Team 5's Morning Report

Identity

Name : Mr. Maruli

Age. : 57 y.o.

Sex. : Male

Admission Date : November 26th 2016

Status : Hospitalized

CC : Gastritis, bronchopneumoniae, hypertension, hypokalemia

Chronological order / Anamnesis :

The patient came with a chief complaint of diarrhea 15 times since 14 hours before came to
the hospital with epigastric pain. The feces had a liquid concistency without mucus or blood.
Nausea and vomiting are also experienced that has been going since a week before came to
the hospital. Blood is not found in the vomit. The patient also admitted that there’s no
problem with urinating He also reported loss of appetite, so she has difficulty in food intake.
His body feels lethargy. He also reported that he had cough with sputum. 1 month before this,
he had hospitalized at PGI Cikini Hospital because of his cough for 7 days. Fever is not found
in this patient. He had history of hypertension since 1 year ago and regularly taking
hypertension drug.

Physical examination

General condition : Moderately sick

Awareness : E4V5M6 (Compos mentis)

BP. : 160/90 mmHg

HR. : 100 times/minute

RR. : 22 times/minute

Temp. : 36.80C

Head. : normochepali, no enlargement at neck’s lymph glands.

Eyes : anemic conjucntiva -/-, ichteric schlerae -/-

Chest :

Inspection : Symmetrical respiratory movements, no uneven rib movement.

Palpation : Symmetrical vocal fremitus

Percussion : Sonor sounds all over lung platforms

Auscultation : breath sound : vesicular. Ronchi -/-, Wheezing -/-

Heart sound : regular. Murmur (-), gallop (-)

Abdomen:

Inspection : appeared flat

Auscultation : Intestinal sounds 6 times/minute

Palpation : Pressure pain (+) at epigastric region, defence muscular (-)

Percussion : tympanic, percussion pain (+) at epigastric region

Extremity : active extremity with warm acrals, CRT <2”, oedema (-)

A/

- Gastritis
- Bronchopneumonia
- Hypertension
- Hypokalemia

P/

Pro Hospitalised

Diet : Soft meal not stimulating

IVFD III RL/24hours.

Laboratory examination : Routine blood test, electrolyte, random blood sugar,

ureum/creatinine.
Mm/

Levofloxacin 1 x 500 mg (IV)

Ranitidine 2 x 25 mg (IV)

Amlodipine 1 x 5 mg (PO)

New Diatab 3 x 1 tab (PO)