Morep Ipd 27 Juli 2014

MORNING REPORTInternist, July 27 2014

C-21

Patient’s Identity

• Name : Mr. Ky• Age : 19 y.o• Religion : Moeslim• Date admission : July 27 2014• Adrress : Balongrejo - Lamongan

Anamnesis

• Chief complaint: abdominal discomfort• Present illnes: Patient was admission on Emergency

department of Muhammadiyah Lamongan hospital because he feel abdominal discomfort since 2 month before hospitalized. Abdominal discomfort especially after eating, he is often burp. Nausea +. Vomiting -. Pain the stomach -, epigastric pain – . Urination and defecation are normal. Patien have been treated but not change.

Anamnesis

• History or past illness : - Alergy -, DM -, Hypertensi -, gastritis -

• History of family : Denial

• History of past treatment :– Omeprazole– Trimetoprim+sulfametoksazole– Fucohelix

Physic Examinations

• GCS : 456, Compos Mentis• Vital Sign

BP : 122/98 mmHgPulse : 98x / minutesRR : 20x / minutesTemp : 36°C

• Man 19 y.o• Abdominal discomfort especially after eating • Burp +• Nausea +

Clue & Cue

Problem list

• Dyspepsia

Physic Examinations

• Head and neck : – Anemic-/ icteric-/ cyanosis-/ dyspneu-

• Thorax : – Pulmo :

• I : Simetric, retraction -/-• P : fremitus + simetric• P : sonor/ sonor• A : ves/ves, rh -/-, wh (-/-)

• Cor : • I : vassoure cardiaque -• P : ictus cordis not palpable• P : heart limit are normal• A : S1-S2 single, murmur(-), gallop(-)

Physic Examinations

• Abdomen : – I : flat– P : soepel, hepar and lien not palpable, pain -– P : tympani – A : bowel sound (+N) ,

• Extremity : warm, dry, red, edema –

Problem List

• Dyspepsia

Assessment

• Dyspepsia

Planning

• Planning Dx :– CBC– SE

• Planning Tx :– Asering 1500 cc/24 hour– Rantin 2x50 mg IV

• Planning Monitoring• Complaint• Vital sign

Prognosis

• Dubia ad bonamEducation

• Explain to the family about the condition of this patient now, its disease, about its examinations, theraphy and intervention will be done, and also about complication and prognosis.