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  • Morpot 30 Oktober Kelompok 1

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    This morning report from the Department of Internal Medicine at the Christian University of Indonesia involves a 52-year-old female patient presenting with epigastric pain. On examination, the patient had pale conjunctiva, icteric sclera, normal neck and jugular vein pulse, symmetrical chest with normal heart sounds, flat abdomen with pressure pain and percussion tenderness in the epigastric region, and no edema or abnormal temperature in the extremities. The assessment is suspected cholelithiasis or cholecystitis. The treatment plan is to hospitalize the patient, check laboratory tests, perform an abdominal ultrasound, provide oxygen via nasal cannula, intravenous fluids, and a soft diet.

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    This morning report from the Department of Internal Medicine at the Christian University of Indonesia involves a 52-year-old female patient presenting with epigastric pain. On examination, the patient had pale conjunctiva, icteric sclera, normal neck and jugular vein pulse, symmetrical chest with normal heart sounds, flat abdomen with pressure pain and percussion tenderness in the epigastric region, and no edema or abnormal temperature in the extremities. The assessment is suspected cholelithiasis or cholecystitis. The treatment plan is to hospitalize the patient, check laboratory tests, perform an abdominal ultrasound, provide oxygen via nasal cannula, intravenous fluids, and a soft diet.

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    9 views2 pages

    Morpot 30 Oktober Kelompok 1

    Uploaded by

    dgumelar
    This morning report from the Department of Internal Medicine at the Christian University of Indonesia involves a 52-year-old female patient presenting with epigastric pain. On examination, the patient had pale conjunctiva, icteric sclera, normal neck and jugular vein pulse, symmetrical chest with normal heart sounds, flat abdomen with pressure pain and percussion tenderness in the epigastric region, and no edema or abnormal temperature in the extremities. The assessment is suspected cholelithiasis or cholecystitis. The treatment plan is to hospitalize the patient, check laboratory tests, perform an abdominal ultrasound, provide oxygen via nasal cannula, intravenous fluids, and a soft diet.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
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    of 2

    Department of Internal

    Medicine
    Christian University of Indonesia

    MORNING REPORT
    October 30th 2015
    TEAM 1

    Mr.s SI, 52 YO
    CC : epigastric pain
    Findings
    Epigastric pain
    GCS: E4V5M6, TD: 120/80, PR 100x, T : 36oC, RR: 19x
    Eye : Pale Conjungtiva -/-, Sclera icteric -/THT : Normal
    Neck : Lymph Nodes not Enlarged
    JVP : normal
    THRORAX

    I : Symmetrical chest wall movement, ictus cordis (-)


    Pal: Symmetrical Vocal fremitus, ictus cordis : palpable
    Per: Sonor/Sonor , cardiac englargement (-)
    Aus: Basic breath sound vesicular, ronchi -/-, wheezing -/-. S1
    and S2 reguler, gallop (-), murmur (-)
    ABDOMEN
    Ins : flat
    X X X
    Aus : Bowel sound (+) 6x/minute
    X
    Pal : Pressure pain (+).
    Per : Timpani, percussion tenderness (+)
    Extremitas : pitting oedem (-), warm acral, CRT < 2, turgor
    normal

    Assesment

    Suspect
    Cholelitiasis
    Cholesistisis

    Therapy
    MM/
    Ceftriaxone 1x2gr (IV) (ST)
    Pumpitor 1x40 (IV)
    Domperidone 3x10mg
    Sucralfat Syr 3x1C
    Sanmol 3x500mg

    Planning
    Hospitalized
    Check lab: H2TL, electrolit,
    SGOT, SGPT, Ur, Cr, Ul, GDS
    Pro USG abdomen after visit
    O2 kanul nasal 3-4 Lpm
    IVFD : II Futrolit / 24 hours
    Diet: tender and not stimulating

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