MORNING REPORT

SMF/ BAGIAN ILMU BEDAH

FK UNDANA PROF. DR. W. Z.
JOHANNES KUPANG
14 OKTOBER 2016
DM SUSAN
D M N A O LY
DM MEGI

CASE 1

IDENTITY
Name

: Tn. SB

Sex

: Male

Age

: 58 y.o

Address

: Eropaun Lewoleba

Date of ER admission : 14 Oct 2016

(14:58)

HISTORY TAKING
Chief Complain
Shortness of breath

HISTORY TAKING
Patient admission to the hospital from Lewoleba
hospital because of difficult to breath since 3 days
ago. The difficult of breath feels continously, and
relieve with O2 inhalations and when he drink a lot of
water.
The patient has lumps at neck right and left since 3
years ago.
At the beginning, the lumps just seems like corn seed
and become like takraw ball in 3 years.
Patient explain that he have lost of weight, hoarse,
fatique, easy to sweat and sometimes have a
nightmare at sleep. Patients didnt have seizure
history.

PHYSICAL EXAMINATION
Vital sign :
BP : 110/70 mmHg
Pulse : 96 times/minutes
Temperature: 36,7 0 C
Respiratory rate: 32 times/minutes
GCS : E4M6V5

PHYSICAL EXAMINATION
Eye : in normal limit
Ear : In normal limit
Nose : In normal limit
Mouth : in normal limit

 Neck : enlargement of the right tyroid

lobe with the size about 7 x 7 x 5 cm and
the left tyroid lobe about 6 x 6x 5 cm,
clear boundaries, flat surface, no
tenderness.
Thoracic : in normal state,
Heart : heart sound 1&2 single, reguler,
murmur (-) gallop (-)
Lung : vesicular +/+, crackles -/-, rales -/-,
wheezing -/-

STATUS GENERALIS
Abdominal : in normal state
Extremity : in normal state

LABORATORY
Hemoglobin : 12.1 g/dL
Leucocyte : 8.92 x10^3/ul
Trombocyte : 332 x 10^3/ul
GDS : 177 mg/dL
Ureum darah : 150.8 mg/dL
Kreatinin : 1.81 mg/dL

FNAB
Conclusions:
Cyst lessions with inflammatory cell
components not found signs of
malignancy

ASSESSMENT
- Dyspneu ec struma thyroid

PLANNING
O2 nasal canule 4 lpm
IVFD RL 20 dpm
PTU and methylprednisolon
Pro surgery

CASE 2

IDENTITY
Name

: An. Miseli Seina

Sex

: Female

Age

: 4 y.o

Address

: Oebufu

Date of ER admission : 14 Oct 2016

(19:10)

HISTORY TAKING
Chief Complain
Abdominal pain

HISTORY TAKING
Patient admission to the hospital from pediatric with
abdomen cyst.
Now, Patient explained that pain of the stomach since
3 days ago. The pain become heavier last night.The
pain feel sharp, not continously in the middle of
abdomen.
Patients cant. Patient explained that
nausea and vomit everytime shes eat. Flatus (+),
stomach filled with more air (-), fever (-).
Patients always get the same complaint since she was
two years old and get some medicine but its not
relieve.

PHYSICAL EXAMINATION
GCS

: E4M6V5

Vital sign :
BP : 110/70 mmHg
Pulse : 96 times/minutes
Temperature: 37 C
Respiratory rate: 20 times/minutes
weight : 12 kg

PHYSICAL EXAMINATION
Eye : in normal limit
Ear : In normal limit
Nose : In normal limit
Mouth : in normal limit

 Thoracic : in normal state,

Heart : heart sound 1&2 single, reguler,
murmur (-) gallop (-)
Lung : vesicular +/+, crackles -/-, rales -/-,
wheezing -/-

STATUS GENERALIS
Abdominal :
INSPEKTION dome shapped
AUSKULTATION Peristaltic in normally
PERCUTION TYMPHANY (+)
PALPATION Tenderness pain in epigastrium regio and
umbilikus regio

Extremity : in normal state

LABORATORY
Hemoglobin : 14,4 g/dL
Leucocyte : 11,10 x10^3/ul
Trombocyte : 580 x 10^3/ul
GDS : 88 mg/dL
Ureum darah : 30,00mg/dL
Kreatinin : 0.46 mg/dL

USG
FINDING :
ABDOMEN CYST

ASSESSMENT
Colic Abdomen ec Abdomen Cyst

PLANNING
IVFD RL
Inj. Ketorolac 1x5,5mg
Domperidon

THANK YOU