MORNING

REPORT
July 18th 2017

DM Eus & DM Hilda

 IDENTITY

Name : By. Ny. CL

Age : 5 days
Sex : Female
Address : Sikumana
 HISTORY TAKING
Keluhan utama :
Riwayat penyakit sekarang : pasien dirujuk dari RS leona karena
lubang anus dan lubang kemaluan menjadi satu.
 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