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    Morning Report: Department of Internal Medicine

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    Ayunita Permata
    A 76-year-old male presented to the hospital with epigastric pain for one week along with nausea and vomiting. On examination, he had abdominal tenderness in the epigastric region. His assessment was dyspepsia syndrome and type 2 diabetes mellitus. His initial treatment included IV fluids, antacids, anti-nausea medication, and oral diabetes medications. Further plans included continued hospitalization, a soft diet, chest x-ray, blood glucose monitoring, and lab tests.

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    Morning Report: Department of Internal Medicine

    Uploaded by

    Ayunita Permata
    26 views11 pages
    A 76-year-old male presented to the hospital with epigastric pain for one week along with nausea and vomiting. On examination, he had abdominal tenderness in the epigastric region. His assessment was dyspepsia syndrome and type 2 diabetes mellitus. His initial treatment included IV fluids, antacids, anti-nausea medication, and oral diabetes medications. Further plans included continued hospitalization, a soft diet, chest x-ray, blood glucose monitoring, and lab tests.

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    morning report

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    Morport Interna

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    A 76-year-old male presented to the hospital with epigastric pain for one week along with nausea and vomiting. On examination, he had abdominal tenderness in the epigastric region. His assessment was dyspepsia syndrome and type 2 diabetes mellitus. His initial treatment included IV fluids, antacids, anti-nausea medication, and oral diabetes medications. Further plans included continued hospitalization, a soft diet, chest x-ray, blood glucose monitoring, and lab tests.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    26 views11 pages

    Morning Report: Department of Internal Medicine

    Uploaded by

    Ayunita Permata
    A 76-year-old male presented to the hospital with epigastric pain for one week along with nausea and vomiting. On examination, he had abdominal tenderness in the epigastric region. His assessment was dyspepsia syndrome and type 2 diabetes mellitus. His initial treatment included IV fluids, antacids, anti-nausea medication, and oral diabetes medications. Further plans included continued hospitalization, a soft diet, chest x-ray, blood glucose monitoring, and lab tests.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 11

    Department of Internal

    Medicine
    Christian University of Indonesia

    MORNING REPORT
    March 15rd 2015
    TEAM 2

    Mr. P (76 yo )
    65-34-06-00
    Findings
    Epigastric Pain since
    approximately 1 week before
    coming to the hospital, nausea
    +, vomit +, T: 36,3C, BP:
    150/80 mmHg, Pul:
    77x/minute, RR: 20x/minute
    Thorax:
    Symmetric, Vocal Fremitus
    symmectric, Sonor Sound
    Symmetric, BND vesical, wh
    -/-, rh -/Abdomen:
    Flat, Bowel Sound + 5x/min,
    Tenderness + on epigastric,
    tympanic sound

    Assessment
    Dyspepsia
    syndrome
    DM type 2

    Therapy
    Initial Therapy (ER) :
    IVFD : Ringer Lactate
    II Kolf / 24 hrs
    MM :
    Ranitidine
    2x1 amp(iv)
    Ondancentrone
    2x4mg (iv)
    Metformin
    3x500mg (po)

    Planning
    Further planning :
    Pro hospitalized
    Diet : soft non
    stimulating food
    Thorax AP Rontgen
    Random glucose test/24
    hour
    Check lab: H2TL, GDS

    Subjective Data
    Name
    : Mr. P
    Address : Kampung Melayu
    TC : Wednesday / 11 March 2015
    CC
    : Epigastric pain since one week

    Anamnesis
    Main symptom
    : Episgastric pain in one week
    Additional symptom : nausea
    Patient came to the hospital with epigastric pain for 1 week. The
    pain is dull and intermittent. The patient also experienced nausea
    and vomiting . Before admission he had been throing up for 3 times.
    No other symptom was found. Bowel activity is normal and so does
    urinary activity, no fever was found . History of hypertension was
    denied, History of high blood sugar was confirmed

    Past Medical History and Treatment


    (denied)

    Family History
    (denied)

    Social History
    Smoking (-), Alcohol (-), Drug induced (-),

    Objective Data
    LOC
    : E4V5M6 ; Compos mentis
    Appearance : mildly ill
    BP
    : 150/80 mmHg
    PR
    : 77 x/min (adequate, regular)
    RR
    : 20 x/min
    Temp
    : 36.40C
    HEAD & EYE : pale conjungtiva -/- ; ict -/THORAX :
    Heart
    Ins : IC invisible
    Pal : IC palpable
    Per : RHB ICS V lin. sternal dext, LHB ICS V lin. Midclavicula sin
    Ausc
    : S1 single, S2 single, regular, murmur (-) gallop (-)

    Objective Data
    PULMO
    Insp: Static and dynamic symmetric
    Pal : VF right and left symmetric
    Perc
    : Sonor symmetric
    Ausc
    : BBS vesicular, Rhonki -/-, Wheezing -/ABDOMEN
    Insp: Stomach looks flat
    Ausc : Bowel sound (+) 8x/m
    Pal : undulation (-), pressure pain (+) in epigastrium
    Perc
    : timpany, pain in percussion (-)
    EXTREMITIES
    Edema (-); warm (+); capp. Refill <2 seconds

    Assessment
    Dyspepsia syndrome
    DM type 2

    Therapy
    Initial Therapy (ER) :
    IVFD : Ringer Lactate II Kolf /
    24 hrs

    MM :
    Ranitidine
    2x1 amp(iv)
    Ondancentrone
    2x4mg (iv)
    Metformin
    3x500mg (po)

    Planning
    Further planning :
    Pro hospitalized
    Diet : soft non stimulating food
    Thorax AP Rontgen
    Random glucose test/24 hour
    Check lab: H2TL, GDS

    Department of Internal
    Medicine
    Christian University of Indonesia

    Thank You

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