MORNING

REPORT
 IDENTITY

Name : Mr. T
Age : 67 y.o
Sex : Male
Adress : Kendari
Occupation : Civil Servant
Admission : January, 20st 2019
Doctor in Charge : dr. H. Syamsul Rijal,
Sp.B
 HISTORY TAKING
• Main Complaint : Right abdominal pain
• Anamnesis :

Suffered since 1 months ago before admitted to hospital, the pain felt
continously. Abdominal pain radiating to the solar plexus. The
complaints accompanied by nausea and vomiting. There was no
history of fever. Urinate seems normal with yellow color. The patients
can defecate after being given medicine, defecate like a goat feces.
History :
There was no history of the same complaint
There was no history of previous operations
There was history of previous medication in Korem Hospital with
IVFD, Analgetik inj. , PPI
GENERAL STATE
General Condition :
Moderate illness, Compos mentis, good nourish
Vital Sign :
BP : 110/70 mmHg
RR :19 x/min
HR : 76 x/min regular, strong
T : 36,50c
GENERAL STATE
 Head : No abnormality found
 Face : No abnormality found
 Eye : No abnormality found
 Nose : No abnormality found
 Mouth : No abnormality found
 Ear : No abnormality found
 Neck : No abnormality found
 Chest : No abnormality found
 Abdomen : Localized state
 Upper & lower limb : No abnormality found
 LOCALIZED STATE

Abdomen region

Inspection : Flat (+), looks yellow

Auscultation: Peristaltic was normal
Palpation : Tenderness (+) at abdomen region
dextra et sinistra
Percussion : Thympani all region of abdomen
Clinical Finding
Planning
 Laboratorium
 Radiology (USG)
Routine Blood

Parameter Result Normal Range

HGB 5,8 12-16

PLT 486 150-400

Neut 55,1 1,50 – 7.00

USG
DIAGNOSIS

Susp. Ikterus Obstruksi

MANAGEMENT

Pharmacological
 IVFD
 PPI
 Analgesik inj
 Antibiotic inj
 Consult general surgeon
 Thank You

BAGIAN ILMU
BEDAH