MORNING REPORT

DEFA AGRIPRATAMA ALI

 IDENTITY

• Name : Mrs. M
• Age : 61 Years old
• Sex : Female
• Address : Jl. LD Abdul Kudus
• Occupation : Merchant
• Admission : July, 15 2019
• Doctor in charge: dr. Syamsul Rijal Sp. B
History
• Chief Complaint : pain at the right lower region of abdomen
• Anamnesis :
Suffered since 2 weeks before entering the hospital
History :
 History of previous treatment (-)
 History of the other diseases :
- There was history of diabetes mellitus type 2 and
hypertention
- There was no history of same complaint in family
- There was no history of trauma
 Other Complaint : loss of appetite since 2 weeks ago, nausea
(+), vomitting (+), fever (-)
PHYSICAL EXAMINATION
• Generalized state:
Moderate illness, good nourish, composmentis
• Vital sign:
 Blood pressure : mmHg
 Heart rate : x/m, regular, strong
 Respiratory rate : x/m, spontaneus, symmetric,
regular, thoracoabdominal type
 Temperature : celcius degree/axillary
 VAS 8/10
PRESENT STATE
• Head : Within normal limit
• Face : Within normal limit
• Eyes : Within normal limit
• Nose : Within normal limit
• Mouth: Within normal limit
• Ears : Within normal limit

• Neck : Within normal limit

• Chest : Within normal limit
• Abdomen : Localized state
• Upper Limb : Within normal limit
• Lower Limb : Within normal limit
• Genitalia : Within normal limit
• Rectal Toucher : Abdomen REGION
• - sphincter strangle Inspection
Distended (-), follow the motion of
• - smooth mucosa breath, darm contour (-), darm steifung
• - ampula ≠ collaps (-)
• - release:
Auscultaion
feces (-), mucous (-), blood (-) Peristaltic (+) Normal

Palpation
Right lower quadrant tenderness (+)

Percution
Tympani (+)
CLINICAL DOCUMENTATION
Manifestations Value
Migration of pain 1
Anorexia 1
Nausea/Vomiting 1
Right lower quadrant tenderness 2
Rebound tenderness 0
Elevated Temperature 0
Leukocytosis 0
Shift of Neutrophils to the left 0
Total 5
PLAN OF DIAGNOSTIC

• Routine blood test (RBT)

Chemical blood test (GDS, Uric
Acid)
• USG Abdomen
 LABORATORIUM FINDING

• Blood routine test

- WBC : 11.41 x 103/uL
- HB : 12.3 g/dL
- PLT : 6.52 x 103/uL
- Neutrofil : 0.03 x 103/uL
USG ABDOMEN
 DIAGNOSE

Diagnosa : Differential
susp Acute Diagnosa :
appendicitis 1. Cholesistitis
2. Nefrolitiasis
 MANAGEMENT
• NON PHARMACOLOGY
PHARMACOLOGY

• IVFD NaCl 20 tpm

• CONSULT TO SURGEON • Paracetamol /8h IV
THANK YOU