MORNING

REPORT
 Name : Mr. U

Age : 68 years old

Sex : Male

Address : Jl. Dermaga, Kolaka

Admission : November, 08th 2019 (17.00 WITA)

DPJP : dr. Wayan Eka, Sp. B

IDENTITY
 HISTORY TAKING
• Chief complain : A complete and tight stomach ache

• Anamnesis : Stomach ache and tightness felt ± 1 day ago

Patient Referral from Benjamin Guluh Hospital. The patient felt a thoroughly abdominal pain
weighing ± 1 day ago. Pain disappearing accompanied by tightness, chest pain, nausea and
vomiting is brown, headache in the past few days accompanied by fever. The patient said 2
days ago entered the Benjamin Guluh Hospital with decreased Hb then received a blood
transfusion. defecation and urination are not smooth.
There was no history of family
There was previous a history of prostate surgery
There was a medical history of IVFD, Antibiotics and Analgetics
 PHYSICAL EXAMINATION

General state
Severed Illness, Compos mentis, Good Nourish

Vital Sign
BP : 120/70 mmHg
HR : 84x/minutes, regular, strong
RR : 33x/minutes, spontaneous,
symmetric, reguler
T : 34,8◦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 decreases

 PER : Thympani (+)

 PAL : Comprehensive abdominal pain (Right upper quadrant, Left upper

quadrant, right lower quadrant, left lower quadrant)

LOCALIZE STATE
Clinical Documentation
 Laboratorium
BNO Abdomen

Planning Diagnostic :
• WBC 8,50 x103 / µl
• RBC 3,95 x106/ µl
• HB 9,3 g/dL
• PLT 491 x103/ µl

Laboratory Findings
Ap Supine/Erect LLD
Peritonitis + Hydroperitoneum Susp.
Perforasi Usus

DIAGNOSIS
MANAGEMENT
Pharmacological
• IVFD
• Antibiotic
• Analgetik
• O2