morport 6 september
TRANSCRIPT
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MORNING REPORT
Department of Internal MedicineChristian University of Indonesia
Sept, 6 th 2014TEAM 4
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Mrs. RA 66 years old
Findings Assesment Therapy - Vomit B lack-red colored- Nausea- headache
PHYSICAL EXAMINATIONLoc: compos mentis, GCS E4V5M6BP : 110/70mmHg, HR : 80x/minRR : 22x/min, T : 36,7CEye : hyperemic conjunctiva (-/-), Icteric sclera -/-THT : normalMouth : normalNeck : lymph nodes not enlarge, JVP : 5-2cmH2OThoraxIns : chest movement symmetricPal : vocal fremitus sound symmetricPer : symmetric sonor soundAus : basic sound of breath vesicular, wheezing (-/-), ronchi (-/-)Heart sound I & II regular, murmur (-), gallop (-)AbdominalIns : looks flatAus : bowel sound (+), 6x/minPer : no percution pain, timpani soundPal : no tenderness and defence muscularExtremitieswarm acral, CRT < 2 s , edema (-)LAB FINDINGHemoglobin : 13,5 g/dlHaematocrit : 43,5%Leucocyte: 10,4ribu/ulThrombocyte : 233.000 /ulGds : 139 mg/dlNa : 140K : 5,3
Cl : 107
Hematemesis ec gastritis erosifDispepsiahiperkalemia
Mm/Domperidon 3x10mgOmz 2x40mgSucralfat 3x2cOndancentron 2x8mgVit ka 3x1 ampAsam tranexamat 3x2
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Subjective Data
Name : Mrs ATC : Saturday, September 6 th 2014CC : Vomit Black-red colored
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AnamnesisMain symptom : Vomit Black-red colored like Jelly
Additional symptom : Headache, NauseaPatient came to Christian University of Indonesia General Hospital w
Vomit, Black-Red Colored and the consistance like a jelly, since 2 hours beforarrived at the Hospital.
In beginning, patient ate boiled noodles with imbibing ABC orange syruAfter that, patient felt nausea and vomit. Patient have went to the doctor not feelin
better. Patient had been felt like this before, with hematemesis & melena 4 years agoHypertension & diabetes mellitus are denied.
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Past Medical History-
History of treatment-
Family HistoryDenied
Social HistorySmoking (-), Alcohol (-)
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Objective Data
Appearance : Being sick
GCS E4M6V5 BP : 110/70 mmHg RR: 22x/minute T : 36,7 C
HR : 80x/minute Eyes: Pale conjunctiva (-/-), sclera icteric (-/-) Ears, nose and mouth: Normal Lymph nodes: Not enlarged JVP : 5-2cm
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Thorax- Ins : Chest wall movement symmetric
- Pal : Vocal fremitus sound symmetric- Per : Symmetric sonor sound- Aus : Basic sound of breath vesicular, wheezing (-/-), ronchi (-/-). Heart sound I & II
murmur (-), gallop (-)
Abdomen- Ins : Looks flat- Aus : Bowel sound (+) 4x/minute- Per : Timpani, percussion tenderness in all abdomens regio (-)- Pal : Abdominal tenderness in all abdomens regio (-), liver and spleen enlargem
Extremities- Warm- Capillary refill time
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Clinical Laboratory
Haemoglobin : 13,5 g/dlHaematocrit : 43,5 %
Leucocyte : 10,4 ribu/ul
Thrombocyte : 233.000 /ul
GDS : 139 mg/dl
Na: 140
K:5,3
Cl: 107
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Assessment
- Hematemesis ec gastritis erosif- Dispepsia- hiperkalemia
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Therapy
Mm/ Omeprazole inj 2 x 40 mg (IV) Domperidon 3x10mg (PO) Sucralfat 3x2c (PO) Ondancentron 2x8mg (IV)
Vit K 3x1amp (IV) Asam tranexamat 3 x 2gr (IV)
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Planning
hospitalizedDiet : fastingIVFD :
I triofucinII futrolit
I RL
24 hours
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Thank You
Department of Internal MedicineChristian University of Indonesia