Department of Internal

Medicine
Christian University of Indonesia

MORNING REPORT
October 27th 2014
TEAM 2

Mr. A (49 YO)

Findings

Assessment
Acute gastroenteritis

CC : breathless
Appearance : mild illness
GCS : E4V5M6
BP: 120/70 mmHg, PR :82 x/min (adequate, regular) RR : 25 x/min, T:
38,5 C
Eye : conjuntiva not pale, Sklera icteric -/Ear, Nose, Throat: normal
Neck : lymph nodes did not enlarged, venous distention THORAX
Insp : symmetric, ictus cordis pulsation in intercosta V,
midclavicula sinistra line
Pal : vf symmetric, ictus cordis palpable
Per : symmetric, sonor sound
RHB ICS V lin. sternal dext, LHB ICS V lin.
Midclavicula sin
Aus : bronchiale rh -/-, wh-/S1 single, S2 single, prolonged expiration, murmur (-)
gallop (-)

Mm:
Ventolin
Pulmicort

Planning
-Pro Hospitalized
-IvFD: II RL, I Futrolit / 24
hour
- Diet: soft
:
-Mm/
ciprofloxacin 2x200 mg
(IV)
omeprazole 2x40 mg (IV)
ondancentron 2x8 mg (IV)
paracetamol 3x500 mg
(po)
-Test: SGOT/SGPT, ureum,
creatinin, urinalisa
-Microbiology: faeces

ABDOMINAL
Ins : stomach looks flat
Ausc : bowel sounds + 8x
Palp : Pressure Pain + at hypochondrium dextra regio
Undulation(-),
Per : hipertimpany, pain in percussion (+) at hypochondrium dextra
regio
Extremitas : warm acral, CR <2, edema -

Therapy

Subjective Data
Name
Address
TC
CC

: Mrs. S
: Kramat Jati
: Senin/27th October 2014
: Diarrhea

Anamnesis
Main symptom
Additional symptom

: Diarrhea
: Fever, Vommitting, nausea

Patient came with diarrhea since 2 days ago. Pastient had

diarrhea 8 times in two days. The faeces was liquid, no no mucus, no
blood. Fever (+), vommitting (+), nausea (+). Intermittent fever
occurred since 2 days ago. Patient already went to the doctor and
got these medicines: paracetamol, loperamide, levofloxacin,
dexamethasone, attalpulgit, but the pasient didnt get well.

Past Medical History and Treatment

(Denied)

Family History
(denied)

Social History
food carelessly

Objective Data
LOC
Appearance
BP
PR
RR
Temp
HEAD & EYE
THORAX
Heart

:
:
:
:
:
:
:
:

E4V5M6 ; Composmentis
mild illness
120/70 mmHg
82 x/min (adequate, regular)
25 x/min
38,50C
pale conjungtiva -/- ; ict -/-

Ins : IC visible in an intercosta V, midclavicula sinistra line

Pal : IC palpable
Per: RHB ICS V lin. sternal dext, LHB ICS V lin. Midclavicula sin
Ausc
: S1 single, S2 single, regular, murmur (-) gallop (-)

Objective Data
PULMO
Insp
Pal
Perc
Ausc
ABDOMEN
Insp
Ausc
Pal
Perc

: thorax movement symmetric

: VF right and left symmetric
: Sonor symmetric
: BBS vesicular, Rhonki -/-, Wheezing -/-

: Stomach looks flat

: Bowel sound (+) 8 times/second
: undulation (-), pressure pain (+) at hypochondrium dextra regio
: hypertimpany, pain in percussion (+) at hypochondrium dextra regio

EXTREMITIES
Edema (-); warm (+); capp. Refill <2 seconds

Assessment

Acute Gastroenteritis

Therapy
Mm/
RL 500 cc/24 hour
Ondancentron 8 mg (IV)

Planning
- Pro Hospitalized
- IvFD: II RL, I Futrolit / 24 hour
- Diet: soft
- Mm/:
- ciprofloxacin 2x200 mg (IV)
- omeprazole 2x40 mg (IV)
- ondancentron 2x8 mg (IV)
- paracetamol 3x500 mg (po)
- Test: SGOT/SGPT, ureum, creatinin, urinalisa
- Microbiology: faeces

Department of Internal
Medicine
Christian University of Indonesia

Thank You