Morning Report

17 Februari 2016

ARDIRESTU S.
NANDA SHASKIA L.
M. CHANDRA F.
NURUS SHUHBAH
DENNY INDRA M.
M. FEBRI S.
SITI KHAIRUNNISA N.H.
SEKAR INTAN P.
FIDYA RAHMADHANY
IKKA NUR A.
AMELIA NINGSIH
LIA ASTUTI

Patients Identity
Name
Sex
Age
Address
Occupation
Ethnic
Religion
Hospitalised
MR Number

: Mr. Anang Ariyanto

: Male
: 42 yo
: Belianti RT. 003/002, Kalsel
: Fisherman
: Banjar
: Islam
since : February 2th, 2016
: 119-87-66

Summary of Data Base

Mr. Anang Ariyanto/42 yo/(Autoanamnesis and Heteroanamnesis)
Chief Complain: Abdominal Pain
Medical History
- Since 4 months ago he complained abominal pain throughout every
region of the abdomen. The first felt is abdominal sudden pain, then the
pain become relapsing-remitting.
- Since being treated in hospital (14 days ago), patients complains of abdominal
pain with dysentery, fresh red stool, sometimes black, the concistency
sometimes dense sometimes liquid. The amount of blood is estimated 1 plastic
cups (300 ml). Patients also complains about activities and apetite disurbance.

- First treatment that he got was a surgery in Kuala Pambuang Hosipital.

Patients are referred to Ulin Hospital Banjarmasin to get further treatment

concomitant complaints : vomitting (+), febris (+), night sweats(+), tidur

gelisah (+). smoking (+), alcohol consumption(+)

Past Medical History

Post Appendictomy 4 months ago DM(-), HT(-),

Kidney Disease(-), Icteric(-), Pulmonary Disease(-)

History of Family Illness

His Siblings passed out because of the same
illness (abdominal Pain)

Riwayat Sosek
Hes a fisherman and a BPJS member

Physical Examination
General
appearance

Looked serious ill, Compos Mentis, GCS

:456

Blood Pressure

80/50 mmHg

Weight

36 kg

Height

158 cm

IMT

14,4 (bad nutrition)

Pulse Rate
Respiration rate
Temp

91 bpm regular , PO2 : 94%

22 ppm
36,3 0C

Head

Pale conjunctiva (+/+), Jaundice sclera (-/-),

decreased visual acuity (-/-), Edema
palpebra
(-/-), Diplopia (-), discharge (-/-), pain (-)

Neck

Lympatic node swelling (-)

Chest Heart

Inspection : ictus invisible

Palpation : palpable in MCS ICS V
Right margin : Right : ICS II-III L.Ster (D).
Auscultation : S1 S2 single, murmur (-)

Physical Examination(contd)
Skin : Hipopigmentasi in face, neck and back. Tanned
Head : normosefali
Eyes : Anemic Conjunctiva(+)
ENT : Normal Condition
Neck
: Normal Condition
Chest : Normal Condition
Cor : Border(N), Heart Sound I-II(N), Pulsasi (+) , Left border
of ICS IV mid clavicula sinistra. Right border of ICS III
Parasternal dextra. Murmur (-), gallop (-).
Pulmo : Sonor, vesicular, Rh-/-, Wh-/Abd.
: H dbn, L ttb, NT Inguinal dextra dan suprapubic(++), NT
Lumbal sinistra, lumbal dextra, umbilicus, Inguinal dextra (+).
BU(+) menurun
Extrem : Cold extrimity, edema-/-, Inguinal Lymph Nodes
Enlargment (+).

SUmmary
A man 42 y.o, AA, complaining abdominal pain,
since14 days ago, Sudden pain, relapsing-remiten,
melena (+),, vol: +/- 300 ml. Activity , physiologic
ttg
Physical examination
T: 36,3oC, BP: 80/50 mmHg, P: 91ppm, PO2: 94%,
GCS: E4V5M6 (Compos mentis), conjunctiva anemi,
Abdominal examination
post op scars reg Ingunal dextra, Tenderness lumbal
dex sin(+), umb (+), ing dex(++) sin (+), sup.pubic
(++)

Problem
1. Abdominal Pain
1.1 Ca colon
1.2 Colitis Ulserosa
1.3 Small Intestinal Carcinoma

Problem List
No.

Problem

1.

Abdominal Pain

Supporting Data

1.1 Ca Colon

Diffuse AP, melena,

hematochezia, weight
loss, anemi conjunc.,
alcoholic, smoker, feses
consistency: solid and
liquid +/- 300 ml ,
Inguinal Lymph Node
Enlargment (+)

1.2 Colitis Ulserosa

Post Apendiktomi, AP,

melena, Weight Loss, fatigue,
fever.

1.3 Small Intestine Carcinoma

Diffuse AP, melena, weight

loss, conjunc.anemi,
alcoholic, smoker, feses
consistency: solid and liquid

No.

Problem

Diagnose Plan

Therapy
Plan

Monitoring
Plan

Educational
Plan

1.

Abdominal Pain

RT, Complete
Blood Exm. , Ca in
loop (barium
enema),
Colonoscopy, Histo
PA.

IVFD RL,
Surflo 18,
infusion set,
injeksi
cotrimoxaszo
l, inj.
ketorolac 1
amo, inj.
Buscopan 1
amp.

General
Cond,
Complaintm
ent, Vital
Sign

Bed rest,
Diet (little
portion, less
saturated
fat), Stop
smoke and
alcohol
consumption
, water drink
(8 cup per
day
minimal),
position
changing for
miniize the
decubitus

Thank you