MORNING REPORT

Department of Internal Medicine

Christian University of Indonesia

March th 2015

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Mr. A, 45 YO

Jakarta

CC : Epigastric pain

TC : Monday 6th March 2015

CM :

FindingsAssessmentTherapyPlanningEpigastric painNauseaVomitingDizzyAppearance: moderate illness, GCS : E4V5M6, BP: 120/80 mmHg, PR : 80 x/min (adequate,regular) RR : 18 x/min, T: 36,6CEye : 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 (+) EpigastricPercussion : Tympani, pain (-)Extremitas : warm acral, CR

Mr. J, 91 YO

Jakarta

CC : Shortness

TC : Monday 6th March 2015

CM :

FindingsAssessmentTherapyPlanningShortnessCough with white phlegmAppearance: moderate illness, GCS : E4V5M6, BP: 130/90 mmHg, PR : 96 x/min (adequate,regular) RR : 30 x/min, T: 37CEye : conjunctiva anemia -/- sclera icteric -/-Ear nose throat : normalNeck : lymph nodes not enlargedJVP : Distended (-)Thorax PulmoInspection : symmetricPalpation : vocal fremitus symmetricPercussion : symmetric, sonor soundAuscultation : long eksperium rhonki -/- , whezing +/+ Heart Sound S1 S2 Normal, murmur ( ), gallop ( )Abdominal Inspection : abdomen looks flatAuscultation : bowel sounds (+) 5x/minutePalpation : Pressure pain (-) Percussion : Tympani, pain (-)Extremitas : warm acral, CR

Subjective Data

Name: Mrs. Saomi

Address: Bekasi

CM: 71-72-03-00

TC: Saturday/ December 7th 2013/ 7.30 AM

CC: Epigastric Pain

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Anamnesis

Main symptom : Epigastric Pain

Additional 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 didnt 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.

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Past Medical History and Treatment

Hypertension (+) 1 year ago use Captopril as the medicine, Diabetes Meillitus (-),

Family History

-

Social History

Smoking (-), Alcohol (-)

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Objective Data

Consciousness : E4V5M6 ; Composmentis

Appearance: moderate ill

Blood Pressure: 140/70 mmHg

Pulse Rate: 108 x/min (adequate,regular)

Respiration Rate : 22 x/min

Temperature: 36,50C

EYE: conjungtiva anemic -/- ; sclera icteric -/-

Ear Nose Throat : Normal

Lips Mucose: dry

Neck: Normal

JVP: Normal (5-2 cmH20)

THORAX:

Heart

Inspection: Ictus Cordis invisible

Palpation: IC not palpable

Percussion: Right heart border Inter Costae IV line Parasternal dextra, Left heart border Inter Costae V mid clavicula sinistra

Auscultation: S1 single, S2 single, regular, murmur (-) gallop (-)

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Pulmo

Inspection: Static and dynamic symmetric

Palpation: Vocal Fremitus right and left symmetric

Percussion: Sonor symmetric

Auscultation: Vesiculer, wheezing -/-, ronkhi +/+

ABDOMEN

Inspection: stomach looks flat

Auscultation: Bowel sound (+), 8 x/min

Palpation: Defense muscular

Pressure pain in epigastrium +

LiverSpleen impalpable ;

Percussion: Tympani; Percussion Pain

EXTREMITIE

Pitting Edema (-/-) in lower extremity; warm (-) ; CRT

Labolatorium Test

Na 143 mmol/L

K 3,9 mmol/L

Cl 108 mmol/L

Assessment

Acute Gastroenteritis with Moderate DehydrationHypertension gr I

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Therapy

Pro Hospitalized

IVFD : III RL / 24 hours

Diit : non-stimulating rice porridge

Mm/

Ranitidin 2x1 amp

Ondancentron 2x4mg ( bolus IV )

Sucralfat syrup 3x2 C a.c.

Zink kid 3x1 tab

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Planning

RehidrationFeces CulturH2TL test

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Thank You

Department of Internal Medicine

Christian University of Indonesia

December, 7th 2013

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