Department of Internal

Medicine
Christian University of Indonesia

MORNING REPORT
December 21h 2015

Mr. Oschin Silintawe D., 54 YO

CC : open wonded
Findings

Assesment

GCS: E4V5M6, TD: 120/80 mmHg, PR : 96 times/minute, T :

36,5oC, RR: 3
Eye : Pale Conjungtiva -/-, Sclera icteric +/+
RPD: controled NIDDM, TB
THT : Normal
Neck : Lymph Nodes not Enlarged
JVP : vein not distended
THRORAX

Anterior STEMI,
acute gastritis, TB on
therapy, NIDDM,
hyponatremia,
hypocalemia.

: Thoraks sinistra and dekstra simetric

Pal: Vocal fremitus simetric
Per: Right lung-sonor , left lung-sonor
Aus: Basic breath sound vesiculer , ronchi -/-, wheezing -/-.
S1 and S2 reguler, gallop (-), murmur (-)
ABDOMEN
Ins : flat
Aus : Bowel sound (+) 8x/minute
Per : tympani, percussion tenderness (-)
Pal : Pressure pain (+) in all regio
Extremitas : oedema (-), warm acral, CRT < 2, turgor
normal

Therapy

Planning
1.

1. NTG drip 5 micro/jam

2. Aspilet 1 x 80 mg
3. Clopidogrel 1 x 75 mg
4. Bisoprolol 1 x 2,5 mg
5. lovenox 2 x 0,6
6. Simvastatin 1 x 20 mg
7. Candesartan 1 x 4 mg
8. Ceftriaxone 2 x1 gr I.V (S.T)
9. Sucralfat 3 x 1C
10. domperidon 3 x 10 mg
11.Ranitidine 2x1 amp I.V
12. continue therapy of TB

2.
3.
4.
6.
7.
8.
9.

Check H2TL, GDS,

electrolyte
Thorax imaging
ECG
O2 nasal canule 3 LPM
Pro ICU
IVFD : I NS 0,9 % + 35 meq
KCl / 12 hour
Diet heart III
Check urea, creatinine, SGOT,
SGPT, blood glucose/day,
cardiac biomarkers in the
room

Subjective Data
Name
: Mr. Ohara Simanjuntak, 54 years
old
TC
: wednesday, September 9th 2015

Anamnesis
Main symptom
: Abdominal pain
Additional symptom : The patient came to IGD RSU UKI with main
complaints of abdominal pain since 4 days before
entering the hospital. Pain is felt in all region
especially in the epigastrium region. Lethargy (+),
nausea (+), vomiting (+) 2 time ( yellow liquid ) ,
constipation . About 3 month patient had plegm
cough in green colour,loss weight 6 kg, fever (-),
night sweats, decreased appetite and hard to
breathe.
There is a 1year history of NIDDM with the drug
glibenclamide 5 mg and in 2005 patient suffer from
TB and has been cured.

Past Medical History and Treatment

(Controled NIDDM, TB )

Family History

(-)
Social History
(-)

Objective Data
Appearance : Moderate Illness
GCS: E4V5M6, TD: 130/90, PR : 84x, T : 36,5oC, RR:
32x
Eye : Pale Conjungtiva -/-, Sclera icteric +/+
RPD: controled NIDDM, TB
THT : Normal
Neck : Lymph Nodes not Enlarged
JVP : vein not distended

 Thorax
I : Thoraks sinistra and dekstra simetric
Pal: Vocal fremitus simetric
Per: Right lung-sonor , left lung-sonor
Aus: Basic breath sound vesiculer , ronchi -/-, wheezing -/-. S1 and S2 reguler, gallop (-), murmur (-)
ABDOMEN
Ins : flat
Aus : Bowel sound (+) 8x/minute
Per : tympani, percussion tenderness (-)
Pal : Pressure pain (+) in all regio

Extremity

- Oedem (-)
- Warm acral
- CRT < 2
- Turgor normal

Clinical Laboratory
wednesday, September 9th 2015
Hematologi
Hemoglobin : 14,1 gr/dl (N : 12-14 gr/dl)
Leukosit : 23,4 rb/ul (N : 5-10 rb/ul)
Hematokrit : 41,1 % (N : 40-48 %)
Trombosit : 272 rb/ul (N : 150-400 rb/ul)
GDS : 100 mg/dl (N : <200)
Natrium : 126 mmol/L (N : 136-145 mmol/L)
Calium : 2,4 mmol/L (N : 3,5 5,1 mmol/L)
Clorida :107 mmol/L (N : 99 111 mmol/L)

EC
G

Thorax
Imaging

Assessment
Anterior STEMI, acute gastritis, TB on therapy, NIDDM,
hyponatremia, hypocalemia.

Therapy
MM/:
1.NTG drip 5 micro/jam
2.Aspilet 1 x 80 mg
3.Clopidogrel 1 x 75 mg
4.Bisoprolol 1 x 2,5 mg
5. lovenox 2 x 0,6
6.Simvastatin 1 x 20 mg
7.Candesartan 1 x 4 mg
8.Ceftriaxone 2 x1 gr I.V (S.T)
9.Sucralfat 3 x 1C
10. domperidon 3 x 10 mg
11.Ranitidine 2x1 amp I.V
12. continue therapy of TB

Planning
1. Check H2TL, GDS, electrolyte
2. Thorax imaging
3. ECG
4. O2 nasal canule 3 LPM
5. Pro ICU
6. IVFD : I NS 0,9 % + 35 meq KCl / 12 hour
7. Diet heart III
8. Check urea, creatinine, SGOT, SGPT, blood glucose/day, cardiac
biomarkers in the room

Department of Internal
Medicine
Christian University of Indonesia

Thank You