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Morning Report: Department of Internal Medicine
Morning Report: Department of Internal Medicine
Medicine
Christian University of Indonesia
MORNING REPORT
June, 7th 2015
TEAM 4
Mr. Y, 49 YO
CC : Epigastric Pain
Findings
Epigastric pain, vomit, nausea
GCS: E4V5M6, TD: 130/70, PR 84x, T : 37,8oC, RR: 22x
Eye : Pale Conjungtiva -/-, Sclera icteric -/THT : Normal
Neck : JVP 5-2 cm, Lymph Nodes not Enlarged
JVP : THRORAX
Assesment
Dyspepsia
Urinary
Tract
Infection
History of
cholelitiasis
Therapy
MM/
Cefxon 1x2 gr (IV)
Sucralfat 3x1 C
Vometa 3x1 tab
Pumpitor 1x1 amp (IV)
Planning
Hospitalized
Check lab : H2TL, SGOT/SGPT,
Ur/Cr, DPL & profil lipid
IVFD : II Futrolit/ 24 hours
Subjective Data
Name
CM
TC
CC
Anamnesis
Main symptom
Additional symptom
: Epigastric Pain
:
Family History
denied
Social History
Smoking (-), consuming alcoholic beverages (-)
Objective Data
Thorax.
Abdomen.
I : flat
Aus : bowel sound (+) 4x/minute
Pal : Pressure pain (+), liver enlargement (-)
Per :timpani, percussion tenderness (+)
Extremity
-
Warm acral
Capillary refilling time <2 second
Edema (-)
Turgor normal
Clinical Laboratory
7/06/2015 (21.30)
H2TL
Hb : 15,8 g/dl
White Blood Cell
: 7.3 /uL
Hematocrite
: 50,3 % (High)
Trombosite
: 197.000/uL
Electrolyte
Na 136 mmol/L K 4.6 mmol/L Cl 107 mmol/L
Urinalisa
Blood +1
Leukosit esterase +1
Urobilinogen 0,2
Leucosit 3-6/ LBP
Bacterial +
Assessment
Dyspepsia
Urinary Tract Infection
History of cholelitiasis
Therapy
Cefxon 1x2 gr (IV)
Sucralfat 3x1 C
Vometa 3x1 tab
Pumpitor 1x1 amp (IV)
Planning
Hospitalized
Check lab : H2TL, SGOT/SGPT, Ur/Cr,
DPL & profil lipid
IVFD : II Futrolit/ 24 hours
Department of Internal
Medicine
Christian University of Indonesia
Thank You