Morning Report 25 August

8/21/2019 Morning Report 25 August

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MORNING REPORT

Department of Internal Medicine

Christian University of Indonesia

August, 25th2014


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2

Findings Assessment Therapy Planning

Weakness

Lack of appetite

Fever

LOC : E4M6V5,compos mentis,being

sick

BP : 100/70 mmHg

PR : 86 x/minute, adequate,

regular

RR : 20 x/minute

Temp : 360 C

Eye : Pale Conjungtiva -/-, SI -/-Coated tounge (-)

Thoraks :

Ins : movement of chest wall

symmetric

right = left, retraction (-)

Pal : vf symmetric, right=left

Per : sonor in all lung field

-DHF grade I

-Tifoid Fever

Diet : Soft, not

stimulate

IVFD : III RL/24hours

Medikamentosa :

-Ciprofloxacin 2 x 200 mg

(IV)

-BD gard 2x1 (PO)

-PCT k/p 3 x 500 mg (PO)

-KSR 3 x 1 (PO)

-Ondancentron 2 x 8 mg (IV)

-Omeprazole 2 x 40 mg (IV)

Pro Hospitalized

simple check of

the internal lab

USG Thorax

Check H2TL/day

Miss. F 24 years Old

Jakarta

TC : Monday / 10.00 PM

Date : 25th/08th/2014

CC : Vomit and nausea


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Abdoment :

Ins : stomach looks flat

Pal : Impalpable,pressure pain (+)

epigastrium

Per : Tympany, percussion pain (+)Aus: Bowel sound 5 times/minute

Extremity : cold (-), cappilary refill


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4

Subjective Data

Name : Miss. F, 24 Years Old

Address : Jakarta

TC : Monday /25 August 2014/10.00 PM

CC Vomit and Nausea


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n mnesis

Main Complaint

Vomit and nausea since 4 days ago

Additional Complaints

Weakness, Lack of Appetite, Fever

Autoanamnesis

on the date 25 August, Time 10.00

PM


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6

Anamnesis

Patient came to emergency room with symptoms of nauseaand vomit since 4 days ago. One day before admitted to thehospital, patient had already been vomiting for about 5

times that day and got worse. Patient also had fever since 4days ago persistently alongside with the nausea andvomiting. Patient already went to other doctor before, feveralready been treated but still nausea and vomiting. Othersymptoms are lack of appetite caused by frequent vomiting,

lightheaded, dizziness, weak, and muscle ache.


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8/31/2014

Family History

(-)


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Objective Data

Appearance :moderate illness

LOC :E4V5M6; CM

BP :100/70mmHg

HR : 86x /minute(adequate,

reguler)

RR : 20x/minute

Temp : 36C


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Objective Data

Head :Normocephali

Konjunctiva Anemis -/-

Sklera Ikterik -/-

Coated Tongue (-)


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ThoraxLeft Right

Inspeksi Front

Static and dynamic symmetric Static and dynamic symmetric

backStatic and dynamic symmetric Static and dynamic symmetric

Palpasi Front VF symmetricVF symmetric

BackVF symmetric VF symmetric

Perkusi Front Sonor Sonor

Back Sonor Sonor

Auskultasi Front BBS Vesicular, Rhonci -/-,

Wheezing -/-

BBS Vesicular, Rhonci -/-,

Wheezing -/-

Front BJ I reguler and BJ II regular,

murmur (-), Gallop (-)


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Abdomen

Inspeksi:

stomach looksflat

Palpasi:

LiverSpleenimpalpable ; ball

-/-;Pressure Pain (+)

Perkusi:

Hipertympani;Percussion Pain(+)

Auskultasi:

Bowel sound (+)

5x/minute


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Lower Extremities

Right Left

Akral Warm Warm

Edema - -

Rumple Lead +


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Upper Extremities

Right Left

Akral Warm Warm

Edema - -


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LABORATORIUM

HEMATOLOGI HASIL NILAI RUJUKAN

Hemoglobin 14,9 g/dl 14-16 g/dL

Leukosit 2.400/UL 5-10 ribu/UL

Hematokrit 43 % 40-48 %

Trombosit 57.000/uL 150-400 ribu/uL

GDS 83 mg/dl


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WIDAL HASIL NILAI RUJUKAN

S.Tiphose H + 1/320 -

S.Paratiphy AH - -

S.Paratiphy BH + 1/320 -

S.Paratiphy CH - -

S. Tiphose O + 1/320 -

S. Paratiphy AO + 1/320 -

S. Paratiphy BO - -

S.Paratiphy CO + 1/320 -


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Assessment

- DHF grade I

- Tifoid Fever

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Therapy

17

Diet : Soft, not stimulateIVFD : III RL/24hours

Medikamentosa :

-Ciprofloxacin 2 x 200 mg (IV)

-BD gard 2x1 (PO)-PCT k/p 3 x 500 mg (PO)

-KSR 3 x 1 (PO)

-Ondancentron 2 x 8 mg (IV)

-Omeprazole 2 x 40 mg (IV)


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Planning

Pro HospitalizedSimple check of the internal lab

USG Thorax

Check H2TL/day


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THANK YOU

Morning Report 25 August

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Transcript of Morning Report 25 August