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Department of Internal Medicine Christian University of Indonesia

MORNING REPORT
December 15th 2013

Mr. Robinson S, 51 YO
Pancoran

CC : Vomit

TC : Sunday/ December, 15 2013/13.00 CM : 77-12-05-00

Findings
Vomit Nausea Diarrhea Loss appetite

Assessment
Gastoenteritis Acute MIld Dehidration

Therapy
Hospitalization IVFD : III RL / 24 h Diit : porigd

Planning
- Electrolyte - Feses

Appearance: mild illness, GCS : E4V5M6, BP: 130/80 mmHg, PR : 82 x/min (adequate,regular) RR : 20 x/min, T: 37,2C Eye : conjunctiva anemia -/- sclera icteric -/Ear nose throat : normal Neck : lymph nodes not enlarged JVP : normal

Mm/ Omeprazole IV 2 x 40 mg Ondancentron IV 2x4 mg Bactrim Forte 2x1

THORAX Pulmo
Inspection : symmetric Palpation : vocal fremitus symmetric Percussion : symmetric, sonor sound Auscultation : vesiculer rhonki -/- , whezing -/- Heart Sound S1 S2 Normal, murmur ( ), gallop ( )

Abdominal Inspection : abdomen looks flat Palpation : Pressure pain (+) Epigastric, umbilical Percussion : Tympani Auscultation : bowel sounds (+) 8x/minute
Extremitas : warm acral, CR<2, pitting edema -/- , Turgor
LAB FINDING : Hb : 15,4 g/dl, Ht : 46,8%, Leu : 9,4 rb/L, Tb : 274 rb/L, GDS : 86 mg/dl, Ur : 32 mg/dl, Cret : 1,19 mg/dl, Na : 137 mmol/L , K : 4 mmol/L , Cl : 101 mmol/L

Subjective Data
Name Address CM TC CC : Mr. Robinson : Pancoran : 77-12-05-00 : Sunday/ December, 15 2013/13.00 : Vomit

Anamnesis
Main symptom : Vomit Additional symptom : Nausea, Diarrhea, Diarrhea, Loss appetite 51 years old male patient come to the emergency with complaints of vomit since 1 day before hospital admission. Patient vomit once a day and vomiting the food that he eat. Patient already go to the clinic and already given drug but the complain didnt change. Patient feels nausea so he didnt want to eat. Patient complain diarrhea 1 day before admission, in that day patient already 15 times defecation, sometimes there is mucus, ground +. Urine normal. Patient still want drink. Patient denied a history of hypertension and diabetes. Patient denied history of allergy.

Past Medical History and Treatment


Hypertension (-), Diabetes Meillitus (-),

Family History
-

Social History
Smoking (+) 5 years, Alcohol (+) 2 years

Objective Data
Consciousness Appearance Blood Pressure Pulse Rate Respiration Rate Temperature EYE Ear Nose Throat Neck JVP THORAX : Heart Inspection Palpation Percussion : : : : : : : : : : E4V5M6 ; Composmentis mild ill 130/80 mmHg 82 x/min (adequate,regular) 20 x/min 37,20C conjungtiva anemic -/- ; sclera icteric -/Normal Normal Normal

: Ictus Cordis visible : IC palpable 1cm lateral ICS V midclavicula sinistra : Right heart border Inter Costae V line Parasternal dextra, Left heart border Inter Costae VI axilaris anterior line Auscultation : S1 single, S2 single, regular, murmur (-) gallop (-)

Objective Data
Pulmo Inspection Palpation Percussion Auscultation : : : : Static and dynamic symmetric Vocal Fremitus right and left symmetric Sonor symmetric Bronchial, wheezing -/-, ronkhi -/-

ABDOMEN Inspection : stomach looks flat Auscultation : Bowel sound (+), 8 x/min Palpation : Defense muscular Pressure pain + in epigastrium and umbilical LiverSpleen impalpable ; Percussion : Tympani; Percussion Pain EXTREMITIE Turgor decrease in extremity; cold (-) ; CR <2 second

Labolatorium Test
Hb : 15,4 g/dl, Ht : 46,8%, Leu : 9,4 rb/L, Tb : 274 rb/L, GDS : 86 mg/dl, Ur : 32 mg/dl, Cret : 1,19 mg/dl, Na : 137 mmol/L , K : 4 mmol/L , Cl : 101 mmlo/L

Assessment
Acute Gastroenteritis Mild dehidration

Therapy
Hospitalization

IVFD : III RL / 24 h
Diit : porigd Mm/ Omeprazole IV 2 x 40 mg Ondancentron IV 2x4 mg Bactrim Forte 2x1

Planning
- Electrolyte - Feses

Department of Internal Medicine Christian University of Indonesia

Thank You
September, 5th 2013