Department of Internal

Medicine
Christian University of Indonesia

MORNING REPORT
March 8th 2015

Mrs. E, 55 YO

TC : Sunday, 8th March 2015

CM : 45430600

Jatinegara

CC : Lower left Abdominal pain

Findings
-

Lower abdominal pain

Epigastric pain
Nausea
micturition pain
Polyuria

Appearance: moderate illness, GCS : E4V5M6, BP: 130/70 mmHg,

PR : 82 x/min (adequate,regular) RR : 22 x/min, T: 37,4C
Eye : conjunctiva anemia -/- sclera icteric -/Ear nose throat : normal
Neck : lymph nodes not enlarged
JVP : Distended (-)

THORAX Pulmo
Inspection : symmetric
Palpation : vocal fremitus symmetric
Percussion : symmetric, sonor sound
Auscultation : vesiculer rhonki -/- , whezing -/- Heart
Sound S1 S2 Normal, murmur ( ), gallop ( )
Abdominal
Inspection : abdomen looks flat
Auscultation : bowel sounds (+) 5x/minute
Palpation : Pressure pain (+) Epigastric, suprapubic
Percussion : Tympani, pain (-), regio CVA left pain (+)
Extremitas : warm acral, CR<2, pitting edema -/- , Turgor
normal

Assessme
nt

Therapy

Dyspepsia

Hospitalization

urinary tract infection

IVFD : I RL / 24 h
Diit : smooth
Mm/
Ranitidine HCl IV 1x50 mg
Ondancentron IV 1x 8mg
Sucralfat syr 3x1 C
Asam mefenamat 3x 500mg
Ceftriaxone 2x1gr

Plannin
g
- Hematology
- Electrolyte
- Urinalisa

Subjective Data
Name
: Mrs. Saomi
Address : Bekasi
CM
: 71-72-03-00
TC
: Saturday/ December 7th 2013/
7.30 AM
CC
: Epigastric Pain

Anamnesis
Main symptom : Epigastric Pain
Additional symptom : Nausea, Vomiting, Diarrhea
68 years old female patient come to the emergency with
complaints of epigastric pain since 5 hours before hospital
admission. Epigastric pain is like kneaded. Epigastric pain occurs
continously. Before the epigastric pain occurs, she ate food from her
neighbour. After she ate the fod, she felt epigastric pain and had
diarrhea as many as 4 times. The feses is like a water, no blood, no
mucus. She didnt eat or drink medicine to reduce the epigastric
pain. The other symptoms were nausea, vomited, diarrhea, malaise,
and lost of appetite. Patient had a history of hypertension since 1
year ago and she never controlled it. Patient consumed Captopril.
Patient had allergy of chicken, prawn, and egg.

Past Medical History and Treatment

Hypertension (+) 1 year ago use Captopril as the
medicine, Diabetes Meillitus (-),

Family History
-

Social History
Smoking (-), Alcohol (-)

Objective Data
Consciousness
: E4V5M6 ; Composmentis
Appearance
: moderate ill
Blood Pressure
: 140/70 mmHg
Pulse Rate
: 108 x/min (adequate,regular)
Respiration Rate
: 22 x/min
Temperature
: 36,50C
EYE: conjungtiva anemic -/- ; sclera icteric -/Ear Nose Throat
: Normal
Lips Mucose
: dry
Neck
: Normal
JVP: Normal (5-2 cmH20)
THORAX :
Heart
Inspection
: Ictus Cordis invisible
Palpation : IC not palpable
Percussion
: Right heart border Inter Costae IV line Parasternal dextra, Left heart
border Inter Costae V mid clavicula sinistra
Auscultation
: S1 single, S2 single, regular, murmur (-) gallop (-)

Objective Data
Pulmo
Inspection
Palpation
Percussion
Auscultation
ABDOMEN
Inspection
Auscultation
Palpation

: Static and dynamic symmetric

: Vocal Fremitus right and left symmetric
: Sonor symmetric
: Vesiculer, wheezing -/-, ronkhi +/+

: stomach looks flat

: Bowel sound (+), 8 x/min
: Defense muscular
Pressure pain in epigastrium +
LiverSpleen impalpable ;
: Tympani; Percussion Pain

Percussion
EXTREMITIE
Pitting Edema (-/-) in lower extremity; warm (-) ; CRT <2 second
Tofus in pedis dextra.
SKIN
Turgor
: decreased

Labolatorium Test
Na 143 mmol/L
K 3,9 mmol/L
Cl 108 mmol/L

Assessment
Acute Gastroenteritis with
Moderate Dehydration
Hypertension gr I

Therapy
Pro Hospitalized
IVFD : III RL / 24 hours
Diit : non-stimulating rice porridge
Mm/
Ranitidin 2x1 amp
Ondancentron 2x4mg ( bolus IV )
Sucralfat syrup 3x2 C a.c.
Zink kid 3x1 tab

Planning

Rehidration
Feces Cultur
H2TL test

Department of Internal
Medicine
Christian University of Indonesia

Thank You
December, 7th 2013