Morning Report GEA-15Des

8/12/2019 Morning Report GEA-15Des

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MORNING REPORT

Department of Internal Medicine

Christian University of Indonesia

December 15th2013


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Findings Assessment Therapy Planning

- Vomit- Nausea

- Diarrhea

- Loss appetite

Appearance: mild illness, GCS : E4V5M6, BP: 130/80 mmHg, PR :

82 x/min (adequate,regular) RR : 20 x/min, T: 37,2C

Eye : conjunctiva anemia -/- sclera icteric -/-

Ear nose throat : normalNeck : lymph nodes not enlarged

JVP : normal

THORAXPulmoInspection : 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

Palpation : Pressure pain (+) Epigastric, umbilical

Percussion : Tympani

Auscultation : bowel sounds (+) 8x/minute

Extremitas : warm acral, CR


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Subjective Data

Name : Mr. Robinson

Address : Pancoran

CM : 77-12-05-00

TC : Sunday/ December, 15 2013/13.00CC : Vomit


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AnamnesisMain symptom : Vomit

Additional symptom : Nausea, Diarrhea, Diarrhea, Loss appetite

51 years old male patient come to the emergency with complaints of vomit

since 1 day before hospital admission. Patient vomit once a day and vomiting the

food that he eat. Patient already go to the clinic and already given drug but the

complain didnt change. Patient feels nausea so he didnt want to eat. Patient

complain diarrhea 1 day before admission, in that day patient already 15 times

defecation, sometimes there is mucus, ground +. Urine normal. Patient still want

drink. Patient denied a history of hypertension and diabetes. Patient denied history of

allergy.


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Past Medical History and Treatment

Hypertension (-), Diabetes Meillitus (-),

Family History

-

Social HistorySmoking (+) 5 years, Alcohol (+) 2 years


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Objective DataConsciousness : E4V5M6 ; Composmentis

Appearance : mild ill

Blood Pressure : 130/80 mmHg

Pulse Rate : 82 x/min (adequate,regular)

Respiration Rate : 20 x/min

Temperature : 37,20C

EYE : conjungtiva anemic -/- ; sclera icteric -/-

Ear Nose Throat : Normal

Neck : Normal

JVP : Normal

THORAX :

Heart

Inspection : Ictus Cordis visible

Palpation : IC palpable 1cm lateral ICS V midclavicula sinistra

Percussion : Right heart border Inter Costae V line Parasternal dextra, Left

heart border Inter Costae VI axilaris anterior line

Auscultation : S1 single, S2 single, regular, murmur (-) gallop (-)


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PulmoInspection : Static and dynamic symmetric

Palpation : Vocal Fremitus right and left symmetric

Percussion : Sonor symmetric

Auscultation : Bronchial, wheezing -/-, ronkhi -/-

ABDOMEN

Inspection : stomach looks flat

Auscultation : Bowel sound (+), 8 x/min

Palpation : Defense muscular

Pressure pain + in epigastrium and umbilical

LiverSpleen impalpable ;

Percussion : Tympani; Percussion Pain

EXTREMITIE

Turgor decrease in extremity; cold (-) ; CR


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Labolatorium Test

Hb : 15,4 g/dl,Ht : 46,8%,

Leu : 9,4 rb/L,

Tb : 274 rb/L,

GDS : 86 mg/dl,

Ur : 32 mg/dl,

Cret : 1,19 mg/dl,

Na : 137 mmol/L ,K : 4 mmol/L ,

Cl : 101 mmlo/L


9/12

Assessment

Acute Gastroenteritis

Mild dehidration


10/12

Therapy

Hospitalization

IVFD : III RL / 24 h

Diit : porigd

Mm/

Omeprazole IV 2 x 40 mg

Ondancentron IV 2x4 mg

Bactrim Forte 2x1


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Planning

- Electrolyte- Feses


12/12

Thank You

Department of Internal Medicine

Christian University of Indonesia

September, 5th2013

Morning Report GEA-15Des

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