MORNING

REPORT
Department of Internal Medicine
Christian University of Indonesia
June, 10
th
2014
TEAM 2
Findings Assesment Therapy Planning
Vomiting , Fever , Loss of appetite, painful swallowing,
cough without phlegm

PHYSICAL EXAMINATION
Appearance : being sick, GCS E4V5M6
BP : 130/70mmHg
HR : 96x/min
RR : 20x/min, T : 37.3C
Eye hyperemic conjunctiva (-/-), Icteric sclera -/-
THT : normal
Mouth : normal
Neck : lymph nodes not enlarge, JVP : 5-2 cmH2O
Thorax
Ins : chest movement symmetric
Pal : vocal fremitus sound symmetric
Per : symmetric sonor sound
Aus : basic sound of breath vesicular, wheezing (-/-), ronchi
(-/-)
Heart sound I & II regular, murmur (-), gallop (-)
Abdominal
Ins : looks flat
Aus : bowel sound (+), 4x/min
Per : percution pain, timpani sound
Pal : tenderness epigastrium and defence muscular
Extremities
warm acral, CRT < 2 s, edema
LABORATORIUM
Hemoglobin : 15,9 g/dl
Haematocrit : 41,1 %
Leucocyte: 17,6 ribu/ul
Thrombocyte : 200.000 /ul
Dyspepsia
Gastritis akut
-Prohospitalized
-Diet : soft, not to stimulate
-IVFD : III RL / 24 hours
-Mm/
Ceftriaxone drip 2 x
200 mg
Paracetamol 3 x 50 mg
Omeperazole 2 x 20mg
Ondansetron 1 amp

Laboratorium (Blood
H2TL)/day
Mr. Fernando, 24 years old
-
- -
-
Tuesday , June 10
th
2014, 07.15 PM
Subjective Data
Name : Mr. Fernando
TC : Tuesdsay , June 10
th
2014
CC : Vomiting

Anamnesis
Main symptom : Vomiting
Additional symptom : Fever, loss of appetite, painful
swallowing, cough without phlegm

Patient came to UKI hospital with vomiting about 1
day ago before entering the hospital. Vomiting containing
liquid and food. Patient also get fever and he felt his
appetite diminished because he felt painful when
swallowing. Patient also complained cough without phlegm.
Bowel and bladder normal.
Past Medical History and Treatment
Gastritis (occur when he get stress)

Family History
Denied

Social History
Smoking (-), Alcohol (-)
Objective Data
Appearance : Being sick
GCS E4M6V5
BP : 130/70 mmHg
RR: 20x/minute
T : 37.3C
HR : 96x/minute
Eyes: Pale conjunctiva (-/-), sclera icteric (-/-)
Ears, nose and mouth: Normal
Lymph nodes: Not enlarged
JVP : Not distended
Thorax
Ins: Chest wall movement symmetric
Pal: Vocal fremitus sound symmetric
Per: Symmetric sonor sound
Aus: Basic sound of breath vesicular, wheezing (-/-), ronchi (-/-)
Heart sound I & II regular, murmur (-), gallop (-)
Abdomen
Ins: Looks flat
Aus: Bowel sound (+) 4x/minute
Per: Timpani, percussion tenderness in all abdomens regio (-)
Pal: Abdominal tenderness in epigastrium regio (+), liver and
spleen enlargement (-)
Extremities
Warm
Capillary refill time <2 seconds
Edema (-)
Clinical Laboratory
Hemoglobin : 15,9 g/dl
Haematocrit : 41,1 %
Leucocyte: 17,6 ribu/ul
Thrombocyte : 200.000 /ul
Assessment
Dyspepsia
Gastritis akut
Therapy
Prohospitalized
Diet : soft, not to stimulate
IVFD : III RL / 24 hours
Mm/
Ceftriaxone drip 2 x 200 mg
Paracetamol 3 x 50 mg
Omeperazole 2 x 20mg
Ondansetron 1 amp

Planning











Check laboratorium (Blood H2TL)/day
Thank
You
Department of Internal
Medicine
Christian University of
Indonesia