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:

History:
- There was history of vomiting twice since 2 hours ago
- There was history of fever and chils there about 2 hours ago
- There was no history of consciousness
- There was no the same complaint in his family
- Treatment history patient referred with acute appendicitis
- There was no history of other disease
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 (+)
Manifestations Value

Migration of pain 1

Anorexia -
1
Nausea/Vomiting 1
-
Right lower quadrant 2 1
tenderness
2
Rebound tenderness 1

Elevated Temperature 1
1 ALVARADO SCORE
Leukocytosis -
1
Shift of Neutrophils to the left 0
-
Total 6
0
6
Diagnosis berdasarkan skor Alvarado
Kurang dari 5 : not sure
Skor 5 -6 : Compatible
Skor 6 – 9 : Propable
Skor > 9 : Confirmea
CLINICAL
FINDING
PLAN OF DIAGNOSE

• Routine Blood Test

LABORATORY FINDING

Result Unit Normal

Hemoglobin 13,2 mg/dl 12.0 – 16.0

Leukosit 21,9 10^3/uL 4.0-10.0

Trombosit 71 10^3/uL 150 - 450

18,7 10^3/uL 1,50-7,00
Neutrofil
85,5 % 37,0-72,0
 DIAGNOSE

Acute Appendicitis
 MANAGEMENT

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

Referred to General Surgeon

THANK YOU