morpot tim 3 sabtu 12 maret 16asfa
TRANSCRIPT
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MORNING REPORT
Department of Internal
MedicineChristian University of Indonesia
March, 12st 2016TEAM 3
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Findings Assesment Therapy
• melena
• GCS: E4V5M6, TD: 130/80, PR 102 x, T : 36,5 oC, RR: 21x
Eye : Pale Conjn!"#$a %/%, S&le'a ()#&"e'#& *
T+T : o'mal
e&- : .VP 5*1 ym oe( no" Enla'!e
THORAX
: Symme"'#&al &e(" all mo$emen", #&"( &o'#( %Pal: Symme"'#&al Vo&al 7'em#"(, #&"( &o'#( : ala)le
Pe': Sono'/Sono'
(: 9a(#& )'ea" (on : $e(#&la', 'on&# %/%, ee#n! %/%; S1
an S2 no'mal, !allo %, m'm' %
ABDOMEN
n( : 7la"
( : 9oel (on * 4x/m#n"e
Pal : P'e(('e a#n * (#n#("'a #l#a&a;
Pe' : T#man#, e'&((#on * (#n#("'a #l#a&a "ene'ne(( %
Extremitas : #""#n! oeem %, a'm a&'al, CRT < 2=, alma'
e'#"em
• melena e&
e'o(#7 !a("'#"#( *
(#'o(#( ea"#( *
anem#a
MM/
V#" > 3 x 1 am-alnex 3 x 1 am
?m '# 2 x 40 m!
C#'o7loxan '# 2 x 200 m!
P'oanolol 1 x 10 m!
+o
D#e
V@
PR
Mr. T , ! "O
## $ melena %&la'( ')l)*r +e'es
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Subecti!e DataName : M'; >, 65 B?
CM : TC : Tuesday, March 1st , !1"
"" # blac$ colour feses
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Anamnesis
Main s%mptom : #$ac% co$our feces
Additional s%mptom :• & Patient 'ith an indication of sudden #$ac% feces
( hours )rior to #ein* su#mitted to the hos)ita$+eforehand, the )atient ate -M)e%.M)e%/ #efore incident to ta%e )$ace+ The )atient has a$ready ind0 times of #$ac% feces, soft and no $iuid found annot fee$ any )ain+ Once it has #een c$eaned, no re
co$our #$ood 'as found in the )rocess+ The )atiennot ta%e any medicine or )rescri)tion #efore the iha))ened moreover, this is the 2rst time the )atisu3er this ty)e of sic%ness+ In addition to his comthe )atient a$so su3ered vomitin* 0 times 'hich a#$ac% co$our+ 4e e5)$ained that he too% consum)tmedicines of anti )ain medication for his 6oints fo
)ast years ho'ever he did not consume it every
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• The )atient has a medica$ recorsirosis he)atis and 8M ty)e II fo$ast years #ut a*ain, did not tamedicine freuent$y+ Moreover, a$so has a trac% record of uric a
denied havin* any hi*h #$ood )
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Past Medica$ 4istory and Treatment
Denied
9ami$y 4istory
denied
ocia$ 4istorySmoking (-), consuming alcoholic beverages (-)
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&becti!e Data
• &))earance : Moderate I$$ness
• GC E;M"?! mmh*,
• RR: 15> minute,
• T : 0"+=@C
• Pu$se : 1!5>minute+• Eye: Pa$e con6unctiva .>. , sc$era su#ic
• Ear, Nose, throat : norma$
• B
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• Thora5+
– I : ymmetrica$ chest 'a$$ movement, Ictus cordis .D
– Pa$: ymmetrica$ onor
– &us: asic #reath sound #ronchia$, ronchi .>., 'heein* .>.+ 1 *a$$o) .D,
murmur .D
• domen+
n( : 7la"
( : 9oel (on * 4x/m#n"e
Pal : P'e(('e a#n * (#n#("'a #l#a&a;
Pe' : T#man#, e'&((#on * (#n#("'a #l#a&a "ene'ne(( %
• Extremitas : #""#n! oeem %, a'm a&'al, CRT < 2=, alma' e'#"em
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Assessment
• melena e& e'o(#7 !a("'#"#( *
(#'o(#( ea"#( * anem#a
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Therap%
MM/
• V#" > 3 x 1 am-alnex 3 x 1 am• ?m '# 2 x 40 m!
• C#'o7loxan '# 2 x 200 m!
• P'oanolol 1 x 10 m!
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'lannin(
+o(#"al#e
D#e" : 7#l"e'e
V@D: ( -ol7 an D( A (
PRC "'an7#(#on 500 &&
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Than$ )ou
Department of Internal
MedicineChristian University of Indonesia