS

Fistel post Op. Ca. Colon

 Management
Pharmacology
• IVFD
• antibiotic
• Analgetic inj

Non-Pharmacology
• Education
Consult to digestive surgeon
 Thank You

BAGIAN ILMU
BEDAH