MORNING REPORT

Department of Internal MedicineChristian University of Indonesia

March 8th 2015

Findings Assessment Therapy Planning- Lower abdominal pain- Epigastric pain- Nausea- micturition pain- Polyuria

Appearance: moderate illness, GCS : E4V5M6, BP: 130/70 mmHg, PR : 82 x/min (adequate,regular) RR : 22 x/min, T: 37,4°C

Eye : conjunctiva anemia -/- sclera icteric -/-Ear nose throat : normalNeck : lymph nodes not enlargedJVP : Distended (-)

THORAX PulmoInspection : symmetricPalpation : vocal fremitus symmetricPercussion : symmetric, sonor soundAuscultation : vesiculer rhonki -/- , whezing -/- Heart Sound S1 S2

Normal, murmur ( – ), gallop ( – )

Abdominal Inspection : abdomen looks flatAuscultation : bowel sounds (+) 5x/minutePalpation : Pressure pain (+) Epigastric, suprapubicPercussion : Tympani, pain (-), regio CVA left pain (+)

Extremitas : warm acral, CR<2”, pitting edema -/- , Turgor normal

• Dyspepsia

• urinary tract infection

Hospitalization

IVFD : I RL / 24 h

Diit : smooth

Mm/ Ranitidine HCl IV 1x50 mgOndancentron IV 1x 8mgSucralfat syr 3x1 C Asam mefenamat 3x 500mg Ceftriaxone 2x1gr

- Hematology- Electrolyte- Urinalisa

Mrs. E, 55 YOJatinegaraCC : Lower left Abdominal pain

TC : Sunday, 8th March 2015CM : 45430600

Subjective DataName : Mrs. SaomiAddress : Bekasi

CM : 71-72-03-00

TC : Saturday/ December 7th 2013/ 7.30 AM

CC : Epigastric Pain

AnamnesisMain symptom : Epigastric PainAdditional symptom : Nausea, Vomiting, Diarrhea

68 years old female patient come to the emergency with complaints of epigastric pain since 5 hours before hospital admission. Epigastric pain is like kneaded. Epigastric pain occurs continously. Before the epigastric pain occurs, she ate food from her neighbour. After she ate the fod, she felt epigastric pain and had diarrhea as many as 4 times. The feses is like a water, no blood, no mucus. She didn’t eat or drink medicine to reduce the epigastric pain. The other symptoms were nausea, vomited, diarrhea, malaise, and lost of appetite. Patient had a history of hypertension since 1 year ago and she never controlled it. Patient consumed Captopril. Patient had allergy of chicken, prawn, and egg.

Past Medical History and Treatment Hypertension (+) 1 year ago use Captopril as the

medicine, Diabetes Meillitus (-),

Family History-

Social HistorySmoking (-), Alcohol (-)

Objective DataConsciousness : E4V5M6 ; ComposmentisAppearance : moderate illBlood Pressure : 140/70 mmHgPulse Rate : 108 x/min (adequate,regular)Respiration Rate : 22 x/minTemperature : 36,50CEYE : conjungtiva anemic -/- ; sclera icteric -/-Ear Nose Throat : NormalLips Mucose : dryNeck : NormalJVP : Normal (5-2 cmH20)THORAX : HeartInspection : Ictus Cordis invisiblePalpation : IC not palpablePercussion : Right heart border Inter Costae IV line Parasternal dextra, Left

heart border Inter Costae V mid clavicula sinistraAuscultation : S1 single, S2 single, regular, murmur (-) gallop (-)

PulmoInspection : Static and dynamic symmetricPalpation : Vocal Fremitus right and left symmetricPercussion : Sonor symmetricAuscultation : Vesiculer, wheezing -/-, ronkhi +/+

ABDOMENInspection : stomach looks flatAuscultation : Bowel sound (+), 8 x/minPalpation : Defense muscular –

Pressure pain in epigastrium +Liver–Spleen impalpable ;

Percussion : Tympani; Percussion Pain –EXTREMITIE

Pitting Edema (-/-) in lower extremity; warm (-) ; CRT <2 secondTofus in pedis dextra.

SKINTurgor : decreased

Objective Data

Labolatorium Test

Na 143 mmol/LK 3,9 mmol/LCl 108 mmol/L

Assessment• Acute Gastroenteritis with

Moderate Dehydration• Hypertension gr I

TherapyPro HospitalizedIVFD : III RL / 24 hoursDiit : non-stimulating rice porridgeMm/ Ranitidin 2x1 ampOndancentron 2x4mg ( bolus IV )Sucralfat syrup 3x2 C a.c.Zink kid 3x1 tab

Planning• Rehidration• Feces Cultur• H2TL test

Thank You

Department of Internal MedicineChristian University of Indonesia

December, 7th 2013