MORNING REPORT

IDENTITY

• Name : Baby. R
• Age : 8 months
• Sex : Male
• Address : Poleang, Bombana
• Occupation : -
• Admission : August, 12 2019/17.00 P.M
• Doctor in charge : dr. Syamsul Rijal, Sp.B
 HISTORY TAKING (AT 17.00 P.M)

• Chief Complaint : defecation was containing mucous and blood

• Anamnesis :
Suffered since ± 1 week ago
• History :
 Mucous and blood defecation was experienced 2-4 times a
day, pulp (-) in small amounts.
 There was history of previous treatment (RSUD Bombana) : IVFD,
antipiretic, antibiotic
 History of the other diseases :
- There was no history of same complaint
- There was no history of same complaint in family
- There was history of fever
- There was no history of weight lose
- There was no history of trauma
 Other complaint : nausea (+), vomitting (+) with frequency of
more than 5 times, yellowish accompanied by flatulance. Fever
(+), anxiety/fuss, and decreased appetite since 1 week ago.
PHYSICAL EXAMINATION (AT 17.10 P.M)

• Generalized state:
Moderate illness, overweight, anxiety
• Vital sign:
Heart rate : 164x/m, regular, strong
Respiratory rate : 36x/m, spontaneus, symmetric,
regular, abdominal type
Temperature : 36,6 celcius degree/axillary
 PHYSICAL EXAMINATION (AT 19.13 P.M)

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
Back : Within normal limit
Upper Limb : Within normal limit
Lower Limb : Within normal limit
Genitalia : Within normal limit
PHYSICAL EXAMINATION (AT 19.20 P.M)

LOCALIZED STATE

ABDOMINAL REGION

I : convex, follow breath motion, distended abdomen(+)

A : Peristaltic (+) decreased, metallic sound (+)
P : there was tenderness (+)
P : hypertympani
CLINICAL FINDING
 PLAN OF DIAGNOSTIC

• Blood routine test (Leukosit, HB,

trombosit)
• BNO 3 Position
• USG Abdominal
LABORATORIUM FINDINGS

• Blood routine test

- WBC : 5,6 x 103/uL
- RBC : 4,58 x 106/uL
- HB : 9,2 g/dL
- PLT : 557 x 103/uL
RADIOLOGY FINDING
DIAGNOSE

Diagnosa
:
Ileus
Obstructive
e.c. Susp.
Invaginasi
 MANAGEMENT

Non Farmacology Farmacology

• Rest
• IVFD
• Oksigenase
• Analgesic
• NGT
• Antipiretic
• Education (life
• H2RA
style modification)

Consult To General Surgeon