MORNING REPORT

IRINA C2
 Patients Identity
Name : Mrs RR
Age : 51
Sex : Female
Address : Bahu
Ocupation : -
Education : Junior High School
Ethnic : Minahasa
Religion : Christian
A 51 year-old female was admitted to
R.D. Kandou Hospital at C2 ward on
March 11st, 2017 at 05.30 am

With main complaint:

Abdominal pain
History of Present Illness :
Abdominal pain, since 3 days b.a,
mainly on epigastrium , intermittent,
spreads to chest, not related to meal.
Black tarry stool (+) since 3 days b.a.
Hard on beggining and then liquid.
Smelly (+). Frequency + 1x/day.
Volume + 50-100 cc. Intermittent. At
examination not defecate anymore
Nausea (+), vomit (-)
weight loss (-)
Fever (-), cough (-), headache (-).
Urinating no complain
Past Medical History
History of Hipertensi (+) since 5 years ago, no
taking medicine
History of diabetes, asthma, kidney, liver
disease was denied
History of taking tradisional since 3 months
Family History
None experienced the same illness
History of allergy :
Unknown

History of immunization :
Unknown

Habit history :
Alkoholism (-)
Smoking (-)
General Anamnesis ( review of
system )
General : poor appetite
Skin : -
Head and Neck :-
Eye : -
Ear : -
Nose : -
Mouth and Throat :-
Respiration : -
Breast : -
Heart : -
Vascular System :
Abdomen : epigastric pain,
black tarry stool
Genital :-
Kidney and Bladder :-
Haematology:-
Endocrine System :-
Musculosceletal System :
Neurology System : -
Abdomen :-
Genitalia : -
Kidney :-
Hematology :-
Endocrine :-
Musculosceletal :-
Neurology :-
Psychology :-
Physical Examination
GC: Moderate ill Sens : CM
C2:BP: 160/90mmHg, PR 79x/m, RR 22x/m, T 36,4C,
Sat. O2 99%
ER :BP: 150/90 , N 79x/m, RR 20x/m, T 36,6 C, Sat.
O2 99%
BW 60 kg, BH 158 cm, BMI 24,03 kg/m2
Head : conj. anemic (+), scl. icteric(-),
Neck : JVP 5+0 cmH20, lymph nodes enlargement (-)
Thorax :
Heart :
Insp : IC not visible
Palp : IC not palpable
Perc : left border: ICS V axillaris anterior line
right border: ICS IV parasternal line
Ausc : SI-II regular, murmur (-), gallop (-)
Physical examination
Lung : Insp : Symmetric R = L
Palp : stem fremitus R = L
Perc : sonor +/+
Ausc : vesicular, ronchi -/-, wheezing -/-
Abd :
Insp : Flat
Palp : Soepel, pain on epigastric (+)
pain on suprapubic (-)
Perc : Timpani, Shifting dullness (-)
Ausc : Bowel sound (+) normal
Extr : edema (-), warm-
RT : melenic stool (+)
 Lab Result
10/3/2017
Leucocyte 6100
Erythrocyte 2,8x106
Hb 7,8
Ht 22,5
Platelet 257.000
MCH 34,7
MCHC 39,1
MCV 80,4
Ureum 51
Creatinine 1,0
Natrium 135
Kalium3,8
Chloride 102,0
RBS 197
SGOT 24
SGPT 9
Comburt
Leu -
Nit -
Uro Normal
Prot -
Blood -
pH 6
SG 1,020
Keton -
Bilirubin -
ECG : Sinus rhythm, 75x/min
 ECG INTERPRETATION
ECG components Interpretatio Value
n
Rhythm Sinus Sinus Rhythm
Speed / HR 75x/min 1500/R-R
(times/mnt)
Axis Normal Normal / RAD / LAD
Morphology P wave 0,08 sec Lead II : Duration 0.10, Height
2.5
PR Interval 0,20 sec 0,12 0,20
QRS complex 0,08 sec 0,05 0,11``
duration
ST segmen Normal Normal / Elevated / Depressed
T wave Normal Normal / abnormal
QT Interval 0,40 sec cQT = QT interval / vR-R
Interval
U wave Absent Appear / not appear
CONCLUSION : Sinus rythm, HR 75 x/m
 Problem List
No CM : 49.40.56 Age :
51 y.o
1. Main complain:
Abdominal pain
2. Anamnesis:
Black tarry stool
History of taking tradisional
since 3 months
Nausea
3. Physical examination
C2:BP: 160/90mmHg, PR 79x/m, RR 22x/m, T
36,4C, Sat. O2 99%

Eye : Conjungtiva anemis (+)

Abd : Pain on epigastric (+)
 Lab Result
10/3/2017
Erythrocyte
2,8x106
Hb 7,8
Ht 22,5
 Glasgow-Blatchford score
Blood urea
Hemoglobin
SBP
Pulse
Melena
Total score = 12 (High risk and need
intervention)
N Problem List Plan Dx Plan Tx Plan Plan
o Educatio Monitoring
n
1 Black tarry Search for Omeprazol Educate Observation
stool, ALARM e inj 2 x 40 the family for vital signs.
History taking sypmtom mg IV about the
tradisional condition of
Sucralfat Observation
RT = Melenic the patient
stoll (+) Endoscopy syr 3 x C1 and plans for melena.
Glasgow- ahead.
Blatchford
score 12 Educate
not to take
Melena ec spicy food
NSAID ducation
Gastropathy about the
disease

Educate to
eat regulary
2 Conjungtiva Retikulosit Transfusion of Educate the Observation for
anemis (+) Blood smear PRC 1 bag/day family vital signs.
Hb 7,8 until Hb>10g/dl about the
condition of
Anemia the patient
normokrom and plans
normositik ec ahead.
N Problem List Plan Dx Plan Tx Plan Plan
o Education Monitoring
3 History of Profil lipid Captopril Educate the Observation for
hypertension 3x1 family about BP
(+) not the condition
taking Looking for of the patient
medication end organ and plans
BP 160/90 target: ahead.
mmHg Consultation
to Neurology, Educate to eat
and low salt
Hypertension Ophthalmolo
gy
department
 Conclusion
It has been reported a female y.o
came to RSUP Prof RD Kandou with
main complain Black tarry stool. The
working diagnosis are Melena e.c
NSAID Gastropathy, Anemia ec GIT
bleeding,hypertension.
 Prognosis
Ad vitam : dubia
Ad functionam : dubia ad bonam
Ad sanationam : dubia ad bonam
Thank You
Upper GI bleeding
UGIB treatment
UGIB treatment
UGIB treatment