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MORNING REPORT

IDENTITY
Name : Miss S
Age : 17 Years Old
Sex : Female
Address : Lepo-lepo
Admission : May, 12th 2018
Doctor in charge : dr. La Ode Rabiul Awal, Sp.B-KBD
HISTORY TAKING
Main Complain : Lower Right Abdominal Pain
Anamnesis :
Patient came with lower right abdominal pain since 1 days ago before admitted to the
hospital. Initially pain felt at epigastric region and then move to lower right abdomen. The
pain felt continuously. There were fever (-), nausea (+), vomit (+), anorexia (+) and still
flatus (+). Urinate was pain. Defecate was normally. Patient have not menstruation.
There was not history of the same symptoms
There was not family history of the same symptoms
There was not history of previous medical treatment
GENERAL SURVEY
General status : Head : Within normal limits
mild illness, GCS 15 Nose : Within normal limits
Vital sign : Mouth : Within normal limits
BP : 110/70 mmHg Neck : Within normal limits
RR : 24 x/minute Chest : Within normal limits
HR : 88 x/minute Abdomen : Localized
T : 37,7°C Upper and lower limb : Within normal limits
Generalized Localized
Abdominal
Inspection : Flat (+), follow the motion breath (+), distended (-)
Auscultation : Peristaltic (+) normally 10x/m
Palpation : Tenderness at Mc Burney Area (+), mass (-), Rovsing sign (+), Blumberg sign (-),
Percussion : Tympani (+)

Rectal Tuoucher
Sphincter Ani was tigh Mucous was smooth
Ampula filled feses, dilated (-),collapse (-) Handscoen : feces (+) brownish, blood (-), mucous (-)
Clinical Documentation
Plan of Diagnostic
o Routine Blood
o Routine Urine
o Plano test
o USG Abdomen
Laboratory Findings
(Routine Blood)
• WBC : 14.43 x 103 u/L
• RBC : 4.69 x 106 u/L
• HB : 12.2 gr/dl
• PLT : 256x 103 u/L
• NEUT : 88.3%
Laboratory Findings
(Routine Urine)
• Plano test : Negative (-)

• Makro : Kuning, jernih


• Kimia : Keton (+++), Leukosit (+)
• Sedimen : Leukosit (+), eritrosit (6-15), epiel sel (+)
Alvarado Score
Manifestations Value
Migration of pain 1
Symptomps Anorexia 1
Nausea/Vomitting 1
Right Lower quadrant
2
tenderness
Signs
Rebound tenderness 1
Elevated temperature 1
Leukocytosis 2
Laboratory Values Shift of neutrophils to the left 1
Total Points 10
USG
Diagnostic
Acute Appendicitis
Management
Farmacology

•IVFD Consult To Digestive


•Antibiotic Injection Surgeon
•Analgetic Injection
•H2RA Injection