MORNING REPORT Enha Muthia Firdiyanti

IDENTITY
Name : Ms. Yuli Neno Besi
Age : 18 y.o
Sex : Female
Address : Raha
Admission : November 5th 2019
DPJP : dr. LD Rabiul Awal, Sp. B
HISTORY TAKING
• Chief Complainment :
Severe abdominal pain
• Anamnesis :
The patien complaind
• MOT :
The patien complained of severe abdominal pain since 4 days ago. Complaints of abdominal
pain felt since 3 months ago but disappeared. Patient were referred from RSUD Raha.
• HOT :
She had no loss of concsciousness. She threw up twice. There were prior medication:
Antasida and Paracetamol.
PHYSICAL EXAMINATION
• Generalized state :
Compos mentis, severe illness
• Vital sign :
 Blood pressure : 100/70 mmHg
 Heart rate : 102 bpm
 Respiratory rate : 42 breaths/min
Temperature : 38,5ºC
Localized state :
Abdomen
• Inspection : Convex, follow the motion of breath
• Auscultation : Peristaltic was normal
• Palpation : Tenderness Mc Burney (+), loose tenderness (+)
• Percussion : Tympani (+), Rovsing sign (+), Psoas sign (+)
PLAN OF DIAGNOSE
• USG
• Laboratory Test:
 Routine blood test
 Clotting time/ Bleeding time
 Blood chemistry test
LABORATORY FINDINGS
Result Unit Normal Result Unit Normal
Hematology Leukocyte
Hemoglobin 13.7 g/dl 12.0 – 16.0 NEUT 3.16 10^3/uL 1.50 – 7.00

Leukosit 4.27 10^3/uL 4.0 - 10.0 LYMPH 0.67 10^3/uL 1.00 – 3.70

Trombosit 195 10^3/uL 150 – 450 MONO 0.41 10^3/uL 0.00 – 0.70

Hematokrit 40.8 % 37.0 - 48.0 EO 0.00 10^3/uL 0.00 – 0.40

MCV 75.8 - fL 80.0 – 97.0 BASO 0.03 10^3/uL 0.00 – 0.10

MCH 25.5 - Pg 26.5 – 33.0

MCHC 33.6 g/dl 31.5 – 35.0
PCT 0.19 % 0.17 – 0.35
DIAGNOSE
APP Perforasi
MANAGEMENT
• Non-pharmacology
 Bed Rest
 Education
• Pharmacology
 IVFD
 Antipiretik
 PPI
 Antibiotik

Consult to Surgeon