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MORNING REPORTDepartment of Internal MedicineChristian
University of IndonesiaSeptember, 11th 2015 TEAM
21FindingsAssesmentTherapyPlanningabdominal pain since 1 day before
admission. The pain is like stabbed with knife. He feel nausea and
vomited every eating and drinking. Appearance : Mild Illness, GCS
E4M6V5,BP : 170/120 mmhg, RR: 36x/ minute, T : 36C,Pulse :
110x/minute. Eye: Pale conjunctiva -/- , sclera icteric -/-, Ear,
Nose, throat : normal,lymph nodes not enlargedTHORAXI : Symmetrical
chest wall movement, ictus cordis (-)Pal : Symmetrical Vocal
fremitus, ictus cordis : palpablePer : Sonor/Sonor Aus : Basic
breath sound vesical, ronchi -/-, wheezing -/-. S1 and S2 reguler,
gallop (-), murmur (-) ABDOMENIns : normalAus : Bowel sound (+) 1
/minutePal : Pressure pain on epigastric, hypocondria dextra, and
sinistra, umbilical (+), shifting dullness (-)Per : Timpani, pain
of percussion (+)Extremitas : warm acral, CRT < 2, edema (-)
dyspepsia polycythemia hypokalemia hyperglycemia hypertension grade
II
Captopril 25 mg (SL)Ondancentron 8 mg (IV)Ranitidin 1 amp
(IV)HospitalizedDiet : soft foods, low saltIVFD : II RL/24 jamMm/
:Ceftriaxone 1x2gr (skin test)Ondancentron 2 x 8mgKSR 2x1
tabAmlodipine 1x5mgUSG abdomen
Mrs I, 48 YOCC : ObstipationSubjective DataName: Mr. C, 63 years
oldCM: TC: Tuesday, September 06th 2015CC: Abdominal pain
3AnamnesisMain symptom : obstipationAdditional symptom :
Patient arrived to UKI hospital with major complain abdominal
pain since 1 day before admission. The pain is like stabbed with
knife. He feel nausea and vomited every eating and drinking. 4Past
Medical History and Treatment -Family History-
Social HistorySmoking (-), consuming alcoholic beverages
(-)5Objective DataAppearance : Mild IllnessGCS E4M6V5BP : 170/120
mmhg, RR: 36x/ minute, T : 36CPulse : 110x/minute.Eye: Pale
conjunctiva -/- , sclera icteric -/-Ear, Nose, throat : normallymph
nodes not enlarged6Thorax. - I : Symmetrical chest wall movement,
ictus cordis (-)- Pal: Symmetrical Vocal fremitus, ictus cordis :
not palpable- Per: Sonor/Sonor - Aus: basic breath sound vesical,
rhonchi -/-, wheezing -/-. S1 and S2 regular, gallop (-), murmur
(-) Abdomen.- Ins : normal- Aus : Bowel sound (+) 1 /minute- Pal :
Pressure pain on epigastric, hypocondria dextra, and sinistra,
umbilical (+), shifting dullness (-)- Per : Timpani, pain of
percussion (+)Extremitywarm acralCapillary refilling time
