MORNING REPORT

AHMAD CHAER DARWIS

IDENTITY

Name : Mr. S

Age : 25 years old

Sex : Male

Address : Lambuya

Admission : September 20th, 2019 (5.30 am)

Doctor in Charge: dr. Edwin, Sp. B

 HISTORY TAKING

Chief Complaint:
Pain at right lower quadrant abdomen

Anamnesis:
Experienced since 4 Days before admission and worsens dramatically over the
course of 1 hours. Pain initially felt in the epigastric region then spreading to the
right lower quadrant of abdomen. Pain was reported as dull and constant that was
exacerbated as he moved, and usually lie to avoid worsening the pain. He also
reported nausea and vomitting over 4 times. She had a history of diarrhea four
times this morning. He had experienced pain while urinating.

History:
He had no history of similar problem. He had no family history of similar problem.
PHYSICAL EXAMINATION

• Generalized state:
Composmentis, moderate illness, well nourished
• Vital sign:
 Blood presure: 120/80 mmHg
 Pulse rate: 96 bpm, regular, strong beats
 Respiratory rate : 18 breaths/min,
spontaneous, regular, thoracoabdominal
type
 Temperature: 36,7’C / axillary
PHYSICAL EXAMINATION

Present State:
 Head : normal Chest : normal
 Face : normal Abdomen : localized
 Eyes : normal Upper Limb : normal
 Nose : normal Lower Limb : normal
 Mouth: normal Genitalia : not examinated
 Ears : normal Vertebrae : normal
 Neck : normal
PHYSICAL EXAMINATION

Localized State:
Abdomen
• Inspection : Convex, follow the motion of
breath
• Auscultation : Peristaltic was increased
• Palpation : Tenderness (+) at hypocondirum
dextra region, mcburney (+), rovsing sign (-),
blumberg sign (-)
• Percussion : Tympani (+)

• Another test: dunphy sign (+), Obturator sign

(+)
1
0
1
2
-
-
2 ALVARADO SCORE
-
6
CLINICAL DOCUMENTATION
PLAN OF DIAGNOSE

Laboratory Test
•Routine Blood Test
LABORATORY FINDING

Result Unit Normal

Hematology
Hemoglobin 11,6 mg/dl 11.0 – 17,9
Leukosit 19,7 10^3/uL 4.0-10.0
Trombosit 317 10^3/uL 150 - 450
Hematokrit 49,5 % 37.0 - 48.0
 DIAGNOSE

Susp. Acute Appendicitis

DD:
Kolesistitis
 MANAGEMENT

• Pharmacology • Non-Pharmacology
IVFD Bed Rest
Antibiotic oral Education
Analgesic oral

Referred to General Surgeon

THANK YOU