MORNING REPORT

13-05-2019
Co-Ass Ansieta, Co-Ass Liberty
Attending : Alders Nitbani,MD, General
Surgeon
IDENTITY
Name : NS
Age : 20 months old
Sex : male
ANAMNESIS
Main Complain : a lump on the right scrotum since1 week ago.
Current History: the patient reffered from RSPP Betun with a diagnosis Hernia
Inguinalis Incarserata (D). At first, there was lump in the right scrotum since1 week
ago, the lump is more visible when the patient cries. Complaint also accompanied by
flatulance, difficulty in defecating, meteorismus (+) and fever. One day ago, patient
vomited 4 times white liquid, food (-), blood (-). Currently, in patients installed NGT
containing blackish brown liquid and chateter. Patient also felt decrease appetite and
fussy. Other than that there are no other complaints.
Treatment History: IVFD ¼ NS 800 cc/24 jam, Inf PCT 3x80 mg iv, Inj. Ceftriaxone
2x200 mg IV, Inj. Ondansentron 2x0,8 cc, Stesolid supp 1x5 g.
PHYSICAL EXAMINATION
General Condition: Medium Sickness
Awaraness: Compos Mentis (E4M6V5)
Vital Sign: Pulse: 110 times/minute reguler, RR 40 times/minute, Temp. 35.7, SpO2 98%.
Head : Normocephal
Eye : pupil isokor (+/+), Direct and Indirect Ligth Reflex (+/+), pale conjungtive (-/-), icteric sclera
(-/-), sunken (+/+)
Ear : ottorea (-/-)
Nose : rhinnorea (-/-)
Thorax
Pulmo : chest expansion bilateral simetric, . Vesicular (+/+), rochi (-/-), whezing (-/-).
Cor : S1/S2 reguler single, mumur (-), gallop (-)
Abdomen
Inspection : flatulance (+), distended (+).
Palpation : tenderness pain (-), mass (-)
Percusion : hypertimpany sound (+)
Auscultation : peristaltics (+) still normally

Genitalia
There was a mass of soft, mobile, round shape in the right scrotum, smooth and
warmly felt.

Extremity
Warm akral, CRT <3, edema (-)
RADIOLOGY IMAGING
LABORATORY

Hb : 10,9 g/dL
RBC: 5,65 x 106/Ul Plt : 435 x 103/Ul
Hct : 36,6 % Temporary Blood Sugar : 278 mg/dL
WBC : 2,81 x 103/Ul Na : 131 mmol/L
Eosinofil : 0,2 K : 3,5 mmol/L
Basofil : 2,3 Cl : 101 mmo/L
Neutrofil : 24,0 Ca Ion: 1.060 mmol/L
Limfosit : 67,3 Tot Ca : 2,2 mmol/L
Monosit: 6,1
DIAGNOSIS
Hernia Inguinalis Incarserata (D)
PLANNING
- Pro Operation
- Observation
- IVFD ¼ NS 800 cc/24 jam
- Inf PCT 3x80 mg iv prn febris
- Inj. Ceftriaxone 2x200 mg IV
- Inj. Ondansentron 2x0,8 cc
- Stesolid supp 1x5 g.
Thank You