MORNING REPORT

FAKULTAS KEDOKTERAN UNIVERSITAS MUHAMMADIYAH MALANG

RUMAH SAKIT MUHAMMADIYAH LAMONGAN
2016
 Status Pasien
Patient Identity

Name : Miss D
Gender : Female
Age : 15 years
Address : Lamongan
admission : 19/09/2016 time: 09:56
 Status Pasien
Anamnesis
Chief Complaint : lower Abdominal Pain
Present illness : abdominal pain since 1 year ago. The patient went to obsgyn
clinic one year ago and diagnosed with cyst ovarii but dont have a courage to
do an operation. Now, the patient complaining about lower abdominal pain
and nausea +. Her period cycle is in a normal limit but she also complaining
about disminorrhea +. defecation and urinary within in a normal limit

Past ilness : DM and HT denial

Family History : -
 Status Pasien
Physical
examination

Kesadaran : Composmentis
GCS : 456
Vital sign :Blood Pressure : 117/78 mmHg
Heart Rate : 86 x/ mnt
Temp : 36oC
RR : 18 x/menit
 Status Pasien
Physical
Examination
Head/ Neck : Inspeksi: anemia -, icterus -, cyanosis -, dispsneu -
Thorax : Simetris +, Retraction -/-
Lung: I : Chest expansion simetris
P : Chest espansion simetris, krepitation -
P : Sonor | Sonor
A : vesikuler/vesikuler Rh -/-, Wh -/-
Cor: I : ictus cordis (-), voussure cardiac (-)
P : thrill (-)
P : Batas jantung normal
A : S1S2 single, Murmur -, gallop -
Abdomen : I : flat
P : Soft, hepar dan lien unpalpable, tenderness mass
palpable
P : thympani
A : Bowel Sound decrease.
Extermity : Normal
 Status Pasien
Clue and Cue

Miss D
Lower Abdominal pain
Dismiorrhea +
Cyst ovary
Assesment
Cyst ovary

Planning Diagnosis
CBC
USG
 Laboratory Findings
GDA 81 Trombosit 286
Lekosit 5.5 MPV 4
Neutrofil 60.2 LED 1 15
Limfosit 26.1 LED 2 31
Monosit 7.5 HbsAg negative
Eusinofil 4.1 Metode 1 non reaktif
Hematokrit 38.7 APTT 38.10
Basofil 2.1 PT 13.70
Eritrosit 4.61
Hb 12.6
MCV: 83.90
MCH 27.30
MCHC 32.60
RDW 11
 Re-assesment

Cyst ovary

Terapi

1.Inf. Asering
1500cc/24 jam
2.Consult SPOG
pro kistektomi
Thankyou