Morning Report

July 31st 2019

Consulent:
dr. Jane, Sp.B
Co Ass Dewa & Co Ass Alvi
 Identity
• Name : Ms. YRR
• Number MR : 516924
• Age : 25 tahun
• Sex : Girl
• Adress : Oebobo
 Anamnesis
• CC: abdominal pain at lower right regio of abdomen .
• History of disease: patient come to ER of WZ Yohanes Kupang
because of abdominal pain at lower right region since 4 P.M. or 9
hours before patient come to ER. Patient said that she feel the
pain suddenly and feels like a stab of the knife. Patient confess
that the pain appear in 2016 at the lower right regio of abdomen
but often its diseppear. Nausea (+), vomitting (-). Fever (-). Patient
said that she drink dyspepsia drug before but the pain is not
diseppear. Defecation and urinate normal. Patient are reffered
from from Leona hospital with DX colic abdomen  App. In
Leona Patient got Nacl 0,9% IVFD, antrain injection, 20 mg of
dyphenhidramin injection, and 1 amp of dexa injection.
• History of other disease: DM (-) HT (-) Asthma (-)
• History of family’s disease: DM (-) HT (-) Asthma (-)
 Physical examination
• General condition : moderate illness
• GCS : E4 V5 M6 (compos mentis)
• BP: 110/80 RR:20x/m
• P: 60x/m T: 36,8 c
• eye : CA (-/-), SI (-/-) edem +/+
• nose : Rhinorrhea (-/-)
• ear : Otorhea (-/-)
• Mouth : dry mucose of lips, sianosis (-)
• Neck : lymphoid enlargment, (-) thiroid
enlargment(-)
 Thoraks
• I : thoraks are simettric D=S, lession (-)
• P : Taktil fremitus D=S, crepitation (-)
• P : Sonor (+/+)
• A : Vesicular (+/+), Ronchi (-/-), Wheezing (-/-)
• Cor : S1S2 Regular, gallop (-), murmur (-).
 Abdomen
• I : Flat, lession (-) wound (-)
• A : BU (+) normal
• P : supel, pain (+) at right inguinal
region of abdomen
• P : Timpani
 Ekstremity
• Warm ekstremity (+)
• CRT <2 sec
• Edema -/-
 Special examination
• Psoas sign (+)
• McBurney sign (-)
• Rousing sign (+)
• Blumbery’s sign (-)
 Alvarado Score
• Migration of pain (-)
• Anorexia (-)
• Nausea (1)
• Tenderness in right lower quadrant (2)
• Rebound pain (-)
• Elevation of temperature (-)
• Leukositosis (2)
• Swift of WBC to the left (1)
• Total  6  likely appendicitis
 Asessment
• Susp appendicitis
 Planning diagnosa
• Laboratory  Complete blood test
• USG abdomen
 Planning Therapy
• IVFD Nacl 0,9% 20 tpm
• Inj ketorolac 3x30 mg IV
 THANKYOU
FOR
THE ATTENTION