MORNING

REPORT
 • Name : Mr. S
• Age : 43 Years old
• Sex : Male
IDENTITY • Address : Kapoiala
• Admission : November, 08, 2017
• Doctor in charge : dr. Laode Rabiul Awal, Sp.B-
KBD
 • Chief Complain : Abdominal Pain
• Anamnesis :
Patient admitted to hospital with complaint abdominal
pain suffered since 3 days ago. Abdominal pain suffered at
epigastrium and upper right regions. The complaint is
HISTORY intermitten. Patient complained about appearance yellow
colour on his body since 1 mounth ago and continuously.

TAKING The other complaints as fever (-), head pain (-), nausea (+),
vomiting (+), decreased appetite (+), weight loss (+).
Micturition was normally, defecate was normally.
 The history of same previous complaint (+)
 History of other disease as Hipertension (-), Diabetes
Mellitus (-)
 The history of previous medication (-)
 History of previous blood transfusion (-)
 The patient was conscious with
moderate ill

Pulse = 74x/m, reguler

PHYSICAL
EXAMINATION Blood Presure = 100/70 mmHg

Respiratory Rate = 20x/m,

simetris, thoracoabdominal type

Temperature = 36,8 OC
 Ears : Normally
Neck : Normally
: Normally
GENERALIZED Head
Face : Normally
Chest : Normally

STATUS Nose : Normally

Extremity
Superior : Normally
Mouth : Normally Inferior : Normally
Genitalia :
Normally
 ABDOMINAL
EYES
REGION
• Inspection : Conjungtival • Inspection : Flat (+), follow
anemis (+/+), Sclera Icteric the motion breath (+), icteric (+)
(+/+)
LOCALIZED • Auscultation : Bowel
peristaltic normally

STATUS • Palpation : Tenderness (+) at

epigastrium and upper left
regions, Palpable mass (-) at
epigastrium region, solid
consistency.

• Percusion : Tympanic is
reduced at epigastrium region
 ANAL REGION
DIGITAL RECTAL EXAMINATION
LOCALIZED • Sfingter Ani : Tight
STATUS • Mucous : Smooth
• Ampulla : Empty
• Handscoen : Blood (-), Mucus (-), Feces
(-)
 Blood
chemistry
PLAN OF Blood
DIAGNOSIS routine
USG
Abdomen
DIAGNOSE

ICTERUS OBSTRUCTIVE
e.c SUSP.
CHOLEDOCHOLITHIASIS
 CONSULT
DIGESTIVE
SURGERY

IVFD
MANAGEMENT
ANALGETIC

H2RA