MORNING

REPORT
15 September, 2023
IDENTITY

● Name : Pujiyanto
● Age : 51 yo
● Gender : Male
● Address : Malang
● Arrival date : 15 September 2023
● Patient type : non Trauma
 ANAMNESIS

Main complaint:
right abdominal pain

Curret medical status : The patient came to the emergency room with complaints of lower right
abdominal pain with a VAS score of 8. The pain was continuous and felt like being stabbed. Pain
spreads throughout the stomach. Pain worsens when moving. Fever (+), Nausea (+), Vomiting (-).

Medical History: CAD, DM

RPO: Warfarin, Metformin

RPK : -
RSos: Self-employed work
 GENERALIST STATUS

Awareness : Composmentis
GCS: 456
TD: 130/85 mmHg
HR: 75 x/menit
RR: 21 x/menit
SPO2: 96% on RA
T: 36.3° C
 Physical Examination
Head: THORAX :
Konjungitva anemis (-/-), sklera ikterik Cor:
(-), PBI 3mm|3mm (isochor), direct light Inspection: ictus cordis not seen
reflex +/+, indirect light reflex +/+, Palpation: ictus cordis palpable in ICS 5
ptosis (-/-) MCL S
Auscultation: S1 S2 single, takikardia,
Neck : murmur (-), gallop (-)
Inspektion: trachea deviation(-) Pulmo:
Palpation: lymph node enlargement(-) Inspection: chest shape normal,
Auscultation : Bruits (-) retraction (-)
Palpation: chest D/S simetric wall chest
movement
Perkusi: sonor
Auscultation:
Ves/ves, rh (-), wh (-)
 Physical Examination
Abdomen
Inspection:
Flat, inflammation (-) scar (-) eritema (-) defans
Rectal Touche:
muscular (-)
Sphingter ani tonus : baik
Auscultation : BU (+) 9x/minute
Mucosa rectum: wet and slippery, pain when
Percution: timpani
palpation (+)
Palpation:
Ampula recti: n, dilatation (-), collaps (-)
Soefl (+) Pain (+) superficial and deep.
Prostat: sulcus medianus (+), pain when
---
palpate (+), pole atas (+), kneeling (-)
--+
Handscoen: feses (+) darah (-)
--+
Extremity:
Mc burney sign (+)
Red Dry Warm Acral, CRT< 2, pitting oedem (-)
Rovsing sign (+)
Obturator sign (+)
Psoas sign (+)

RT : SDE karena pasien mengeluhkan sakit hebat.

Laboratorium
16 September
2023
Laboratorium
16 September
2023
 PROBLEM LIST & PLANNING
Problem list Definitive Diagnosis Planning Planning Therapy
Diagnosis

• Mr. P, YO • USG Abdomen • Lactate test • IVFD RL 20 tpm

• Alvarado score: • Inj. Ondansentron
• Migration pain 1 4 mg
• Anorexia 0 • Inj. Omeprazol 40c
• Nausea 1
• Tenderness in right lower quadrant 2
• Rebound pain 1
• Elevated
• Temp 0
• Leucocytosis 0
• Shift to the left 0
• Total score 5

• Appendicitis observasi/ admisi

• Usulan terapi:
BNO Abdomen
15 September
2023
CT Scan
Abdomen 16
September
2023
CT Scan
Abdomen 16
September
2023
Tn. Pujiyanto/51 th/3H/Abdominal Pain, Susp. App
perforasi, DM, CAD/dr. Dana Sp.B, dr. Ferdinan Sp.
PD, dr. Arief Sp. JP, dr. Teguh Sp. An P
Sp. B
S : Pasien mengeluhkan nyeri pada perut bagian IVFD NS 0.9%
kanan, mual (+), pusing (-) Drip Tramadol
Laparotomy tunda +-7hari
O:GCS 456TD 112/69 mmHgHR 99x/ mntRR 20x/
mntT 36.3CSpO2 : 92% on RA Sp. PD
Kepala dan leher a/i/c/d -/-/-/- Cor: S1 S2 tunggal, Lantus 0-0-10iu SC
murmur(-), gallop (-) Apidra 3x4iu
Pulmo ves (+/+), rh(-/), wh (-/-)
Abdomen: soefl, BU (+) 15x/menit, timpani, Nyeri Sp. JP
tekan++ -++-++- ASA, CPG, Amlodipin tunda
Ekstremitas: AKHM, CRT < 2s
Sp. An
A Abdominal Pain, Susp. App perforasi, DM, CAD Jika App perforasi acc operasi
THANK YOU