MORNING REPORT

Department of Internal Medicine

Christian University of Indonesia
Sept, 6
th
2014
TEAM 4
Mrs. RA 66 years old Tuesday, Sept 6
nd
2014
Findings Assesment Therapy Planning
- Vomit Black-red colored
- Nausea
- headache

PHYSICAL EXAMINATION
Loc: compos mentis, GCS E4V5M6
BP : 110/70mmHg, HR : 80x/min
RR : 22x/min, T : 36,7C
Eye : hyperemic conjunctiva (-/-), Icteric sclera -/-
THT : normal
Mouth : normal
Neck : lymph nodes not enlarge, JVP : 5-2cmH2O
Thorax
Ins : chest movement 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 : looks flat
Aus : bowel sound (+), 6x/min
Per : no percution pain, timpani sound
Pal : no tenderness and defence muscular
Extremities
warm acral, CRT < 2 s, edema (-)
LAB FINDING
Hemoglobin : 13,5 g/dl
Haematocrit : 43,5%
Leucocyte: 10,4ribu/ul
Thrombocyte : 233.000 /ul
Gds : 139 mg/dl
Na : 140
K : 5,3
Cl : 107
Hematemesis ec gastritis erosif
Dispepsia
hiperkalemia

Mm/
Domperidon 3x10mg
Omz 2x40mg
Sucralfat 3x2c
Ondancentron 2x8mg
Vit ka 3x1 amp
Asam tranexamat 3x2
-hospitalized
-Diet : fasting
-IVFD :
I triofucin 1000
II futrolit
I RL
24hours
Subjective Data
Name : Mrs A
TC : Saturday, September 6
th
2014
CC : Vomit Black-red colored

Anamnesis

Main symptom : Vomit Black-red colored like Jelly
Additional symptom : Headache, Nausea
Patient came to Christian University of Indonesia General Hospital with
Vomit, Black-Red Colored and the consistance like a jelly, since 2 hours before
arrived at the Hospital.
In beginning, patient ate boiled noodles with imbibing ABC orange syrup.
After that, patient felt nausea and vomit. Patient have went to the doctor not feeling
better. Patient had been felt like this before, with hematemesis & melena 4 years ago.
Hypertension & diabetes mellitus are denied.
Past Medical History
-

History of treatment
-

Family History
Denied

Social History
Smoking (-), Alcohol (-)
Objective Data
Appearance : Being sick
GCS E4M6V5
BP : 110/70 mmHg
RR: 22x/minute
T : 36,7C
HR : 80x/minute
Eyes: Pale conjunctiva (-/-), sclera icteric (-/-)
Ears, nose and mouth: Normal
Lymph nodes: Not enlarged
JVP : 5-2cm
Thorax
- Ins : Chest wall movement 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 (-)
Abdomen
- Ins : Looks flat
- Aus : Bowel sound (+) 4x/minute
- Per : Timpani, percussion tenderness in all abdomens regio (-)
- Pal : Abdominal tenderness in all abdomens regio (-), liver and spleen enlargement (-)
Extremities
- Warm
- Capillary refill time <2 seconds
- Edema

Clinical Laboratory
Haemoglobin : 13,5 g/dl
Haematocrit : 43,5 %
Leucocyte : 10,4 ribu/ul
Thrombocyte : 233.000 /ul
GDS : 139 mg/dl
Na: 140
K:5,3
Cl: 107


Assessment
- Hematemesis ec gastritis erosif
- Dispepsia
- hiperkalemia
Therapy
Mm/
Omeprazole inj 2 x 40 mg (IV)
Domperidon 3x10mg (PO)
Sucralfat 3x2c (PO)
Ondancentron 2x8mg (IV)
Vit K 3x1amp (IV)
Asam tranexamat 3 x 2gr (IV)
Planning











hospitalized
Diet : fasting
IVFD :
I triofucin
II futrolit
I RL
24 hours
Thank You
Department of Internal Medicine
Christian University of Indonesia