MORNING

REPORT
Monday, 5 December 2022
IDENTITY

● Name : Mrs. A
● Age : 48 years old
● Gender : Women
● Address : Batu
● Arrival Date : 3 December 2022 at 2.45 am
● Patient Type : Non Trauma
 ANAMNESIS
Main Complaint: Abdominal pain
History of Present Illness: The patient complained of abdominal pain in the entire abdominal area since 2 weeks ago. Pain like
squeezing. Vas score 7. Previously the patient had undergone hernia surgery on 5/11/2022 at RSKH. Then after returning home
from RSKH, the patient complained of abdominal pain so he was taken to Baptist Hospital and MRS for 4 days. At Baptist
Hospital, an USG was performed: a thickening of the bowel wall was visualized in the left right paracolica and suprapubic
regions accompanied by increased echogeneity of the surrounding peritoneal fat. Then 6 days after MRS the patient returned to
Baptist Hospital with complaints of abdominal pain and was MRS for 3 days. At Baptist Hospital the patient was advised to
return to RSKH to be treated by the operating doctor. Two days before entering RSKH (4/12/2022) the patient had diarrhea 5
times with a liquid consistency. However, last afternoon the patient complained that she could only defecate a little. Flatus (+)
last night. Fever (-) Nausea (+) Vomiting 2x .
Past Medical History: Hernia surgery 3 years ago
Family History: -
Medicine History:
Buscopan plus tab 500mg 2x1
Alergic History: -
 GENERALIST STATUS
General Condition : Weak
Consciousness : Composmentis
GCS : 456
BP : 149/75 mmHg
HR : 92 x/m
RR : 18 x/m
SpO2 : 100% on RA
Tax : 36,5 C
 PHYSICAL
EXAMINATION
THORAX :
HEAD/NECK:
Cor:
Head:
Inspection: ictus cordis invisible
Eyes: Anemic conjunctiva (-/-), icteric sclera (-), pupil isocor
Palpation: ictus cordis palpable at ICS 5 MCL S
3mm|3mm, direct light reflex +/+, indirect light reflex +/+
Percussion: D heart border at ICS 4 PSL D, heart border S
Ears: otorrhea (-/-)
at ICS 5 MCL S
Nose: flaring breath (-) deformity (-)
Auscultation: S1 S2 single, regular, murmur (-), gallop (-)
Mouth: trismus (-), cyanosis (-)
Neck :
Pulmo:
Inspection: tracheal deviation (-)
Inspection: normal chest wall shape, retraction (-)
Palpation: enlarged lymph nodes (-)
Palpation: symmetrical D/S chest wall movement
Auscultation : Bruit (-)
Percussion: sonor
Auscultation:
Ves + + Wh - - Rh - -
+ + - - - -
+ + - - - -
 PHYSICAL
EXAMINATION
Abdomen: Rectal Touche:
Inspection : Distended (+), surgical scars (+) in regio - Tonus sphincter ani: good
inguinal dextra and sinistra - Rectal mucosa: smooth, slick, no palpable mass
Auscultation : BU (+) increase - Tenderness (-)
Palpation: defans muscular (-) - Blood (-), feces (+)
Superficial tenderness: Deep tenderness:
+ + + + + +

+ + + + + +

+ + + + + +

Percussion: tympanic (+)

Ekstremitas:
warm dry red acral +/+/+/+, oedema -/-/-/-, CRT<2
 SUPPORTING
EXAMINATION
Thorax AP (6/12/22 in Etty Hospital)

Conclusion:
 SUPPORTING
EXAMINATION
BOF 3 Position (6/12/22)

Herringbone apparance
 SUPPORTING
EXAMINATION
LABORATORY (6/12/22)
 PROBLEM LIST & PLANNING
Problem list Initial Diagnosis Planning Diagnosis Planning Therapy
Main Complaint: Abdominal pain Colitis - Pro laparotomy
History of Present Illness: The patient complained of abdominal pain in the dd chron disease Inf RL 30tpm
entire abdominal area since 2 weeks ago. Pain like squeezing with vas score 7, IV ranitidin 50mg
nausea (+), vomiting (+), Flatus (+) last night and she could only defecate a little. IV ondansetron 4 mg
Past Medical History: -

Physical examination:
Head/neck: dbn
Nose: dbn
Abdomen: dbn
Auscultation : BU (+) increase
Palpation: defans muscular (-)
Superficial tenderness: Deep tenderness:

+ + + + + +
+ + + + + +
+ + + + + +
Suporting examination:
BOF 3 position:
Hernia surgery 3 years ago
THANK YOU