MORNING REPORT

IDENTITY

Name : Mr. A

Age : 55 years old

Sex : Male

Address : Andowia

Admission : December 1th, 2019 (23.00 pm)

Doctor in Charge: dr. Edwin Ardiansyah M,Sp.B., M.Kes

 HISTORY TAKING

Chief Complaint:
Lower right abdominal pain

Anamnesis:
Patient referred to emergency room with complaint of right lower abdominal
pain since ± 13 hours ago. pain such as tingling the first complaint was felt,
a history of fever (+), nausea (-), vomiting (-), decreased appetite (+),
normal bowel movements & urination. The patient also complained of a
lower right abdomen that was felt since ± 5 years ago. Lumps arise (but are
not obtained during examination)

History:
- There was history of HT
- There was history of previous treatment with analgetic & NSAID
- There was no the same complaint in his family
PHYSICAL EXAMINATION

• Generalized state:
Composmentis, moderate illness, well nourished
• Vital sign:
 Blood presure: 150/100 mmHg
 Pulse rate: 92 bpm, regular, strong beats
 Respiratory rate : 20 breaths/min,
spontaneous, regular, thoracoabdominal
type
 Temperature: 38,5’C / axillary
PHYSICAL EXAMINATION

Present State:
 Head : normally Chest : normally
 Face : normally Abdomen : localized
 Eyes : normally Upper Limb : normally

 Nose : normally Lower Limb : normally

 Mouth: normally Genitalia : normally

 Ears : normally Vertebrae : normally

 Neck : normally
PHYSICAL EXAMINATION

Localized State:
Abdomen
• Inspection : Convex, follow the motion of
breath
• Auscultation : Peristaltic was normaly
• Palpation : Tenderness (+) at hypocondirum
dextra region, mcburney (+), blumberg sign (+)
rovsing sign (-), psoas sign (+), obturator sign
(+)
• Percussion : tympani (+)
1
-
1
2
1 ALVARADO SCORE
1
-
0
6
CLINICAL
FINDING
PLAN OF DIAGNOSE

• Routine Blood Test & Blood Chemistry Test

• BNO 3 Position (AP/Erect/LLD)

LABORATORY FINDING

WBC : 14.3 (103/uL)

Routine blood and
blood chemistry HB : 13,0 (103/uL)
finding HCT : 37,7 (%)
PLT : 207 (103/uL)
AP ERECT LLD
 DIAGNOSE

Acute Appendicitis
 MANAGEMENT

• Pharmacology • Non-Pharmacology
IVFD Bed Rest
Antibiotic injection Education
Analgesic injection
NSAID

Referred to General Surgeon

THANK YOU