MORNING REPORT

PATIENT IDENTITY

Name
Gender
Age
Occupation
Address
Ethnic
Religion
Marriage st.

: An APS
: Female
: 4 y.o
:: Bluluk, Lamongan
: Javanesse
: Moslem
: Single

SUMMARY OF DATABASE
Chief of complaint:
Bloody diarrhea

History of present illness

These patient is referred by ngimbang hospital with bloody diarrhea
since this morning before admission suddenly. Patient defecates 3
times a day, with liquid and sometime with grouts, fresh blood +,
mucus -. She feels pain while defecating.
Patient is also feeling colic pain at Left upper quadrant and
sometime at right lower quadran. Theresnt any migration pain or
any epigastrium pain before.
Nausea and vomiting +, each vomit consists food and water that
consumed before. Blood Loss appetite since 3 days before admission
Fever, caugh (-)
last urination is at 10 AM, with small amount of volume.
Pain while urination denied
Stomach bloating +

 History of past illness:

Before abdominal pain exist, parent told that she
couldnt defecate 5 days before admission, without
any confession about flatus whether she did or did
not.
Parent told that she never took any anti- diarrhea
before pain happen.
Any drug Allergic -

History of family illness:

Same complaint before denied

History of social illness:

Bowel habit/ chronic constipation - , urination habit
Last meal before pain and bloody feces happen was
sausages.

PHYSICAL EXAMINATION
Vital Sign:
Blood Pressure
Pulse Rate
Respiration Rate
Temperature

: 0/0 mmHg
: 114 x/minutes
: 24 x/minutes
: 38 C

Generalis Examination:
Head/Neck: anemis -/-, jaundice -/-, cyanosis -/-,
dyspnoe -/-. Dry mouth mucose +, sunken eye -|-.
Chest:
Inspection: symmetrical, retraction -/-,

Palpation: normal/ normal

Percussion: sonor/sonor
Auscultation: vesicular/vesicular, Rh -/-, Wh -/-

Cor:
Inspection: Ictus cordis(-)
Palpation: ictus (-), thrill (-)
Percussion: the normal size of heart
Auscultation: S1/S2 single and reguler, murmur -, gallop

Abdomen:
Inspection: Flat,
Palpation: soepel, some masses + on the RLQ long like sausage, solid,
reguler, tenderness -, mobile. hepar and lien not palpable, tenderness -,
Mc Burney sign (-), Rovsing sign, blumberg sign (-), turgor slowly ,
Percussion: tymphani
Auscultation: bowel sound (+), metallic sound (+)
Extrimity :

warm, dry, red, CRT < 2

CLUE AND CUE

Bloody feces paroxismal

Tenesmus
Colic pain
Nausea and vomitting
Lost appetite
Urination pain
Bloating +
Obstipasi history + and using anti diarrhea
Takikardia
Dry mouth mucose +
Some Masses et regio iliaca D long like sausage , solid, reguler, mobile, tenderness
-, metalic sound +
Leucocyte 12.3
USG ; susp. invaginasi
Kolon in loop ; intusepsi

PROBLEM LIST
Susp ileus obstruktif

PLANNING DIAGNOSIS
DL
USG
Colon in loop

LABORATORIUM

Hb
: 11.5
Lekosit
: 25.000
Erytrocyte : 4.48
Hematocrete : 34.4
Platelets : 414.000
Eosinophyl : 2.2
Basofil
: 1.7
Neutrophyle : 89.1
Lymphocyte : 3.4
Monocyte : 3.6

K
NA
Cl
GDA

: 4.4
: 131
: 99
: 51

USG

Re- assessment
Intususepsi

PLANNING THERAPY
Ivfd Kaen 3B loading 300cc status dehidrasi
terkoreksi maintananance 1200cc/24
jam
Inj. Ceftriaxon 2 x 1 gr IV
Inj. Ondansetron 2 x 2 mg IV
Drip D40 1 fl cek GDA
Pro laparotomy

EDUCATION

Inform parent about diagnosis.

Inform parent about result of physical examination and planning of other
examination
Inform and educate parent about therapy planning whether konservatif or
operatif..
Inform about complication of disease and therapy.