Department of Internal

Medicine
Christian University of Indonesia

MORNING REPORT
September, 11th 2015
TEAM 2

Mrs I, 48 YO
CC : Obstipation

Findings

Assesment

abdominal pain since 1 day before admission.

The pain is like stabbed with knife. He feel
nausea and vomited every eating and drinking.
Appearance : Mild Illness, GCS E4M6V5,BP :
170/120 mmhg,
RR: 36x/ minute, T : 36C,Pulse : 110x/minute. Eye:
Pale conjunctiva -/- , sclera icteric -/-, Ear, Nose,
throat : normal,
lymph nodes not enlarged
THORAX

dyspepsia
polycythemia
hypokalemia
hyperglycemia
hypertension
grade II

: Symmetrical chest wall movement, ictus cordis (-)

Pal : Symmetrical Vocal fremitus, ictus cordis : palpable
Per : Sonor/Sonor
Aus : Basic breath sound vesical, ronchi -/-, wheezing -/-. S1
and S2 reguler, 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 (+)
Extremitas : warm acral, CRT < 2, edema (-)

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.

Past Medical History and Treatment

-

Family History
-

Social History
Smoking (-), consuming alcoholic beverages (-)

Objective Data

Appearance : Mild Illness

GCS E4M6V5
BP : 170/120 mmhg,
RR: 36x/ minute,
T : 36C
Pulse : 110x/minute.
Eye: Pale conjunctiva -/- , sclera icteric -/Ear, Nose, throat : normal
lymph nodes not enlarged

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)

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

Department of Internal
Medicine
Christian University of Indonesia

Thank You