Morpot 6 April
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Transcript of Morpot 6 April
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MORNING REPORT
Department of Internal Medicine
Christian University of Indonesia
March th 2015
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Mr. A, 45 YO
Jakarta
CC : Epigastric pain
TC : Monday 6th March 2015
CM :
FindingsAssessmentTherapyPlanningEpigastric painNauseaVomitingDizzyAppearance: moderate illness, GCS : E4V5M6, BP: 120/80 mmHg, PR : 80 x/min (adequate,regular) RR : 18 x/min, T: 36,6CEye : conjunctiva anemia -/- sclera icteric -/-Ear nose throat : normalNeck : lymph nodes not enlargedJVP : Distended (-)Thorax PulmoInspection : symmetricPalpation : vocal fremitus symmetricPercussion : symmetric, sonor soundAuscultation : vesiculer rhonki -/- , whezing -/- Heart Sound S1 S2 Normal, murmur ( ), gallop ( )Abdominal Inspection : abdomen looks flatAuscultation : bowel sounds (+) 5x/minutePalpation : Pressure pain (+) EpigastricPercussion : Tympani, pain (-)Extremitas : warm acral, CR -
Mr. J, 91 YO
Jakarta
CC : Shortness
TC : Monday 6th March 2015
CM :
FindingsAssessmentTherapyPlanningShortnessCough with white phlegmAppearance: moderate illness, GCS : E4V5M6, BP: 130/90 mmHg, PR : 96 x/min (adequate,regular) RR : 30 x/min, T: 37CEye : conjunctiva anemia -/- sclera icteric -/-Ear nose throat : normalNeck : lymph nodes not enlargedJVP : Distended (-)Thorax PulmoInspection : symmetricPalpation : vocal fremitus symmetricPercussion : symmetric, sonor soundAuscultation : long eksperium rhonki -/- , whezing +/+ Heart Sound S1 S2 Normal, murmur ( ), gallop ( )Abdominal Inspection : abdomen looks flatAuscultation : bowel sounds (+) 5x/minutePalpation : Pressure pain (-) Percussion : Tympani, pain (-)Extremitas : warm acral, CR -
Subjective Data
Name: Mrs. Saomi
Address: Bekasi
CM: 71-72-03-00
TC: Saturday/ December 7th 2013/ 7.30 AM
CC: Epigastric Pain
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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.
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Past Medical History and Treatment
Hypertension (+) 1 year ago use Captopril as the medicine, Diabetes Meillitus (-),
Family History
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Social History
Smoking (-), Alcohol (-)
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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 (-)
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Pulmo
Inspection: Static and dynamic symmetric
Palpation: Vocal Fremitus right and left symmetric
Percussion: Sonor symmetric
Auscultation: Vesiculer, wheezing -/-, ronkhi +/+
ABDOMEN
Inspection: stomach looks flat
Auscultation: Bowel sound (+), 8 x/min
Palpation: Defense muscular
Pressure pain in epigastrium +
LiverSpleen impalpable ;
Percussion: Tympani; Percussion Pain
EXTREMITIE
Pitting Edema (-/-) in lower extremity; warm (-) ; CRT
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Labolatorium Test
Na 143 mmol/L
K 3,9 mmol/L
Cl 108 mmol/L
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Assessment
Acute Gastroenteritis with Moderate DehydrationHypertension gr I*
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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
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Planning
RehidrationFeces CulturH2TL test*
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Thank You
Department of Internal Medicine
Christian University of Indonesia
December, 7th 2013
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