MORNING

REPORT
January 22th 2017

DM Inggrit & DM Tieta

 IDENTITY

Name : An. AW
Age : 11 y.o
Sex : Male
Address : Sikumana
 HISTORY TAKING
Chief complain: the lower right abdominal pain
History of present illness : patient referrals from Boromeus
hospital with the lower right abdominal pain since the twenty-
two hours prior to hospital admission. Initially pain in the
epigastric and then a few hours spread to the lower right
abdomen. Pain that is felt constantly and like punctured. This
time the pain has been reduced. Patients also complain of fever
coincide with the onset of pain. Nausea (+), vomiting (+) by
more than ten times contain liquids and food, no blood.
Decreased appetite (+), headache (+), urinate within normal
limits, no pain when urinating, defecate within normal limits.
 PHYSICAL EXAMINATION
GCS : E4 V5 M6
TD : 100/60 mmHg, P = 115 x/m, RR = 32 x/m, T = 39,6
Head : in normal limit
Skin : rumple leede (+), petechie (+)
Eye: conjungtiva anemic (-/-), sclera icteric (-/-), direct light
reflex (+/+), hematom (-)
Nose : in normal limit
Throat : in normal limit
 Chest :
Inspection : symemetrical chest expansion, no retraction
Palpation : vocal fremitus (+/+)
Percussion : sonor (+/+)
Auskultation : vesicular (+/+), ronchi (-/-), wheezing (-/-)
Cor : S1S2 single, reguler, murmur (-/-), gallop(-/-)
 Abdomen
Inspection : flat
Auskultation : normal bowel sounds
Palpation : tenderness in the epigastric region and right hipokondrium (+), rebound pain (-)
Percussion : tympani
RT Strong anal sphincter tone, mucosal slippery, ampulla recti did not collapse, no pain.
Handscoen : feces -, blood
Urine bag concentrated urine color like the color of tea.
Extremity : in normal limits
 LABORATORY

Complete blood Complete urine

Hb 12,6 g/dL Keton 3+ mg/dl
RBC 4,94 x 10^6/ul
Ht 33.6%
WBC 16,77 x 10^3/ul
Platelet 435 x 10^3/ul
Neutrofile 83,5%
Neutrofile count 14,00 10^3/ul
 PLANNING DIAGNOSTIC

USG Abdomen
 ASSESMENT

Abdominal pain ec ??
 ADDITIONAL WORKUP

IVFD RL 1500 cc/24 jam

Inj Ranitidine 2x25 mg
Paracetamol tab 3x250 mg
 IDENTITY

Name : Mr. SL
Age : 21 y.o
Sex : Male
Address : Bakunase
 HISTORY TAKING
Chief complain: abdominal pain
History of present illness : patients present with complaints of
abdominal pain below the center since 19 hours before entering
the hospital. abdominal pain occurs after the patient has
experienced a collision on the motorcycle tank. Abdominal pain
continuously and to this day is still the same intensity. Such pain
and needles punctured and would not spread. Patients also
complain of nausea (+), vomiting (+) 6 times contain mucus
mixed with blood spots. Fever (-), headache (-), chest pain (-),
shortness of breath (-). BAK after this one, yellow without blood,
pain during urination (-), BAB within normal limits.
 PRIMARY SURVEY

Airway : clear, patent

Breathing : spontan RR = 22 x/minute
Circulation : TD = 110/70 mmHg, N = 80 x/minute
Disabillty : GCS =15, E4V5M6, pupile isokhor +/+, direct light reflex +/+,
NVD in normal limit
Exposure : in normal limit
 SECONDARY SURVEY
Head : in normal limit
Eye : anemic conjungtiva -/-, icteric sclera -/-
Mouth : in normal limit
Neck : in normal limit
Ear : in normal limit
Chest : in normal limit
Abdomen :
inspection : flat, lesion (-)
Auscultation : normal bowel sounds
Palpation : sociable, no mass, suprapubic tenderness (+)
Percussion : timpani
Extremity : in normal limit
 LABORATORY RESULTS

Hb : 15,1 g/dl
RBC : 5,99 x10^6/uL
Lekosit :5,96x 10^3/uL
Trombosit :272 x10^3/uL
Complete urine : in normal limit
 PLANNING DIAGNOSTIC

USG Abdomen
 ASSESMENT

Abdominal pain ec blunt trauma

 ADDITIONAL WORKUP

IVFD RL 1500 cc/24 jam

Inj. Ketorolac 3% 1 Ampul/iv
Inj. Ranitidine 1x50 mg/iv
 THANK YOU
KEEP FIGHTING AND GOD BLESS YOU