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MORNING REPORTDepartment of Internal MedicineChristian University of IndonesiaJune, 10nd 2014 TEAM 21FindingsAssesmentTherapyPlanning Vomiting Fever Loss of appetitepainful swallowinghacking coughPHYSICAL EXAMINATION Appearance : being sick, GCS E4V5M6BP : 130/70mmHgHR : 96x/minRR : 20x/min, T : 37.3C Eye hyperemic conjunctiva (-/-), Icteric sclera -/- THT : normal Mouth : normalNeck : lymph nodes not enlarge, JVP : 5-2 cmH2O Thorax Ins : chest movement symmetricPal : vocal fremitus sound symmetric Per : symmetric sonor sound Aus : basic sound of breath vesicular, wheezing (-/-), ronchi (-/-)Heart sound I & II regular, murmur (-), gallop (-) Abdominal Ins : looks flat Aus : bowel sound (+), 4x/minPer : percution pain, timpani sound Pal : tenderness epigastrium and defence muscularExtremitieswarm acral, CRT < 2 s, edema Pemeriksaan LABHemoglobin : 15,9 g/dl Hematokrit : 41.1 % leukosit: 17.6 ribu/ul trombosit : 200 ribu/ul DyspepsiaGastritis akut-Unhospitalized -Diet : soft, not to stimulate-IVFD : III RL / 24 hours-Mm/ Ceftriaxone drip 2 x 200 mgParacetamol 3 x 50 mgOmeperazole 2 x 20mgOndansetron 1 ampLaboratorium (Blood H2TL)/dayControl again in next few daysMr. Boy 25 years old----Tuesday , June 10nd 2014, 19.15 PM y2Subjective DataName: Mr. Fernando CM: TC: tuesdsay , june 10nd 2014CC: vomiting

3AnamnesisMain symptom: vomitingAdditional symptom :4Past Medical History and Treatment Denied

Family HistoryDenied

Social HistorySmoking (-), Alcohol (-)5Objective DataAppearance : Being sickGCS E4M6V5BP : 130/70 mmHg RR: 20x/minuteT : 37.3CHR : 96x/minuteEyes: Pale conjunctiva (-/-), sclera icteric (-/-)Ears, nose and mouth: NormalLymph nodes: Not enlargedJVP : Not distended6Thorax- Ins: Chest wall movement symmetric- Pal: Vocal fremitus sound symmetric- Per: Symmetric sonor sound- Aus: Basic sound of breath vesicular, wheezing (-/-), ronchi (-/-). Heart sound I & II regular, murmur (-), gallop (-)Abdomen- Ins: Looks flat- Aus: Bowel sound (+) 4x/minute- Per: Timpani, percussion tenderness in all abdomens regio (-)- Pal: Abdominal tenderness in epigastrium regio (+), liver and spleen enlargement (-)ExtremitiesWarmCapillary refill time