MORNING REPORT

Date : 14-07-2019

Physician in charge

I :

II CVCU : dr.

II HCU : dr.

II UGD : dr.

Chief on duty : dr.

Consultant on duty : dr.

Facilitator : dr.
 Summary of Database
Mr. S/ 55 y.o/ward 24B Bed 8C
Autoanamnesa
Chief Complaint: Back Pain
History of Present Illness:
• Back pain 1 month ago, intermittent. Getting worst by standing or sitting. The patient can
only lie down. Pain is felt like being stabbed.
• Nausea vomiting since 1 week ago. Vomiting after eating and drinking, appetite decreases.
Vomiting contains water and leftovers. Complaints improved two days.
• Patients post car accidents 1.5 years ago, and got right shoulder fractures.
• Six months ago, patient fell while carrying 25 kilos of rice. Tilted to the left, then the
patient had difficulty turning to the left.
 Abdominal USG (27 /07/2019)
• Liver: Normal shape and size. Flat edge. The lobe sinistra is
sharp. Parenchym is homogeneous. Normal echo intensity.
Billiard system, portal vein, normal vasculair. There is no cyste,
nodule, calcificatie.
• Gall Bladder: Normal shape and size. The wall does not thicken
There is no stone / sand. Normal CBD.
• Pancreas / lien: Normal. Lien did not look abnormal.
• Ren Dextra / left: The shape and size of the right and the size of
the left are normal. the cortex and right / left kidney medulla
are firm. Pelviocalyceal system of the right / left kidney is
normal. There is no cyaste, nodule, stone (-).
• Vesica urine: Normal. There is no stone or tumor mass.
• Prostate: Normal.
• Mc Burney point: Normal. There is no appendix inflammation.

conclusion:Abdomen ultrasound is currently normal echo.