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  • Morpot 11des17

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    reza prayoga
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    Mr. Lucas, a 93-year-old man from Jakarta, was admitted to the hospital with epigastric pain, nausea, vomiting, constipation, and fever. His assessment was dyspepsia. Therapy included IV fluids, omeprazole, sucralfate syrup, ondansetron, and monitoring. He was planned for hospitalization, complete blood examination, and electrolyte checks. Physical examination found abdominal pressure pain and normal vital signs. Laboratory findings showed normal hemoglobin, hematocrit, leukocyte count, and platelet count with elevated glucose.

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    Mr. Lucas, a 93-year-old man from Jakarta, was admitted to the hospital with epigastric pain, nausea, vomiting, constipation, and fever. His assessment was dyspepsia. Therapy included IV fluids, omeprazole, sucralfate syrup, ondansetron, and monitoring. He was planned for hospitalization, complete blood examination, and electrolyte checks. Physical examination found abdominal pressure pain and normal vital signs. Laboratory findings showed normal hemoglobin, hematocrit, leukocyte count, and platelet count with elevated glucose.

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    19 views3 pages

    Morpot 11des17

    Uploaded by

    reza prayoga
    Mr. Lucas, a 93-year-old man from Jakarta, was admitted to the hospital with epigastric pain, nausea, vomiting, constipation, and fever. His assessment was dyspepsia. Therapy included IV fluids, omeprazole, sucralfate syrup, ondansetron, and monitoring. He was planned for hospitalization, complete blood examination, and electrolyte checks. Physical examination found abdominal pressure pain and normal vital signs. Laboratory findings showed normal hemoglobin, hematocrit, leukocyte count, and platelet count with elevated glucose.

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    of 3

    NIGHT SHIFT’S MORNING REPORT

    GROUP ONE
    Monday ,11 of December 2017

    Mr.Lucas , 93 years old MR : 00031435


    Jakarta TC : Monday
    Cc: Dsypepsia Date : 11 – 12 – 2017
    Findings Assessment Therapy Planning
    - Epigastric pain - Dsypepsia - IVFD: - Pro-hospitalized
    I NaCl 0,9% 500 cc/ 8 hours - Check Complete Blood
    - Nausea (+), vomiting (+) ±10 Futrolit /24 hours Examination, Electrolyte
    times a day - MM/
    - Omeprazole 40 mg 1x1
    - Constipation (+) for 10 days
    IV
    - High fever (+) - Sucralfat syr 3x1 PO
    - Ondancentron 3x4 IV
    Physical Examination:
    LOC: E4 M6 V5
    BP: 130/100 mmHg
    HR: 80x/min
    RR: 24x/min
    T: 37,1°C

    Head: Normocephaly
    Eye: conjunctiva anemic -/-
    sclera icteric -/-
    ENT: normal
    Mouth: normal
    Neck: No lymph node enlargement
    Thorax:
    - Ins: Symmetrical respiratory
    movements
    - Pal: Symmetrical vocal
    fremitus
    - Per: Sonor sounds all over
    lung platform
    - Aus: lungs sounds vesicular
    Rhonchi -/-, Wheezing -/-,
    Heart sound I & II regular,
    Murmur - /-, Gallop -/-
    Abdominal:
    - Ins: Appeared flat
    - Aus: Intestinal sounds (+),
    4x/min
    - Per: Timpanic, percussion pain
    (-), acites (-)
    - Pal: Pressure pain (+ =
    epigastrica area), release pain
    (-), defense muscular (-)
    Extermities:
    Oedema: CRT <2”

    Warm extermities

    Laboratory Findings
    11 December 2017
    Complete Blood Examination
    - Hemoglobin: 14,4 g/dl
    - Hematocrit: 43,9 %
    - Leukocyte: 5,5 thousand/ul
    - Trombosit: 180.000 u/L
    - GDS: 170 mg/dL

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