Morning Report

Tetanus Grade II ec Vulnus

Punctum

SKDI : 4A
ICD X : A35

Rizka Oktaviana
1208112289

PATIENT IDENTITY
Name : Tn. KS
Sex : Male
Age : 62 yo

Anamnesis
Chief Complain
Jaw discomfort, inability to open his mouth fully
and difficulty in swallowing since one week
before admission to the hospital.

Present Ilness History

Twenty days prior to presentation at
the hospital, he reported a minor
injury, his right foot was punctured
by rusty nail, size 3cm. He had not
sought medical attention at the time.
Ten days later, he had spasm in jaw
muscle which he wasnt able to open
his mouth.

Present Ilness History

Over the next two days, he admitted to
Santa Maria Hospital with spasm in jaw
muscle and seizures.
Seizures were described as generalized
tonic-clonic, > 6x in a day, < 10
minutes, no episodes of unconscious.
At the hospital, he was treated with
infusion, O2, NGT, DC, antibiotics,
wound care, ATS.

 One week after hospitalized in Santa

Maria Hospital, the patient was referred
to Arifin Acmad Pekanbaru Hospital with
spasm in jaw muscle and dysphagia.
Nausea (-), Vomit (-), Fever (+), Anorexia
(-), Sore throat (-)
Had not received immunization

Past illness history

Toothache 5 years, cavities (+)
History of previous seizures (-)
Otitis media (-)
Stroke (-)
Trauma (-)
Insect or animal bites (-)
Drugs allergy (-)

Family ilness history

Nobody of family members are
complaining about the same thing
with the patient

Maternity history
No problems when pregnancy, got 3 times
ANC at midwife, anorexia (-), severe
nausea and vomit (-).

Birth and Immunization history

Patient is second child of 4 siblings. Born
at Pekanbaru, October, 20th 2002.
Normal spontaneous delivery, aterm,
helped by midwife with weight 2,9 kg.
Patient got complete immunization.

Physical examination
General Status
General condition : severe illness
Awareness : compos mentis
GCS : E4 V4 M6=14
Vital Sign
Blood Pressure : 120/80 mmHg
Heart Rate : 95 x/min
Respiratory Rate : 35 x/min
Temperature: 37oC

Head and Neck Examination : anemic of

conjunctiva (+/+),
icteric of sclera (-/-)
Thorax Examination : Normal
Abdomen Examination : Localized Status
Extremity Examination : Normal
Limph Gland Examination : Normal
Genitourinary
: Normal

Localized Status : Abdomen

Inspection :
Distention (-), scar (-), inflamations sign (-)
Auscultation :
Bowel sounds (+) normal
Palpation :
Defense muscular (-), Mc. Burneys sign (+) dan
Rebound tenderness(+) at lower right quadrant
abdomen, rovsing sign (+) at lower left quadrant
abdomen. No palpable mass at right lower quadrant
abdomen.
Percussion:
Tymphani (+)
Other Physical Examination:
psoas sign (+), obturator sign (+)

Diagnosis
Working Diagnosis :
Abdominal pain et causa Suspect Acute
Appendicitis
Diffrential Diagnosis :
Gastroenteritis
Dengue Fever

Supporting Examination
Laboratory : Blood Test

Suggest of Supporting
Examination
Abdominal Ultrasonography
(USG)

Laboratory
HBG :
HCT :
WBC :
PLT :

12,9 g/dL
38,6 %
16.500 /L
263.000 /L

Suggest Treatment
Pharmacological
Ceftriaxone 2 x 1 gr
Operative :
Appendictomy

Thank you