MORNIN

G
REPORT
J A N U A RY 1 6 T H
2017

DM Inggrid, DM Rises
IDENTITY

Name : Mr. MR
Age : 46 y.o
Sex : Male
Address :Alak
HISTORY TAKING
Chief complain : pain at wound on patients bottom.
History of present illness: patient came to the hospital with pain at wound on
his bottom since 1 month ago. The pain was sharp and located only around its
wound. There were no aggravating or mitigating factors toward his complaint.
Firstly the wound emerged as considerable small abscess which then burst and
discharged yellowish and foul smelled pus. Patient had fever a week after and
drastic weight loss since then. Urinating and defecating were normal, there were
no symptoms of nausea and vomiting.
past medical history: there wasnt any history of any disease
family history of disease: there were no family members with same disease or
same complaint
 treatment history: patients had previously been treated in a clinic and got four types of oral
medication, but he couldnt mention any of those medications.
PHYSICAL EXAMINATION
GCS : E4 V5 M6
Eye: anemic (+/+), direct light reflex (+/+), icteric (-/-)
Mouth : leucoplakia (+)
Nose : normal findings
Throat : normal findings
Chest :
Symemetrical chest expansion, no retraction
Normal heart and lung sounds, no additional sound
 Abdomen : normal finding
Gluteus : Location status: there are multiple ulcers with soiled base, PIS (+)
. Extremity : normal finding
LABORATORY RESULTS

Hb : 5,7 g/dl
RBC : 2,44x10^6/uL
HT : 18,1 %
Lekosit :20,43x 10^3/uL
Trombosit : 161 x10^3/uL
GDS: 104 mg/dL
Ureum : 73,90 mg/dL
Kreatinin : 0,62 mg/dL
ASSESMENT

multiple ulcers in the gluteal region + suspect B20+ anemia

ADDITIONAL WORKUP

IVFD RL 20 tpm
Inj. Ketorolac 3% 1 A/iv
Paracetamol 3x500 mg tab
blood transfusion 1 bag per day
Wound toilet
Culture PUS
CC : Pain in RLQ Abd Reg
Pain in rigth ission. Continuus shapr pain, localized and not migranting to other
abdomen regio. The patient try to reduced the pain but cannot relieved. Before pain
developed, hours before the patient felt epigastric pain that occurs several hours that
travel to right lower regio in abdomen. Afterward, patient vomiting for about 5 times,
contains meal and waters that was eaten before, and also patient develop fever until
admission to ER.
Patient felt the appetite decreases.
Defecation (-), urinating (+).
Past medical history (-), Family medical history (-)
Past medication history :
referal from other local hospital
Medication : IVFD NS 0,9%, omeprazole injection 40mg, ceftriaxone
injection 1 gr day 2, buscopan injection 3x1, ondansentron injection 8 mg
PHYSICAL EXAMINATION

Compos Mentis
Vital sign:
BP: 130/90
PR: 92 x/m
RR: 28 x/m
T: 37.8
Abdomen
Inspection: flat
Auscultation : normal bowel sounds
Percussion : tympani
Palpation : defans muscular (-), mass (-), rebound tenderness (+), rovsing sign (+)

Extremity: Obturator sign (+), psoas sign: (+)

 Hb 9.6 g/dL
WBC 23.49 uL
Neutrofil 77.5 %
Platelet 395
GDS 169 mg/dL
Abdominal pain e.c. Appendeicitis acute
 IVFD NaCl 0.9% 20tpm
Inj. Omeprazole 2x40mg IV
Inj. Ranitidin 2x 50 mg IV
THANK YOU
KEEP FIGHTING AND GOD BLESS YOU