Morpot Tim 3 Sabtu 12 Maret 16asfa

8/19/2019 Morpot Tim 3 Sabtu 12 Maret 16asfa

1/12

MORNING REPORT

Department of Internal

MedicineChristian University of Indonesia

March, 12st 2016TEAM 3


2/12

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


3/12

Subecti!e DataName : M'; >, 65 B?

CM : TC : Tuesday, March 1st , !1"

"" # blac$ colour feses


4/12

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


5/12

• 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 )


6/12

Past Medica$ 4istory and Treatment

Denied

9ami$y 4istory

denied

ocia$ 4istorySmoking (-), consuming alcoholic beverages (-)


7/12

&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


8/12

• 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


9/12

Assessment

• melena e& e'o(#7 !a("'#"#( *

(#'o(#( ea"#( * anem#a


10/12

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!


11/12

'lannin(

+o(#"al#e

D#e" : 7#l"e'e

V@D: ( -ol7 an D( A (

PRC "'an7#(#on 500 &&


12/12

Than$ )ou

Department of Internal

MedicineChristian University of Indonesia

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Morpot Tim 3 Sabtu 12 Maret 16asfa