MORNING REPORT

Department of Internal Medicine
Christian University of Indonesia
June, 12
th
2014
TEAM 4
Ms. MZ (20 YO)
Findings Assesment Therapy Planning
Nausea
Vomit
Weakness
Loss of appetite
Constipation
Appearance : moderate illness, GCS E4V5M6, BP : 110/80 mmHg, PR : 88x/min, RR : 32x/min, T : 36,6°C
Eye : hyperemic conjunctiva -/-, icteric sclera -/-
THT : normal
Mouth : coated tongue -, tremor -
Neck : lymph nodes not enlarge, JVP : 5-2 cmH2O
Thorax
Ins : 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 : flat
Aus : bowel sound 4x/min
Pal : pain on hypochondriac dex&sin, epigastric, lumbar dex&sin, and umbilical region, liver and spleen not palpable
enlarged
Per : percution pain +

X X X

X X X

Extremities : warm acral, CRT < 2”, edema –

LAB FINDING
Hemoglobin : 13,4 g/dl
Hematokrit : 37,8 %
Leukocytes : 7800 /ul
Plateletes: 221.000 /ul
Na 142 mmol/L
K 3,6 mmol/L
Cl 104 mmol/L
 Acute Gastritis Pro Hospitalized
Diet : Rice porridge
IVFD : I futrolit
II RL / 24hrs
Mm/
Omeprazol drip 2x1
Inpepsa 3x2
Ondancentron 2x4mg
Rebamipid tab 2x1
- H2TL
Subjective Data
Name : Ms. Miftahul Z
CM : 09.66.05.00
TC : Thursday, June 12
st
2014
CC : Abdominal Pain

Anamnesis
Main symptom : Abdominal pain
Additional symptom :Nausea
Vomit
Weakness
Loss of appetite
Constipation

Patient came with Abdominal pain since 2 days ago. She felt intermittent
abdominal pain. The other complain were nausea and vomit. Patient vomit
5 times already and vomit consists of water and food. Beside that, the
patient has not defecate since 3 days ago.
Past Medical History and Treatment
denied

Family History
denied

Social History
denied
Objective Data
• Appearance : Moderate Illness
• GCS E4M6V5
• BP : 110/80 mmhg,
• RR: 32x/ minute,
• T : 36,6
o
C
• Pulse : 88x/minute.
• Eye: Pale conjunctiva -/- , sclera icteric -/-
• Ear, Nose, throat : normal
• Mouth : coated tongue -, tremor -
• Neck : lymph nodes not enlarge, JVP : not distended


• Thorax.
– I : symmetrical, non-visible ictus cordis
– Pal: symmetrical vocal fremitus, ictus cordis : unpalpable
– Per: Sonore, cardiac englargement (-)
– Aus: Vesical basic breath sound, ronchi (-), wheezing(-). Normal heart sound, gallop (-), murmur
(-)
• Abdomen.
– I : flat
– Aus : bowel sound (+) 4x/minute
– Per :timpani, percussion tenderness (+)
– Pal : abdominal tenderness (+), liver and spleen enlargement (-)
• Extremity
- Warm
- Capillary refilling time <2 second
- Edema (-)

Clinical Laboratory
• LAB FINDING
Hemoglobin : 13,4 g/dl
Hematokrit : 37,8 %
Leukocytes : 7800 /ul
Plateletes: 221.000 /ul
Na 142 mmol/L
K 3,6 mmol/L
Cl 104 mmol/L

Assessment
Acute Gastritis
Therapy
• Pro Hospitalized
• Diet : Rice porridge
• IVFD : I futrolit
• II RL / 24hrs
• Mm/
Omeprazol drip 2x1
Inpepsa 3x2
Ondancentron 2x4mg
Rebamipid tab 2x1
Planning











•Lab:
H2TL
Thank You
Department of Internal Medicine
Christian University of Indonesia