MORNING REPORT

Department of Internal MedicineChristian University of Indonesia

Oct 30 2014 TEAM 1

Findings Assessment Therapy Planning

Appearance: moderate illness, GCS : E4V5M6, BP: 130/80 mmHg, PR : 86 x/min (adequate, regular) RR : 28 x/min, T: 36° CEye : conjuntiva not pale, Sklera icteric -/-Ear, Nose, Throat: normalNeck : lymph nodes did not enlargedTHORAX Insp : symmetric, ictus cordis (-)Pal : vf symmetric, ictus cordis not palpablePer : symmetric, sonor sound RHB ICS V lin. sternal dext, LHB ICS V lin. Midclavicula sinAus : vesicular rh -/-, wh-/- S1 single, S2 single, regular, murmur (-) gallop (-)ABDOMINALIns : flatened abdominal wallAusc : bowel sounds + 3xPalp : Pressure Pain + Undulation (-), Per : timpany, shifting dulness (+), Extremitas : warm acral, CR<2”, edema

LAB FINDING:Complete Perifer Blood :Hb : 11.2 gr/dl, Ht : 35.7,2%, trombo: 377.000/uL Leu: 18.500

Dyspepsia syndromeAcute Gastroenteritis

Pro Hospitalized IVFD : RL III/24hrsDiet : softMm/ Ceftriaxone 2 x 1grRantin 2 x 1 Metronidazole 3 x 500 mgOmeprazole inj 2 x 40 mgSucralfat 3 x 1 C

- Glucose plasma test

Mr W. (52 YO)

CC : epigastric pain, breathless

+_

-+

Subjective DataName : Mr. WAddress : JakartaTC : Tuesday, 30th October 2014CC : nausea

AnamnesisMain symptom : nauseaAdditional symptom : vomit, bloating, epigastric pain

52th years old male came with chief complaint: nausea. This symptom happened during 7 days and exaggerated in 3 days

Patient is a smoker, coffee drinker, and he said he eat nothing today. The patient denied also has complain in gastrointestinal system. he voids waterry diarrhea.

Mr. W also had complain of stomach pain, which is locate on upper and left abdomen, vomiting, sour and bitter taste inside his mouth. He vomit for about 4 times, the colour of his vomit is bright yellow and sometimes, it just water that came out.

Past Medical History and Treatment (denied)

Family History(denied)

Social History , Alcohol (-), smoking (+),

Coffee drinker (+)

Objective DataLOC : E4V5M6 ; ComposmentisAppearance : mild illBP : 110/70 mmHgHR : 86 x/min (adequate, regular)RR : 28x/minTemp : 360CHEAD & EYE : lymph nodes not palpableTHORAX :

HeartIns : IC invisiblePal : IC not palpablePer : RHB ICS V lin. sternal dext, LHB ICS V lin. Midclavicula sinAusc : S1 single, S2 single, regular, murmur (-) gallop (-)

PULMOInsp : Static and dynamic symmetricPal : VF right and left symmetricPerc : Sonor symmetric Ausc : BBS Vesicular, Rhonki -/-, Wheezing -/-

ABDOMENInsp : flattened abdominal wall

Ausc : Bowel sound (+) 5 times a minutePal : tenderness (+), palpation pain (+)Perc : shifting dulness (-), percussion pain (-)

EXTREMITIESEdema (-/-/-/-); warm (+); capp. Refill <2

seconds

Objective Data

- +

- -

Clinical Laboratory

•Hb : 11.2 gr/dl•Ht : 35.7%•Trombo: 377.000/uL •Leu: 18.500

Assessment

•Dyspepsia Syndrome•Acute Gastroenteritis

TherapyPro Hospitalized IVFD : RL III/24hrsDiet : softMm/ Ceftriaxone 2 x 1grRantin 2 x 1 Metronidazole 3 x 500 mgOmeprazole inj 2 x 40 mgSucralfat 3 x 1 C

Planning- Glucose plasma test

Thank You

Department of Internal MedicineChristian University of Indonesia