Department of Internal Medicine

Christian University of Indonesia

MORNING REPORT
November 6nd 2014
TEAM 4

Mr. B (67 yo)

Findings

Assessment

CC :Diarrhea
Appearance: moderate illness, GCS : E4V5M6, BP:
120/70 mmHg, PR : 68 x/min (adequate,regullar) RR : 22
x/min, T: 36,5 C
Eye : anemic conjungtiva -/-, Sklera icteric -/Ear, Nose, Throat: normal
Neck : lymph nodes did not enlarged, venous distention THORAX
Insp : symmetric, ictus cordis (-)
Pal : vf symmetric, ictus cordis palpable, JVP 5-2
Per : symmetric, sonor sound
RHB ICS V lin. sternal dext, LHB ICS IV lin.
Midclavicula sin ICS V lin
Aus : bronchial rh -/-,wh-/BJ I dan II regular, murmur (-) gallop (-)
ABDOMINAL
Ins : stomach looks flat
Ausc : bowel sounds (+) , 6x/minute
Palp : Pressure Pain (+) epigastrium
Undulation(-),
Per : timpany, shifting dulness (-)
Per : CVA (-/-)
Extremitas : edema - -/- -, warm acral, CR <2, edema
Skin turgor : decreased
LAB FINDING:
Complete Perifer Blood :
Hb : 14,8 gr/dl Leu : 8,7 ribu/ul ; Ht : 43,7 %
Tr : 177.000 /ul ; GDS 124
Na : 137 ; K : 4,7 ; Cl : 102

-Acute Gastroenteritis
-Mild dehydration

Therapy
Pro Hospitalized
IVFD : I RL 20
drops/minute
Diit : smooth not
stimulated
Mm/
ciprofloksasin 2x200 mg
(iv)
Metronidazole 3x500 mg
(iv)
OMZ 2X40 mg (iv)
Ondancentron 2x8 mg (iv)

Planning
Check balance

Subjective Data
Name
Address
TC
CC

: Mr. B
: Jakarta
: Friday/14nd November 2014
: Diarrhea

Anamnesis
Main symptom
Additional symptom

: Diarrhea
: vomitus

67 years old male patient came to the hospital with complaint diarrhea since
two days before admission. with frequency 10 times a day and watery consistancy,
melena (-), mucus (-). The complaint came suddenly and continously. He already
taking the medicine but the complaint is not getting better. he lost appetite, had mild
epigastric pain and nausea.
Patient has no history of hypertension, and diabetes . But he told that he has
gastritis since he was young.

Past Medical History and Treatment

gastritis

Family History
(denied)

Social History
Smoke(-), Alcohol (-)

Objective Data
LOC
Appearance
BP
PR
RR
Temp
EYE
THORAX
Heart
Ins
Pal
Per
Ausc

:
:
:
:

: E4V5M6 ; Composmentis
: moderate ill
: 120/70 mmHg
: 68 x/min (adequate,regular)
: 22 x/min
: 36,50C
: anemic conjungtiva -/- ; ict -/:

IC not visible
IC palpable
RHB ICS IV lin. sternal dext, LHB ICS IV lin. Midclavicula sin ICS V lin
S1 single, S2 single, regular, murmur (-) gallop (-)

Objective Data
PULMO
Insp
: Static and dynamic symmetric
Pal
: VF right and left symmetric
Perc
: Sonor symmetric
Ausc
: BBS Brochial, Rhonci -/-, Wheezing -/ABDOMEN
Insp
: Stomach looks flat
Ausc
: Bowel sound (+) 6 x/minute
Pal
: undulation (-) , pressure pain (+) in epigastrium
Perc
: shifting dulnes (-)
BACK
Perc
: CVA (-)
EXTREMITIES
Edema (- -/- - ); warm (+); capp. Refill <2 seconds
Skin turgor : decrease

Clinical Laboratory

Hb : 14,8 gr/dl
Leu : 8,7 ribu/ul
Ht : 43,7 %
Tr : 177.000 /ul
GDS 124
Na : 137
K : 4,7
Cl : 102

Assessment

acute gastroenteritis
Mild dehydration

Therapy
Pro Hospitalized
IVFD : I RL 20 Drops/minute
Diit : smooth not stimulated
Mm/
Ciprofloxacin 2x200 mg (iv)
Metronidazole 3x500 mg (iv)
OMZ 2X40 mg (iv)
Ondancentron 2x8 mg (iv)

Planning
Check balance

Department of Internal Medicine

Christian University of Indonesia

Thank You