MORNING REPORT

Internist, July 27 2014

C-21

Patients Identity

Name
: Mr. Ky
Age
: 19 y.o
Religion
: Moeslim
Date admission
: July 27 2014
Adrress
: Balongrejo - Lamongan

Anamnesis
Chief complaint: abdominal
discomfort
Present illnes: Patient was admission on
Emergency department of Muhammadiyah Lamongan
hospital because he feel abdominal discomfort since 2
month before hospitalized. Abdominal discomfort especially
after eating, he is often burp. Nausea +. Vomiting -. Pain
the stomach -, epigastric pain . Urination and defecation
are normal. Patien have been treated but not change.

Anamnesis
History or past illness :
- Alergy -, DM -, Hypertensi -, gastritis History of family :
Denial
History of past treatment :
Omeprazole
Trimetoprim+sulfametoksazole
Fucohelix

Physic Examinations

GCS : 456, Compos Mentis

Vital Sign
BP
: 122/98 mmHg
Pulse
: 98x / minutes
RR
: 20x / minutes
Temp
: 36C

Clue & Cue

Man 19 y.o
Abdominal discomfort especially after eating
Burp +
Nausea +

Problem list
Dyspepsia

Physic Examinations
Head and neck

Anemic-/ icteric-/ cyanosis-/ dyspneu-

Thorax :
Pulmo :

I : Simetric, retraction -/P : fremitus + simetric

P : sonor/ sonor
A : ves/ves, rh -/-, wh (-/-)

Cor

I : vassoure cardiaque P : ictus cordis not palpable

P : heart limit are normal
A : S1-S2 single, murmur(-), gallop(-)

Physic Examinations
Abdomen

I : flat
P : soepel, hepar and lien not palpable, pain P : tympani
A : bowel sound (+N) ,

Extremity : warm, dry, red, edema

Problem List

Dyspepsia

Assessment
Dyspepsia

Planning
Planning Dx :
CBC
SE

Planning Tx :
Asering 1500 cc/24 hour
Rantin 2x50 mg IV

Planning Monitoring
Complaint
Vital sign

Prognosis
Dubia ad bonam

Education
Explain to the family about
the condition of this patient
now, its disease, about its
examinations, theraphy and
intervention will be done, and
also about complication and
prognosis.