morport 6 september

8/11/2019 Morport 6 September

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MORNING REPORT

Department of Internal MedicineChristian University of Indonesia

Sept, 6 th 2014TEAM 4


2/12

Mrs. RA 66 years old

Findings Assesment Therapy - Vomit B lack-red colored- Nausea- headache

PHYSICAL EXAMINATIONLoc: compos mentis, GCS E4V5M6BP : 110/70mmHg, HR : 80x/minRR : 22x/min, T : 36,7CEye : hyperemic conjunctiva (-/-), Icteric sclera -/-THT : normalMouth : normalNeck : lymph nodes not enlarge, JVP : 5-2cmH2OThoraxIns : chest movement symmetricPal : vocal fremitus sound symmetricPer : symmetric sonor soundAus : basic sound of breath vesicular, wheezing (-/-), ronchi (-/-)Heart sound I & II regular, murmur (-), gallop (-)AbdominalIns : looks flatAus : bowel sound (+), 6x/minPer : no percution pain, timpani soundPal : no tenderness and defence muscularExtremitieswarm acral, CRT < 2 s , edema (-)LAB FINDINGHemoglobin : 13,5 g/dlHaematocrit : 43,5%Leucocyte: 10,4ribu/ulThrombocyte : 233.000 /ulGds : 139 mg/dlNa : 140K : 5,3

Cl : 107

Hematemesis ec gastritis erosifDispepsiahiperkalemia

Mm/Domperidon 3x10mgOmz 2x40mgSucralfat 3x2cOndancentron 2x8mgVit ka 3x1 ampAsam tranexamat 3x2


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Subjective Data

Name : Mrs ATC : Saturday, September 6 th 2014CC : Vomit Black-red colored


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AnamnesisMain symptom : Vomit Black-red colored like Jelly

Additional symptom : Headache, NauseaPatient came to Christian University of Indonesia General Hospital w

Vomit, Black-Red Colored and the consistance like a jelly, since 2 hours beforarrived at the Hospital.

In beginning, patient ate boiled noodles with imbibing ABC orange syruAfter that, patient felt nausea and vomit. Patient have went to the doctor not feelin

better. Patient had been felt like this before, with hematemesis & melena 4 years agoHypertension & diabetes mellitus are denied.


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Past Medical History-

History of treatment-

Family HistoryDenied

Social HistorySmoking (-), Alcohol (-)


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Objective Data

Appearance : Being sick

GCS E4M6V5 BP : 110/70 mmHg RR: 22x/minute T : 36,7 C

HR : 80x/minute Eyes: Pale conjunctiva (-/-), sclera icteric (-/-) Ears, nose and mouth: Normal Lymph nodes: Not enlarged JVP : 5-2cm


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Thorax- Ins : Chest wall movement symmetric

- Pal : Vocal fremitus sound symmetric- Per : Symmetric sonor sound- Aus : Basic sound of breath vesicular, wheezing (-/-), ronchi (-/-). Heart sound I & II

murmur (-), gallop (-)

Abdomen- Ins : Looks flat- Aus : Bowel sound (+) 4x/minute- Per : Timpani, percussion tenderness in all abdomens regio (-)- Pal : Abdominal tenderness in all abdomens regio (-), liver and spleen enlargem

Extremities- Warm- Capillary refill time


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Clinical Laboratory

Haemoglobin : 13,5 g/dlHaematocrit : 43,5 %

Leucocyte : 10,4 ribu/ul

Thrombocyte : 233.000 /ul

GDS : 139 mg/dl

Na: 140

K:5,3

Cl: 107


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Assessment

- Hematemesis ec gastritis erosif- Dispepsia- hiperkalemia


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Therapy

Mm/ Omeprazole inj 2 x 40 mg (IV) Domperidon 3x10mg (PO) Sucralfat 3x2c (PO) Ondancentron 2x8mg (IV)

Vit K 3x1amp (IV) Asam tranexamat 3 x 2gr (IV)


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Planning

hospitalizedDiet : fastingIVFD :

I triofucinII futrolit

I RL

24 hours


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Thank You

Department of Internal MedicineChristian University of Indonesia

morport 6 september

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