MORNING REPORT

CASE

16th July, 2012

PATIENT’S IDENTITY
Name : SA
Age : 17 yo
Gender : Female
Ethnicity : javanese
Religion : Islam
Occupation: employee
Address : Sumber Tumpuk Pasuruan
ToA : 14th July 2012 02.00 pm
ANAMNESIS

 Chief complain :
vommit
 Present history :

 Patient came with chief complained of

vommiting since 30 minutes BATH, after
consumed 28 tablets of bodrex which was
mixed with a bottle of kratingdaeng adn 2
bottles of sprite at 11.00 am.
 The colour of vommit was light orange and
was mixede with black colour. The vommit was
complained more than 10 times, average a
half of aqua glass each vommit. Nausea
happened prior to vommit. Patient also
complained malaise.
 Patient also complained of epigastrial pain
which came suddenly after consumed bodrex.
The pain was felt throbbing and didn’t
recovery with changing position
 Patient also complained shortness of breath and
headache, which came together 1 hour after she
consumed bodrex. These conmplained make she felt
weak.
 Defecation and urination was normal before she
consumed bodrex.
 Past illness history
 patient had no history of gastritis or other
gastrointestinal disease
 Patient had no history of consumed jamu and
NSAID
 Social History :
 Patienthad no history of alcohol consumption and
smoking.
 Meal pattern was iregularly after she had problem with
her boyfriend.
 Medication history
patient usually takes mefenamat acid during
menstruation, other medication was denied.
 PHYSICAL EXAMINATION
General appearance : Moderately ill
Level of consciousness : CM
GCS : E4V5M6
VAS : 3/10 location: epigastrial

Vital Sign:
 BP : 130/90 mmHg
 RR : 20 x/min
 PR : 80 x/min
 tax : 36,5°C
 Height : 160 cm BMI : 27,3 kg/m2
 Weight : 70 kg
Eyes : conj. Pale (-/-); icterus (-/-);
Rp +/+ isocoric, oedema palp. (-/-)

ENT : Tonsils T1/T1; pharyngeal hyperemia (-);

tongue normal; lip cyanosis (-)

Neck : JVP RP 0 cmH2O;

lymph node enlargement (-)
Thorax : Simetris, retraction (-)
Cor
Inspection : Ictus cordis unseen
Palpation : Ictus cordis unpalpable
Percussion :
UB : ICS II
LB : at MCL S ICS V
RB : at PSL D
Auscultation : S1 S2 single regular, murmur (-)

Po
Inspection : Symetric (static and dinamic)
Palpation : VF N/ N
Percussion : dull/dull
Auscultation : Bronchovesikular + / + , Rh -/-, wh -/-
Abdomen :
Inspection : Distention (-); ascites (-)
Auscultation : Bowel sounds (+) normal
Percussion : Tymphany
Palpation : liver, spleen unpalpable
(pain on epigastrium)

Extremities: Warm +/+; edema -/-

+/+ -/-
 Complete blood count
Parameter Result Unit Remarks Reference range
WBC 11,00 103/μL 4,5 – 11,00
-Ne 74,30% 2,20 103/μL 47,00 – 80,00
-Ly 20,20% 0,50 103/μL 13,0 – 40,0
-Mo 4,70% 0,50 103/μL 2,00 – 10,00
-Eo 0,60% 0,10 103/μL 0,00 – 5,00
-Ba 0,00% 0,00 103/μL 0,0 0 – 2,00
RBC 4,43 106/μL 4,50 – 5,90
HGB 13,40 g/dL 13,50 – 17,50
HCT 39,90 % 41,00 – 55,00
MCV 90,10 fL 80,00 – 100,00
MCH 30,30 pg 26,00 – 34,00
MCHC 33,60 g/dL 31,00 – 36,00
RDW 14,10 % 11,60 – 14,90
PLT 269 103/μL 150,0 – 440,0
MPV 6,80 fL 6,80 – 10,00
 Blood chemistry panel

Parameter Result Unit Remarks Reference range

SGOT 13,11 U/L 11,00 – 33,00
SGPT 12,97 U/L 11,00 – 50,00
BUN 11,303 mg/dL 10,00 – 23,00
Creatinine 0,67 mg/dL 0,50 – 1,20
Na 145 mmol/L 136,00 – 145,00
K 3,70 Mmol/L 3,5 - 5,1
ASSESMENT

 Suspect ulcus pepticum

PLANNING
 Therapy
 hospitalized

 IVFD Na CL 0,9% 20dpm

 Soft Diet 2100 kal + 60 gr protein

 Sucralfat 3 x CI

 Antasida 3 x CI

 Omeprazole 2 x 40 mg
 Pdx
 EGD

 H. Pylori serology

 Monitoring
 Vital
sign
 Complaints
THANK YOU