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MORNING REPORT

Department of Internal Medicine

Christian University of Indonesia

October 11th2014

TEAM 2

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Subjective DataName : Mrs. I

Address : PalembangTC : Saturday/11thOctober 2014

CC : Difficulty breathing

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Anamnesis

Main symptom : Difficulty breathing

Additional symptom : -

Patient came with difficulty breathing. The symptom felt since thirty

after the patient eat prawns for dinner. Rash was denied, swelling on the lip

palpebra denied, nausea and vomit were denied. Patient quickly came to the

after her symptoms develop.

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Past Medical History and Treatment

Allergic to antalgin, amoxycylin

Family History

(denied)

Social HistorySmoking (-), Alcohol (-), Drug induced (-),

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Objective Data

LOC : E4V5M6 ; Composmentis

Appearance : moderate illBP : 130/80 mmHg

PR : 80 x/min (adequate, irregular)

RR : 32 x/min

Temp : 36,50C

HEAD & EYE : pale conjungtiva -/- ; ict -/-

THORAX :Heart

Ins : IC invisible

Pal : IC palpable

Per : RHB ICS V lin. sternal dext, LHB ICS V lin. Midclavicula

Ausc : S1 single, S2 single, regular, murmur (-) gallop (-)

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PULMO

Insp : Static and dynamic symmetric

Pal : VF right and left symmetric

Perc : Sonor symmetric

Ausc : BBS bronchovesicular, Rhonki -/-, Wheezing +/+

prolonged expiration

ABDOMEN

Insp : Stomach looks flat

Ausc : Bowel sound (+)

Pal : undulation (-), pressure pain (-)

Perc : timpany, pain in percussion (-)

EXTREMITIES

Edema (-); warm (+); capp. Refill

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Assessment

Anaphylactic reaction

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Therapy

O2nasal canule 3-4 LPM

IVFD : RL 500 cc

Mm/

Dexamethasone 1 cc (IV)

Icadryl 1 cc (IV)

Loratadine 2x1 (PO)

Metil-prednisolone 2x4 (PO)

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Planning

- Check blood gas analysis- Complete leukocyte count

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Thank You

Department of Internal Medicine

Christian University of Indonesia