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Department of Internal

Medicine
Christian University of Indonesia

MORNING REPORT
June, 7th 2015
TEAM 4

Mr. Y, 49 YO
CC : Epigastric Pain
Findings
Epigastric pain, vomit, nausea
GCS: E4V5M6, TD: 130/70, PR 84x, T : 37,8oC, RR: 22x
Eye : Pale Conjungtiva -/-, Sclera icteric -/THT : Normal
Neck : JVP 5-2 cm, Lymph Nodes not Enlarged
JVP : THRORAX

I : Symmetrical chest wall movement, ictus cordis (-)


Pal: Symmetrical Vocal fremitus, ictus cordis : palpable
Per: Sonor/Sonor , cardiac englargement (-)
Aus: Basic breath sound vesical, ronchi -/-, wheezing -/-. S1 and
S2 reguler, gallop (-), murmur (-)
ABDOMEN
Ins : flat
X
Aus : Bowel sound (+) 4x/minute
Pal : Pressure pain (+).
X
X
Per : Timpani, percussion tenderness (+)
Extremitas : pitting oedem (-), warm acral, CRT < 2, turgor
normal

Assesment
Dyspepsia
Urinary
Tract
Infection
History of
cholelitiasis

Therapy
MM/
Cefxon 1x2 gr (IV)
Sucralfat 3x1 C
Vometa 3x1 tab
Pumpitor 1x1 amp (IV)

Planning
Hospitalized
Check lab : H2TL, SGOT/SGPT,
Ur/Cr, DPL & profil lipid
IVFD : II Futrolit/ 24 hours

Subjective Data
Name
CM
TC
CC

: Mr. Y, 49 Years Old


:
: Sunday, June 7th 2015
: Epigastric Pain

Anamnesis
Main symptom
Additional symptom

: Epigastric Pain
:

Patient arrived to UKI hospital to complain


epigastric pain since 2 days ago. The
complain felt continiously. The patient also
complain nausea and vomit 3 times this day.

Past Medical History and Treatment


History of cholelitiasis

Family History
denied

Social History
Smoking (-), consuming alcoholic beverages (-)

Objective Data

Appearance : Moderate Illness


GCS E4M6V5
BP : 130/70 mmhg,
RR: 22x/ minute,
T : 37.8C
Pulse : 84x/minute.
Eye: Pale conjunctiva -/- , sclera icteric -/Ear, Nose, throat : normal
JVP : normal , 5-2 cm, lymph nodes not
enlarged

Thorax.

I : Symmetrical chest wall movement, Ictus cordis (-)


Pal: Symmetrical Vocal fremitus, ictus cordis : palpable
Per: Sonor/Sonor, cardiac englargement (-)
Aus: Basic breath sound vesical, ronchi -/-, wheezing -/-. S1 and S2 irreguler, gallop (-), murmur (-)

Abdomen.

I : flat
Aus : bowel sound (+) 4x/minute
Pal : Pressure pain (+), liver enlargement (-)
Per :timpani, percussion tenderness (+)

Extremity
-

Warm acral
Capillary refilling time <2 second
Edema (-)
Turgor normal

Clinical Laboratory

7/06/2015 (21.30)
H2TL
Hb : 15,8 g/dl
White Blood Cell
: 7.3 /uL
Hematocrite
: 50,3 % (High)
Trombosite
: 197.000/uL
Electrolyte
Na 136 mmol/L K 4.6 mmol/L Cl 107 mmol/L
Urinalisa
Blood +1
Leukosit esterase +1
Urobilinogen 0,2
Leucosit 3-6/ LBP
Bacterial +

Assessment
Dyspepsia
Urinary Tract Infection
History of cholelitiasis

Therapy
Cefxon 1x2 gr (IV)
Sucralfat 3x1 C
Vometa 3x1 tab
Pumpitor 1x1 amp (IV)

Planning
Hospitalized
Check lab : H2TL, SGOT/SGPT, Ur/Cr,
DPL & profil lipid
IVFD : II Futrolit/ 24 hours

Department of Internal
Medicine
Christian University of Indonesia

Thank You