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MORNING REPORTMarwah, Sept 30 th 2014

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Patient’s Identity

• Nae ! Mr" #

• $%e ! 4&y"'

• Re(i%i'n ! M'es(i• )'r* ! Mer+hant

• #ate ! 30th Sept 2014

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$nanesis

• Chief complaint: Abdominal pain

• Present illnes:  Patients present withcomplaints of diffuse abdominal pain

epigastrium, reffered to back. Like stabbedand feel hot. Pain incrased when activity anddecrase when resting. patients alsocomplained of nausea when patient eating

and headaches since 1 day before coming tothe emergency room., vomit (!. "efecationand urination normal

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 Anamnesis

• #istory or past illness $ #% (&! three years (1')*! "+ "enial astritis (&! - years (promagh!

• #istory of family $

"enial

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Physi+ Eainati'ns

• G-S ! 4./

• ita( Si%n

P ! 1&011. %P(se ! 54 intes

RR ! 1& intes

 Tep ! 3/,3 6-

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Physi+ Eainati'ns

• ead and ne+* ! $nei+7 i+teri+7+yan'sis7 dyspne7

• Th'ra ! sietri+ 8i(atera((y, retra+ti'n 977:,• P(' ! ;es;es, rh 977:, wh 977:• -'r ! S17S2 sin%(e, re%(er, rr97:, %a(('p97:

• $8d'en !

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-(e and -e

• +ale, * y.o

•  Abdominal pain

(epigastric!

• /ausea (&!

• #ypertension

  9P! 1&011.

%:

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Problem List

• 0risis #ypertension

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$ssessent

• #yspepsia

• ypertensi'n sta%e II @N- A

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P(annin%

• P(annin% # !

o 00

o "A

o 23%

o 40

o 3unduscopy

o 52ay %hora6

• P(annin% T !B IC# aserin% i.00++days

B InD Metai'(e 31 i;

B InD Pant'pra'(e 50% drip  

aintenen+e pp4ap(24Da

B Ora(! -apt'pri( 2.% =Spir'n'(a*t'n

B -'ns( Sp"P#

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Fa8'rat'ry Cindin%s•

#i? +'nt 00/132A• eat'+rit 41,/

• ae'%('8in 1.,0%dF

• Fe*'+yte ."500

•  Tr'8'+yte 240"000• SGOT 1. F

• SGPT 15F

• -('rida ser 10. '(F

• Ha(i ser 3,2 '(F

• Natri ser 13& '(F

• Ser +reatinin 0,A %dF

•>rea 15 %dF

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Prognosis

• #8ia ad 'na

Education

• %ake a planty of rest

• Ep(ain t' the ai(y a8't

the +'nditi'n ' this patientn'w, its disease, a8't itseainati'ns, theraphy andinter;enti'n wi(( 8e d'ne, and

a(s' a8't +'p(i+ati'n andpr'%n'sis"