Department of Internal

Medicine
Christian University of Indonesia

MORNING REPORT
Oct 30 2014
TEAM 1

Mr W. (52 YO)

Findings

Assessm
ent

CC : epigastric pain, breathless

Dyspepsia syndrome
Acute Gastroenteritis

Appearance: moderate illness, GCS : E4V5M6, BP:

130/80 mmHg, PR : 86 x/min (adequate, regular)
RR : 28 x/min, T: 36 C
Eye : conjuntiva not pale, Sklera icteric -/Ear, Nose, Throat: normal
Neck : lymph nodes did not enlarged
THORAX
Insp : symmetric, ictus cordis (-)
Pal : vf symmetric, ictus cordis not palpable
Per : symmetric, sonor sound
RHB ICS V lin. sternal dext, LHB ICS V lin.
Midclavicula sin
Aus : vesicular rh -/-, wh-/S1 single, S2 single, regular, murmur (-) gallop
(-)
ABDOMINAL
Ins : flatened abdominal wall
Ausc : bowel sounds + 3x
Palp : Pressure Pain +
+
Undulation (-),
_
Per : timpany, shifting dulness (+),
Extremitas : warm acral, CR<2, edema
LAB FINDING:
Complete Perifer Blood :
Hb : 11.2 gr/dl, Ht : 35.7,2%, trombo:
377.000/uL Leu: 18.500

Therapy
Pro Hospitalized
IVFD : RL III/24hrs
Diet : soft
Mm/
Ceftriaxone 2 x 1gr
Rantin 2 x 1
Metronidazole 3 x 500 mg
Omeprazole inj 2 x 40 mg
Sucralfat 3 x 1 C

Plannin
g
- Glucose plasma
test

Subjective Data
Name
: Mr. W
Address : Jakarta
TC : Tuesday, 30th October 2014
CC
: nausea

Anamnesis
Main symptom
: nausea
Additional symptom : vomit, bloating, epigastric pain
52th years old male came with chief complaint: nausea. This
symptom happened during 7 days and exaggerated in 3 days
Patient is a smoker, coffee drinker, and he said he eat nothing
today. The patient denied also has complain in gastrointestinal
system. he voids waterry diarrhea.
Mr. W also had complain of stomach pain, which is locate on
upper and left abdomen, vomiting, sour and bitter taste inside his
mouth. He vomit for about 4 times, the colour of his vomit is bright
yellow and sometimes, it just water that came out.

Past Medical History and Treatment

(denied)

Family History
(denied)

Social History
, Alcohol (-), smoking (+),
Coffee drinker (+)

Objective Data
LOC
: E4V5M6 ; Composmentis
Appearance : mild ill
BP
: 110/70 mmHg
HR
: 86 x/min (adequate, regular)
RR
: 28x/min
Temp
: 360C
HEAD & EYE : lymph nodes not palpable
THORAX :
Heart
Ins : IC invisible
Pal : IC not palpable
Per : RHB ICS V lin. sternal dext, LHB ICS V lin. Midclavicula sin
Ausc
: S1 single, S2 single, regular, murmur (-) gallop (-)

Objective Data
PULMO
Insp: Static and dynamic symmetric
Pal : VF right and left symmetric
Perc
: Sonor symmetric
Ausc
: BBS Vesicular, Rhonki -/-, Wheezing -/ABDOMEN
Insp: flattened abdominal wall
Ausc : Bowel sound (+) 5 times a minute
Pal : tenderness (+), palpation pain (+)
Perc
: shifting dulness (-), percussion pain (-)

+
-

EXTREMITIES
Edema (-/-/-/-); warm (+); capp. Refill <2 seconds

Clinical Laboratory
Hb : 11.2 gr/dl
Ht : 35.7%
Trombo: 377.000/uL
Leu: 18.500

Assessment

Dyspepsia Syndrome
Acute Gastroenteritis

Therapy
Pro Hospitalized
IVFD : RL III/24hrs
Diet : soft
Mm/
Ceftriaxone 2 x 1gr
Rantin 2 x 1
Metronidazole 3 x 500 mg
Omeprazole inj 2 x 40 mg
Sucralfat 3 x 1 C

Planning
- Glucose plasma test

Department of Internal
Medicine
Christian University of Indonesia

Thank You