Scribd Logo
Upload

Welcome to Scribd!

  • Physical Examination Loc: E4 M6 V5

    Uploaded by

    ankaenka
    7 views2 pages
    1. The morning report describes a 42-year-old male patient named Mr. Amri who presented with vomiting blood for 4 hours. 2. On examination, the patient was found to have anemia, epigastric tenderness, and normal lung and heart sounds. 3. Laboratory tests showed the patient's hemoglobin was low at 9.1 g/dL, suggesting anemia, while other tests like electrolytes were normal.

    Original Description:

    morpot

    Original Title

    morpot minggu 2

    Copyright

    © © All Rights Reserved

    Available Formats

    DOCX, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    Report this Document
    1. The morning report describes a 42-year-old male patient named Mr. Amri who presented with vomiting blood for 4 hours. 2. On examination, the patient was found to have anemia, epigastric tenderness, and normal lung and heart sounds. 3. Laboratory tests showed the patient's hemoglobin was low at 9.1 g/dL, suggesting anemia, while other tests like electrolytes were normal.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    7 views2 pages

    Physical Examination Loc: E4 M6 V5

    Uploaded by

    ankaenka
    1. The morning report describes a 42-year-old male patient named Mr. Amri who presented with vomiting blood for 4 hours. 2. On examination, the patient was found to have anemia, epigastric tenderness, and normal lung and heart sounds. 3. Laboratory tests showed the patient's hemoglobin was low at 9.1 g/dL, suggesting anemia, while other tests like electrolytes were normal.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 2

    GROUP FIVE NIGHT SHIFT ‘S MORNING REPORT

    Wednesday, 12th of October 2017

    Mr. Amri, 42 years old

    Jakarta,

    Date : Thursday, 14 -10 - 2017

    CC: vomiting of blood

    Findings Assessment Therapy Planning


     Vomiting of Hematemesis ec  IVFD: RL  Pro –
    blood since 4 gastritis + anemia 500/24 hours hospitalized
    hours  Omeprazole 1 x  Soft diet
     ARV B20 on ARV 40 mg PO  Observe
    routines  Ondansetron 2 x
    medication + 8 mg PO
     Coughing  Sucralfat 3 x 1 C
    leads to  Ranitidine Inj
    vomit +

    Physical Examination

    LOC : E4 M6 V5

    BP :100/70 mmHg

    HR :96x/min

    RR :18x/min

    T :37° C

    Head : Normocephaly

    Eye : Anemic conjuctive -/-

    Icteric sclera -/-

    ENT : Normal

    Mouth : Normal

    Neck : No lymph node enlargement


    Thorax:

     Ins : Symmetrical respiratory movements


     Pal : Symmetrical vocal fremitus
     Per : Sonor sounds all over lung platforms
     Aus : Lungs sounds vesicular, rhonchi -/-, wheezing -/-, heart sound I and II
    regular, murmur -/-, gallop -/-

    Abdominal:

     Ins : Appeared Flattened


     Aus : Intestinal sounds (+), 4x/min
     Per : Timpanic sound, percussion pain (+) epigastrium
     Pal : Supple, Pressure pain (+) epigastrium, release pain (-), defense muscular (-)

    Extermities:

    Oedema:

    CTR: <2 s

    Warm extermities

    Laboratory Findings

    Hemoglobin : 9.1 g/dL

    Leucocyte : 7.200 / ul

    Hematocrit : 28.3 %

    Trombosit : 438.000 / ul

    GDS: 156 mg/dL

    Na: 140 mmol/L

    K: 4 mmol/L

    Cl: 103 mmol/L

    You might also like