Team 5's Morning Report (27-28 Oct 2016)

Identity
Name

: Mr. Tugimin

Age.

: 65 y.o.

Sex.

: Male

Admission Date

: 28/10/2016

Status

: Hospitalized

CC

: Melena

Chronological order / Anamnesis :

The patient came with a chief complaint of stomachache and nausea after using nasogastric
tube +/- 7 hours before came to hospital, he couldnt sleep because of this. Sometimes he
vomited. Blood is not found in the vomit. Patients also reported that he has black stool since a
week ago. He also reported that he had trouble breathing and hoarseness beacause of his
nasogastric tube. He often using anti-pain medication and herbs because of his rheumatic, but
he doing this without doctors prescription. The patient admitted he often urinating until more
than 5 times a night. He also reported loss of appetite so he has difficulty in food intake.
Cough and fever is not found in this patient.

Physical examination
General condition

: Moderately sick

Awareness

: E4V5M6 (Compos mentis)

BP.

: 130/70 mmHg

HR.

: 84 times/minute

RR.

: 18 times/minute

Temp.

: 36,20C

Head.

: normochepali, no enlargement at necks lymph glands.

Eyes

: anemic conjunctiva +/+, ichteric schlerae -/-

Chest :
Inspection

: Symmetrical respiratory movements, no uneven rib movement.

Palpation

: Symmetrical vocal fremitus

Percussion

: Sonor sounds all over lung platforms

Auscultation : breath sound : vesicular. Ronchi -/-, Wheezing -/Heart sound : regular. Murmur (-), gallop (-)
Abdomen:
Inspection

: appeared flat

Auscultation : Intestinal sounds 4 times/minute

Palpation

: Pressure pain (-), defence muscular (-)

Percussion

: tympanic, percussion pain (+) at umbilicus region

Extremity : cold acrals, CRT <2, oedema (-)

A/
-

Melena

P/
Pro hospitalised
Diet : Soft meal
IVFD II RL/24h.
Laboratory examination : Complete blood count (CBC), random blood glucose (CBG)

H2TL (08/10/2016)

Result

Reference value

Haemoglobine
Leukocytes

8,9
16,2

14-16
5-10

Hematocrit

26,5

40-48

Thrombocytes

316

150-400

Random blood glucose (08/10/2016)

GDS

Result
95

Mm/
Vit K amp no. I (IV)
Tranexamide acid amp 500 g No. I (IV)
Omeprazole amp 40 g No.I (IV)
Ciprofloxacine amp 200 g No. II (IV)
Sucralfat flc 3 dd 1 C (PO)

Reference value
< 200