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Morning Report january 18, 2016

Dept of internal medicineF24

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IdentityName Mr!" # $ge %& year! old'ccupation (

$ddre!! )ucu*(+amongan$dmi!!ion Marc -, 2016 at 0%"4. )M

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/ ief /omplaint

)re!ent i!tory

Rig t upper a dominal pain

)atient complain pain at rig t upper a dominal !ince t i!morning at 0."00 am, continuou!ly, not reduced it re!t,pain li*e a punctured" )atient! complain a e omiting

lac* lood 23 le!! t an alf of gla!!, t e la!t t o our!efore admitted" )atient al!o complain of alc* !tool it

a pa!te con!i!tency li*e a peti!5 13 at t e morning"$ppetite decrea!ed lately, nau!ea " )atient !aid oftenadmitted in R7M+ it t e !ame complaint" )atient a eyello urination ut e er a e urination color li*e tea"Di ine!! (, fe ri! ("

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)a!t i!tory of Illne!!

Family i!tory

• 79 : ; routine control to dr 7p" )D• DM denied• 9? denied

No familial related

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7ocial i!tory

/igarrete :(;

/o@e :(;$lco ol :(;

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Aital 7ign!)ul!e

11&3Bmin

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$ clear, gargling :(;, !noring :(;, !pea*Cuently : ;, potential o !truction :(;< !pontan, RR 223Bmin, e! B e!, r (B(,

(B(, 7a '2 .& it out '2 !upport/ e3tremity >D), /R? E2 , N 11&3Bmin, ?D104B62 mm9gD G/7 4%6, lat (, )

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G=N=R$+ 7?$?H7

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General condition ell$ arene!! compo! menti!G/7 4%69BN a Bi(Bc(Bd(

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? ora3In!pection

7ymmetrical, retraction ()alpation

Fremitu! >N+, t rill :(;

)ercu!!ion+ung! !onor B/or N

$u!cultation+ung! e! B e!, r (B(, (B(/or 71 72 !ingle, mur (, gall(

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$ domenIn!pectionFlat, collaterral ein! : ;, inCammation !ign! :(;$u!cultation

Met (, gut noi!e >N+

)alpation=piga!tric pain :(;Mc urney(

?urgor >N++i er 2cm a o e arcu! co!tae

)ercu!!iontymp any

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=3tremitie!In!pection

/lu ing nger! : ;, icteric :(;, cyano!i! :(;)alpation

>arm, pale and dry, /R? E2

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/+H= $ND /H=

Female %& year! oldRig t upper a dominal painAomiting lac* lood

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)lanning Diagno!e/

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$!!e!ment/irr o!i! 9epati!$nemia9emateme!i! Melena

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+a oratory Finding!

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=#G

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)lanning ? erapy

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)+$NNING M'NI?'RING

Aital 7ign!)atient ! complaintNG? production

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)+$NNING =DH/$?I'N

=3plain to t e patien and i! family a out t edi!ea!e, cau!e, !tadium of t e di!ea!e,complication, inter ention of t e t erapy andprogno!i!"