MORNING

REPORT
 Name : Ms. J

Age : 48 years old

Sex : Female

Address : Wawonii

Admission : November, 04th 2019 (13.18 WITA)

DPJP : dr. Wayan Eka, Sp. B

IDENTITY
 HISTORY TAKING
• Chief complain : Abdominal pain and fever

• Anamnesis : Since 1 month ago and has worsen since 2 days before entering the hospital.
Appear increasingly weak until the decline in consciousness.

• Mechanism of trauma : Patient from Santa Ana hospital with pneumoperitonium et causa
suspect perforation. According ti his family, the patient complaned of abdominal pain since 1
month ago and worsen since 2 days before entering hospital. The patient is accompanied by his
family about 2 hours before being admitted to the hospital with decreased consciousness

• History of trauma :
 There was a history of unconscious. Patient collapsed after 2 hours ago complaining of
abdominal pain
 There was a history before the patient was referred from Langara Hospital due to abdominal
pain
 PHYSICAL EXAMINATION

General state
Severed Illness, Compos mentis, Good Nourish

Vital Sign
BP : 140/90 mmHg
HR : 96x/minutes, regular, strong
RR : 24x/minutes, spontaneous,
symmetric, reguler
T : 36,8◦C
 Head : Within Normal Limit Abdomen : Localized state
Face : Within Normal Limit Upper limb : Within Normal Limit
Eyes : Within Normal Limit Lower limb : Within Normal Limit
Nose : Within Normal Limit
Mouth : Within Normal Limit
Ears : Within Normal Limit
Neck : Within Normal Limit
Chest : Within Normal Limit

PRESENT STATE
Abdominal Region
 INS : Distended (+), follow the motion of breath

 AUS : Peristaltic (+) in the normal limit

 PER : Thympani (+)

 PAL : Pain (+) at right lower quadrant regio iliaca dekstra , Mcburnay Sign
(+), psoas sign (+), rovsing sign (+)

LOCALIZE STATE
ALVARADO
SCORE
Manifestations Value
Migration of pain 1
Anorexia 0
Nausea/Vomiting 1
Right lower quadrant tenderness 2
Rebound tenderness 1
Elevated Temperature 0
Leukocytosis 1
Shift of Neutrophils to the left 0
Total 6
Clinical Documentation
 Laboratorium
X-Ray

Planning Diagnostic :
• WBC 1,8 x103 / µl
• RBC 3,52 x106/ µl
• HB 11.6 g/dL
• PLT 379 x103/ µl

Laboratory Findings
Ap supine LLD
 Peritonitis susp. Perforasi Gaster

DIAGNOSIS
MANAGEMENT
Pharmacological
• IVFD Nacl/RL
• Antibiotic
• Antipiretik
• PPI