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Department of Internal Medicine Christian University of Indonesia

MORNING REPORT
December 31st 2013 TEAM 5

Mrs.F (32 YO)

Findings
CC : pain in epigastrium
Nausea and Vomitting, Fever
Appearance: moderate illness, GCS : E4V5M6, BP: 110/70 mmHg, PR : 84 x/min (adequate,regullar) RR : 20 x/min, T: 37 C Eye : hiperemic conjuntiva -/-, Sklera icteric -/Ear, Nose, Throat: normal Neck : lymph nodes did not enlarged, venous distention THORAX Insp : symmetric, ictus cordis (-) Pal : vf symmetric, ictus cordis palpable Per : symmetric, sonor sound RHB ICS V lin. sternal dext, LHB ICS V lin. Midclavicula sin Aus : vesicular rh -/-,wh-/S1 single, S2 single, regular, murmur (-) gallop (-) ABDOMINAL Ins : stomach looks flat Ausc : bowel sounds + 4x/m, Palp : Pressure Pain + in epigastrium Undulation(-) Per : timpany, shifting dulness (-), - Extremitas : warm acral, CR<2, edema LAB FINDING: - Complete Perifer Blood : Hb : 12,1 gr/dl Leu : 9.100/ul ; Ht : 36,4% Tro : 251.000/ul LED: 23 ; Na: 141; K: 3,5; Cl: 104; MCH: 27,6; MCV: 82,9; MCHC: 33,3

Assessment
Chronic Gastritis

Therapy
Hospitelize IVFD : II Futrolit / 24 hour Diit : Smooth doesnt stimulating Mm/ Ranitidine 2x1 amp Omeprazole 1x1 amp Sucralfate syrp 3x2C

Planning
Gastroscopy

Subjective Data
Name Address CM TC CC : Mrs. Fakland : : 37-49-04-0 : Friday/27th December2013 : Pain in Epigastrium

Anamnesis
Main symptom Additional symptom : Cough : Breathless, fever
Patient was come to the hospital with the main complain is cough since 4 days before admission. The complain heavier at night and this complain felt every day. The type of cough is productive and the colour of mucus is yellow. The patient has been treated the laserin and the symptom perceived reduced. The additional symptom is breathless, the additional symptom is breathless and this complain felt since 4 days before admission. The other additional symptom is fever since 3 days before admission.

Past Medical History and Treatment (denied)

Family History
(denied)

Social History
Smoking (-) , Alcohol (-), Drug induced (-), Tatoo (-), Free sex (-), Sport (-)

Objective Data
LOC Appearance BP PR RR Temp EYE THORAX Heart
Ins Pal Per Ausc : : : :

: E4V5M6 ; Composmentis : moderate ill : 110/70 mmHg : 84 x/min (adequate,regular) : 20 x/min : 370C : anemic conjungtiva -/- ; ict -/:
IC visible IC palpable RHB ICS V lin. sternal dext, LHB ICS V lin. Midclavicula sin S1 single, S2 single, regular, murmur (-) gallop (-)

Objective Data
PULMO Insp Pal Perc Ausc ABDOMEN Insp Ausc Pal Perc : Static and dynamic symmetric : VF right and left symmetric : Sonor symmetric : BBS Vesicular, Rhonci -/-, Wheezing -/-

: Stomach looks flat : Bowel sound (+) 4 x/min : Pressure Pain + in epigastrium : Timpany; Percussion Pain + in epigastrium
EXTREMITIES Edema (-); warm (+); capp. Refill <2 seconds

Clinical Laboratory
Hb Ht Leukosit Trombosit LED Eritrosit MCV MCH MCHC Na K Cl : 12,1 : 36,4 ( ) : 9.100 : 251.000 : 23 ( ) : 4.400.000 ( ) : 82,9 : 27,6 : 33,3 : 141 : 3,5 : 104

Assessment

Chronic Gastritis

Therapy
Pro Hospitalized IVFD : II Futrolit / 24 hours Diit : Smooth doesnt stimulating Mm/ - Rantidine 2x1 amp (IV) - Omeprazole 1x1 amp (IV) - Sucralfat syrp 3x2C

Planning
Gastroscopy

Department of Internal Medicine Christian University of Indonesia

Thank You
December, 31st 2013