MORNING REPORT

Marwah, Sept 30 th 2014

Patients Identity
Name :
Age
:
Religion
Work :
Date :

Mr. D
49y.o
: Moeslim
Merchant
30th Sept 2014

Anamnesis
Chief complaint: Abdominal pain
Present illnes: Patients present with
complaints of diffuse abdominal pain
epigastrium, reffered to back. Like stabbed
and feel hot. Pain incrased when activity and
decrase when resting. patients also
complained of nausea when patient eating
and headaches since 1 day before coming to
the emergency room., vomit (-). Defecation
and urination normal

Anamnesis

History or past illness :

HT (+) three years (180/90)
DM Denial
Gastritis (+) 7 years (promagh)

History of family :
Denial

Physic Examinations
GCS : 456
Vital Sign
BP
Pulse
RR
Temp

:
:
:
:

190/115 mmHg
84x / minutes
19x / minutes
36,3 C

Physic Examinations
Head and neck : Anemic-/ icteric-/
cyanosis-/ dyspneu Thorax : simetric bilaterally, retraction (-/-),
Pulmo : ves/ves, rh (-/-), wh (-/-)
Cor
: S1-S2 single, reguler, murmur(-), gallop(-)

Abdomen
: flat, soepel, abdominal pain
(+), meteorismus (-), epigastric tenderness
(+), BU(+N), undulasi (-), shiffting dulnes (-) ,
hepar and lien not palpable
Extremity : akral cold, dry, red (+), edema
(-/-)

Clue and Cue

Male, 49 y.o
Abdominal pain
(epigastric)
Nausea (+)
Hypertension
(BP: 190/115
mmHg)

Problem List
Crisis Hypertension

Assessment
Dyspepsia
Hypertension stage II JNC 7

Planning

o
o
o
o
o
o

Planning Dx :
CBC
GDA
RFT
ECG
Funduscopy
X-Ray Thorax

Planning Tx :
IVFD asering i500cc/days
Inj Metamizole 3x1 iv
Inj Pantoprazole 80mg drip
maintenence pump
4ampl/24jam
Oral: Captopril 25mg +
Spironolakton
Consul Sp.PD

Laboratory Findings

Diff count 0/0/61/32/7

Hematocrit 41,6%
Haemoglobin 15,0mg/dL
Leukocyte 5.800
Trombocyte 240.000
SGOT 15 u/L
SGPT 18/L
Clorida serum 105 mol/L
Kalium serum 3,2 mol/L
Natrium serum 139 mmol/L
Serum creatinin 0,7 mg/dL
Urea 18 mg/dL

Prognosis
Dubia ad Bonam

Education
Take a planty of rest
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.