Professional Documents
Culture Documents
Medicine
Christian University of Indonesia
MORNING REPORT
September, 11th 2015
TEAM 2
Mrs I, 48 YO
CC : Obstipation
Findings
Assesment
dyspepsia
polycythemia
hypokalemia
hyperglycemia
hypertension
grade II
Therapy
Captopril 25 mg (SL)
Ondancentron 8 mg (IV)
Ranitidin 1 amp (IV)
Planning
Hospitalized
Diet : soft foods,
low salt
IVFD : II RL/24 jam
Mm/ :
Ceftriaxone 1x2gr
(skin test)
Ondancentron 2 x
8mg
KSR 2x1 tab
Amlodipine 1x5mg
USG abdomen
Subjective Data
Name
: Mr. C, 63 years old
CM
:
TC : Tuesday, September 06th 2015
CC
: Abdominal pain
Anamnesis
Main symptom
: obstipation
Additional symptom :
Patient arrived to UKI hospital with
major complain abdominal pain since
1 day before admission. The pain is
like stabbed with knife. He feel nausea
and vomited every eating and
drinking.
Family History
-
Social History
Smoking (-), consuming alcoholic beverages (-)
Objective Data
Thorax.
- I : Symmetrical chest wall movement, ictus cordis (-)
- Pal: Symmetrical Vocal fremitus, ictus cordis : not palpable
- Per: Sonor/Sonor
- Aus: basic breath sound vesical, rhonchi -/-, wheezing -/-. S1 and S2 regular, gallop (-), murmur (-)
Abdomen.
- Ins : normal
- Aus : Bowel sound (+) 1 /minute
- Pal : Pressure pain on epigastric, hypocondria dextra, and sinistra, umbilical (+), shifting dullness (-)
- Per : Timpani, pain of percussion (+)
Extremity
-
warm acral
Capillary refilling time <2 second
Edema (-)
Turgor normal
Clinical Laboratory
H2TL
Hb
: 21,3 g/dl (H)
White Blood Cell
: 17.200 /uL (H)
Hematocrite
: 65,9% (H)
Trombosite
: 187.000/uL
GDS
: 209 (H)
Electrolyte
Na
: 141
K
: 3,1 (L)
Cl
: 134
Assessment
dyspepsia
polycythemia
hypokalemia
hyperglycemia
hypertension grade II
Therapy
Captopril 25 mg (SL)
Ondancentron 8 mg (IV)
Planning
Hospitalized
Diet : soft foods, low salt
IVFD : II RL/24 jam
Mm/ :
USG abdomen
Department of Internal
Medicine
Christian University of Indonesia
Thank You