MORNING REPORT

Department of Internal MedicineChristian University of Indonesia

October 30th 2015 TEAM 1

Findings Assesment Therapy Planning

Epigastric pain GCS: E4V5M6, TD: 120/80, PR 100x, T : 36oC, RR: 19xEye : Pale Conjungtiva -/-, Sclera icteric -/-THT : NormalNeck : Lymph Nodes not EnlargedJVP : normalTHRORAX

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

Pal: Symmetrical Vocal fremitus, ictus cordis : palpablePer: Sonor/Sonor , cardiac englargement (-)Aus: Basic breath sound vesicular, ronchi -/-, wheezing -/-. S1

and S2 reguler, gallop (-), murmur (-) ABDOMENIns : flatAus : Bowel sound (+) 6x/minutePal : Pressure pain (+).Per : Timpani, percussion tenderness (+)Extremitas : pitting oedem (-), warm acral, CRT < 2”, turgor

normal

• Suspect Cholelitiasis

• Cholesistisis

MM/Ceftriaxone 1x2gr (IV) (ST)Pumpitor 1x40 (IV)Domperidone 3x10mgSucralfat Syr 3x1CSanmol 3x500mg

HospitalizedCheck lab: H2TL, electrolit,SGOT, SGPT, Ur, Cr, Ul, GDSPro USG abdomen after visit

O2 kanul nasal 3-4 Lpm

IVFD : II Futrolit / 24 hours

Diet: tender and not stimulating

Mr.s SI, 52 YOCC : epigastric pain

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