MORNING

REPORT
5 Oktober 2023
IDENTITY

● Name : An. M. Reza

● Age : 12 years old
● Gender :Male
● Address : Batu
● Arrival Date : 5 Oktober 2023
● Patient Type : non Trauma
 ANAMNESIS

Main Complaint:
Abdominal pain regio RLQ

Illness:
The patient came to the emergency room with complaints pain on abdomen regio right lower
quadrant since Monday (02/10/2023) which got worse early at Thursday morning (05/10/2023)
around 01.00 and was taken to the emergency room at 01.30. the VAS score is 7-8. The patient
complained of nausea, vomiting and fever since Monday. He was taken to the community health
center but the complaints did not get better. The patient has been constipated for 3 days, urination
is normal. The patient’s mother said, the he likes to

Past Medical History: -

Medicine History:
Paracetamol and other medicine (the patient forgot it)
Family History: -
-
 GENERALIST STATUS
Consciousness: Composmentis
GCS : 456
HR : 113 x/minute
RR : 30 x/minute
SpO2 : 99% on RA
Tax : 37.6 C
 PHYSICAL
EXAMINATION
THORAX :
HEAD/NECK: Cor:
Head: Inspection: ictus cordis invisible
Eyes: Anemic conjunctiva (-/-), icteric Palpation: ictus cordis palpable at ICS 5 MCL S
sclera (-/-), PBI 3mm|3mm isochor, direct Percussion: D heart border at ICS 4 PSL D,
light reflex +/+, indirect light reflex +/+ heart border S at ICS 5 MCL S
Auscultation: S1 S2 single, regular, murmur (-),
gallop (-)
Neck :
Inspection: tracheal deviation (-) Pulmo:
Palpation: enlarged lymph nodes (-) Inspection: normal chest wall shape, retraction
Auscultation : Bruits (-) (-)
Palpation: symmetrical D/S chest wall
movement
Percussion: sonor
Auscultation: Ves + + Wh - - Rh - -
+ + - - - -
+ + - - - -
 PHYSICAL
EXAMINATION
Abdomen
Inspection: Extremity:
Flat, inflammation (-) scar (-) eritem (-) Dry red warm akral
Auscultation : BS (+) 8x/minute CRT< 2, oedem (-)
Abdominal percussion: timpany
Abdominal Palpation:
Tenderness (+) superficial and deep.
++-
++-
+++
Mc Burney (+)
Rosving sign (+)
Obturator sign (+)
Psoas sign (+)
Defans muscular (+)
 PROBLEM LIST & PLANNING
Problem list Initial Diagnosis Planning Planning Therapy
Diagnosis
• Pain on abdomen regio right lower quadrant since • Susp. Laboratory (DL) • Inf. RL 16 tpm
Monday (02/10/2023) which got worse early at Appendicitis BOF 2 position • Inj. Ranitidin 50 mg
Thursday morning, nausea, vomiting and fever perforation
since Monday
Physical examination
HR : 113 x/minute
RR : 30 x/minute
SpO2 : 99% on RA
Tax : 37.6 c
Abdominal Palpation:
Tenderness (-) superficial and deep.
++-
++-
+++
Mc Burney (+)
Rosving sign (+)
Obturator sign (+)
Psoas sign (+)
Defans muscular (+)
 Laboratorium (05/10/2023)
Jenis Pemeriksaan Hasil NILAI RUJUKAN

HGB 14.9 14.0-17.5 gr/dl

RBC 5.34 4.5-5.9 10^6/uL
HCT 40.6 40.0-52.0%
MCV 76.0 L 80 - 97 fL
MCH 27.9 26.5 - 33..5 pg
MCHC 36.7 31.5-35 g/dL
WBC 26.10 H 4.4-11.3 10^3/uL
EO % 0.2 L 2-4%
BASO % 0.5 0-1 %
NEUT% 81.4 H 50-70%
LYMPH% 12 25-40%
MONO% 1.53 2-8%
Foto BOF (05/10/2023)
 PROBLEM LIST & PLANNING
Problem list Definitive Planning Planning Therapy
Diagnosis Diagnosis
Pain on abdomen regio right lower quadrant since Monday • Acute • Inf. RL 16 tpm
(02/10/2023) which got worse early at Thursday morning, appendicitis • Inj. Ranitidin 50 mg
nausea, vomiting and fever since Monday • Inj. Ceftriaxone 500
Physical examination mg
HR : 113 x/minute
RR : 30 x/minute
SpO2 : 99% on RA
Tax : 37.6 c
Abdominal Palpation:
Tenderness (-) superficial and deep.
++- Alvarado Score:
++-
Migration of pain (+1)
+++
Anorexia (+1)
Mc Burney (+) Nausea (+1)
Rosving sign (+) Tenderness in RLQ (+2)
Obturator sign (+) Rebound pain (0)
Psoas sign (+) Elevated temp (+1)
Defans muscular (+) Leukositosis (+2)
• Laboratory Shift to the left (+1)
Total score 9
WBC 26.10 (H)
NEUT% 81.4 (H)
 PROBLEM LIST & PLANNING
Problem list Definitive Planning Planning Therapy
Diagnosis Diagnosis
Xray BOF 2 position • Acute - • Inf. RL 20 tpm
• The liver and spleen contours are good, the psoas line • Inj. Ranitidin 50
appendicitis
is good, the kidney contour is covered by intestinal gas,
mg
the distribution of intestinal gas is decreased, there is
fecal material, there is no free air in the peritoneum • Pro exploration
laparotomy and
appendectomy
THANK YOU