MORNING

REPORT
 Name : Mr. Dino
Age : 22 years old
Sex : Male
IDENTITY Address : Bau-Bau
Admission : October, 30th, 2019 (10.45 am)
Doctor in Change : dr. LD. Rabiul Awal, Sp.B-KBD
 Main Complain: Abdominal pain
Anamnesis: Referral patients from Siloam Bau-Bau
hospital with complaints of abdominal pain after
laparatomy surgery appendicitis since 5 days ago.
Other complaints: no nausea, no vomiting, no
fever, decreased appetite. Urination and
HISTORY defecation are normal. Attached to the stomach
with a volume of approximately 100 ml, reddish
TAKING brown liquid.

• History of previous operations (+) : after

appendicitis surgery.
• History of illness with the same complaint (-).
• Treatment history (+): Referral patient from Siloam
hospytal; IVFD, antibiotic injection, analgetic
injection.
 General status :
Severe illness, composmentis Head : Normally
Nose : Normally
Vital sign : Mouth : Normally
GENERAL BP : 140/80 mmHg Neck : Normally
RR : 22 x/minute Chest : Normally
SURVEY HR : 80 x/minute, rregular Abdomen : Localized
T : 37,0 °C Upper and lower limb : Normally
 Abdomen region :
• Inspection : attached abdominal drain
• Auskultation : decreased peristaltik
• Palpation : tenderness (+), distended
abdomen (-)
Generalized • Perkution : thympani (+)

Localized
Rectal Examination :
Sphincter : Tight
Mucosa : Smooth
Ampulla : Feces (+)
Handscoen : Feces (+), Blood (-), Mucus (-)
CLINICAL
FINDINGS
 • Routine Blood
PLAN OF
DIAGNOSTIC • Blood Chemistry
• Immune-serology
 Blood Chemistry
Routine Blood
WBC 11,28 x 10^3 /uL GDS 73 mg/dl
HGB 11,6 g/dL Ureum 38 mg/dl
PLT 393 x 10^3 /uL SGOT 17 U/L
SGPT 24 U/L

Immune-serology
HBsAg non reaktif
 DIAGNOSE

Acute abdominal susp. of postoperative caecum

perforation Laparatomy appendicitis
 • IVFD
• Antibiotic injection
• Analgetic injection
MANAGEMENT

Consult To Digestive Surgeon