Morning Report

FEBRUARY

4TH, 2015

DOCTOR IN CHARGE: DR. ABIMANYU, SP. PD

Group
Dini Desviana R.
Devi Rahma Yulianti
Tika Nurulita
Ekky Adrianto C.G
Abdul Latif
Azizatul Aulia
Hutama Satriya Wibawa
Selvia Wijayanti

Patients Identity

Name
Sex
Age
Occupation
Address

: Mrs. Melinda
: Female
: 34 yo
: Teacher
: Bumi mas raya Jl. Wijaya
Rt. 17
Hospitalized since : February 8th, 2015

Summary of Data Base

Mrs.M/ 33yo /Female (Autoanamnesis)
Chief Complaint : Abdominal pain
Patient has right hypochondriac region pain
since 4 day ago. Pain radiating to the back,
continuous, and sometimes shifts. Patient felt
nausea and vomit after eating. Patient also
headache and insomnia. Patient often eat
fatty foods.
History of Past illness: Hypertension, gastritis
History of Family illness:-

Physical Examination
General appearance

Looked moderately ill, Conscious, GCS : 4 5 6

H: 144 cm W: 85 kg IMT = 41,06

Vital Signs

BP=200/120 mmH;PR= 80 bpm regular, strong;RR=16 Tpm; T=36C axilla

Head

Pale conjunctiva (-/-), Jaundice sclera (-/ - ), Edema palpebral (-/-), Diplopia (-), discharge
(-/-), exophthalmus (-/-), lid retraction (-/-), lid lag (-/-)

Neck

Lymphatic node swelling (-), struma (-), bruit thyroid (-)

Chest Heart

Inspection : ictus invisible

Palpation : palpable in MCS ICS V
Right margin : Right : ICS 5 L.Ster (D).
Auscultation : S1 > S2 single, murmur (-) gallop (-)
Inspection : Symmetric, barrel chest (-)
Palpation : FV symmetric
Percussion :
Auscultation :
S | S
V |V
S | S
V |V
D | D
- |Wheezing (-), Rhonchi (-)
Inferior margin : D = ICS5
S = ICS6

Lung

Abdomen

Percussion:
D | D |D
D | D |D
D | D |D

Tenderness:
+ |- |- |- |- | -|-

Extremities

Superior D & S : Edema (-/-), Pain (-/-), Weakness (-/-), tremor (-/-)
Inferior D & S : Edema (-/-), Pain (-/-), Weakness (-/-), tremor (-/-)

Laboratory findings
th 2015
January
19
Examinatio Value
Referred
Unit
n

Value

Hb

14,9

12,00-16,00

g/dl

leukosit

11,2

4,0-10,5

th/ul

eritrosit

5,06

3,90-5,50

million/ul

hematokrit

42,8

37,00-47,00

Vol%

Trombosit

225

150-450

th/ul

GDS

94

<200

mg/dL

SGOT

88

0-46

U/I

SGPT

60

0-45

U/I

Ureum

24

10-50

Mg/dL

Creatinin

1,0

0,6-1,2

Mg/dL

Examinatio
n

Value

Referred
Value

BJ

1.005

1.005-1.030

pH

6,5

5.0-6.5

Urobilinogen

0,2

0,1-0,2

leukosit

4-6

0-3

Unit

Problem list
Female, 33yo
1.Abdominal pain
1.1 Cholelithiasis

1.2 Cholesistitis

Data Support

Planning
Diagnosis

Planning therapy

Monitor

Education

Ax:
1.1 Vomit
nausea
abdominal pain
right hipocondriac
regio
History of past
illnes hipertension
and gastritis,
colelitiasis
1.2 Vomit
nausea
abdominal pain
right hipocondriac
regio

2. Hipertensi grade III

.BP=200/120 mmHg

USG
Abdomen
Lab
(Bilirubin
total, direct
indirect,
Lipid profile)

Confirm
vital sign
Diagnosis
observation
Inf NS 0,9 % 20
tpm
Inj. OMZ
P.o PCT 3x1
Urdafalk 3x500
mg

Complete
blood

Captopril

Vital sign
observation

Bed rest
Nonfatty
diet

Thank you