Department of Internal

Medicine
Christian University of Indonesia

MORNING REPORT
March, 12st 2016
TEAM 3

Mr. T , 65 YO
CC : melena (black colour feces)
Findings

Assesment

melena
GCS: E4V5M6, TD: 130/80, PR 102 x, T : 36,5oC, RR: 21x
Eye : Pale Conjungtiva -/-, Sclera subicteric +
THT : Normal
Neck : JVP 5+1 Lymph Nodes not Enlarged
THORAX

melena ec
erosif gastritis +
sirosis hepatis +
anemia

I : Symmetrical chest wall movement, ictus cordis (-)

Pal: Symmetrical Vocal fremitus, ictus cordis : palpable
Per: Sonor/Sonor
Aus: Basic breath sound : vesicular, ronchi -/-, wheezing -/-. S1
and S2 normal, gallop (-), murmur (-)
ABDOMEN
Ins : flat
Aus : Bowel sound (+) 4x/minute
Pal : Pressure pain (+) sinistra iliaca.
Per : Timpani, percussion (+) sinistra iliaca tenderness (-)
Extremitas : pitting oedem (-), warm acral, CRT < 2, palmar
eritem

Therapy
MM/
Vit K 3 x 1 ampkalnex 3 x 1 amp
Omz drip 2 x 40 mg
Ciprofloxacin drip 2 x 200 mg
Propanolol 1 x 10 mg

Planning
Hospitalized
Diet : filtered
IVFD: Ns I kolf and I Ds Ns
PRC tranfiusion 500 cc

Subjective Data
Name
: Mr. K, 65 YO
CM
:
TC : Tuesday, March 1st , 2016
CC
: black colour feses

Anamnesis
Main symptom
: black colour feces
Additional symptom :
A Patient with an indication of sudden black feces found
9 hours prior to being submitted to the hospital.
Beforehand, the patient ate Mpek-Mpek before this
incident to take place. The patient has already indicated
3 times of black feces, soft and no liquid found and did
not feel any pain. Once it has been cleaned, no red
colour blood was found in the process. The patient did
not take any medicine or prescription before the incident
happened moreover, this is the first time the patient
suffer this type of sickness. In addition to his complaint,
the patient also suffered vomiting 3 times which also
black colour. He explained that he took consumption of
medicines of anti pain medication for his joints for the
past 2 years however he did not consume it everyday,

 The patient has a medical record of

sirosis hepatis and DM type II for the
last 2 years but again, did not take the
medicine frequently. Moreover, patient
also has a track record of uric acid, but
denied having any high blood pressure.

Past Medical History and Treatment

Denied

Family History
denied

Social History
Smoking (-), consuming alcoholic beverages (-)

Objective Data

Appearance : Moderate Illness

GCS E4M6V5
BP : 130/80 mmhg,
RR: 21x/ minute,
T : 36.5C
Pulse : 102x/minute.
Eye: Pale conjunctiva -/- , sclera subicteric +
Ear, Nose, throat : normal
JVP : normal, lymph nodes not enlarged

Thorax.

I : Symmetrical chest wall movement, Ictus cordis (-)

Pal: Symmetrical Vocal fremitus, ictus cordis : palpable
Per: Sonor/Sonor
Aus: Basic breath sound bronchial, ronchi -/-, wheezing -/-. S1 and S2 weakened,
gallop (-),
murmur (-)

Abdomen.

Ins : flat
Aus : Bowel sound (+) 4x/minute
Pal : Pressure pain (+) sinistra iliaca.
Per : Timpani, percussion (+) sinistra iliaca tenderness (-)

Extremitas : pitting oedem (-), warm acral, CRT < 2, palmar eritem

Assessment
melena ec erosif gastritis +
sirosis hepatis + anemia

Therapy
MM/
Vit K 3 x 1 ampkalnex 3 x 1 amp
Omz drip 2 x 40 mg
Ciprofloxacin drip 2 x 200 mg
Propanolol 1 x 10 mg

Planning
Hospitalized
Diet : filtered
IVFD: Ns I kolf and I Ds Ns
PRC tranfiusion 500 cc

Department of Internal
Medicine
Christian University of Indonesia

Thank You