MORNING REPORT

Department of Internal MedicineChristian University of Indonesia

Mei, 28th 2013

2

Findings Assessment Therapy Planning

- Epigastric Pain- Nausea- Vomiting

BP : 120/80 mmhgPR : 78x/minute, adequate, regularRR : 20x/minuteTemp : 36°c

LAB FINDING From UKI:Hemoglobin : 14,1 g/dl (12 – 14)Leukosit : 8,7 ribu/ul (5 – 10)Trombosit : 224 ribu/ul (150 – 400)Hematokrit : 42,0 % (37 – 43)

USG Findings :Resume : CholelithiasisHepatomegali non spesific.Splen and renal normal

Susp cholelithiasis

Diit : lunak tidak merangsangIVFD : Ranitidine 2x50 mg I RL+ 2 tramadol/24jamMM/: ceftriaxone 1x2grRanitidine 2x1ampAntasid 3x2 cth

Lab : SGPT SGOTBilirubin total I and II

Ms,Siti Aisyah 31YOcipayung kp. Melayu

TC : Saturday /08 June 2013/23.16CM : 73-59-04-00

3

Subjective DataName : Mrs. Sitanggang Chandra Feri , 27 YO

Address : Raya Cendar no8 RT09/05

CM : 47-56-04-00

TC : Tuesday/28 may 2013/23:32

CC : Fever

Anamnesis

Main Complaint

• Fever since 7 days ago

Additional Complaints

Nausea, Vomiting and Headache

Autoanamnesis dan Alloanamnesis on the date 28 May 2013, Time

23.32 WIB

5

Anamnesis

Patient admitted to UKI Hospital with a complain of a fever that has been felt for seven days, the fever is fluctuative, the highest temperatur that the patient felt was 41°C, patient told that the fever mostly occur at night time. Before the complain occur, patient recently traveled to the island of Borneo. Other than that, Patient also complain of nausea, vomitting and also low appetite. A day before admitted at RS UKI, patient was admitted at RSIA Restu Kasih and was diagnosed malaria, but from microscopic examination, there has not been found any paracyte.

04/17/23

Past Medical History and Treatment

Hypertension (-)History of Diabetes Melitus (-)Operative History (-)History of trauma (-)

Family History(-)

Social HistorySmoking (+) , Alcohol (-)

Objective DataAppearance : moderate

illness

LOC : E4V5M6;

CM

BP : 120/70mm

Hg

HR : 80x /menit

(adequate, reguler)

RR : 24x /menit

Temp : 37,7°C

Objective Data Head :Normocephali

Konjunctiva anemic -/-

Sklera Ikterik -/-

ThoraxPulmonal Left Right

Inspeksi FrontStatic 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 -/-

Back BBS Vesicular, Rhonci -/-,

Wheezing -/-

BBS Vesicular, Rhonci -/,

Wheezing -/-

Inspection Looks iktus cardiac pulsation in ICS VI

Palpation Iktus cardiac pulsation palpable 1 finger left anterior linea axillaris anterior in IC 6

Percussion

Right limit ICS 4 linea right sternal

Left limit ICS 6, 2 finger lateral linea left midclavicularis

Auscultation BJ I reguler and BJ II regular, murmur (-), Gallop (-)

Abdomen

Inspeksi:

stomach looks flat

Palpasi:

Liver–Spleen impalpable ; ball -/-;Pressure Pain -

Perkusi:

Tympani; Percussion Pain -

Auskultasi:

Bowel sound (+)

Lower Extremities

Kanan Kiri

Muscle

Tonus Normotonus Normotonus

Massa Normal Normal

Joint in all directions in all directions

Move in all directions in all directions

Power +5 +5

Akral Warm Warm

Edema - -

13

Upper Extremities

Kanan Kiri

Muscle

Tonus Normotonus Normotonus

Massa Normal Normal

Joint in all directions in all directions

Move in all directions in all directions

Power +5 +5

Akral Warm Warm

Edema - -

LABORATORIUM

HEMATOLOGI HASIL NILAI RUJUKAN

Malaria antigen + Negatif

Widal

Salmonela typhi OSalmonela Paratyphi OASalmonela Paratyphi OBSalmonela Paratyphi OCSalmonela Thypi HSalmonela Parathypi HASalmonela Paratyphi HBSalmonela Paratyphi HC

+ 1/80+ 1/80+ 1/80

-+ 1/80

-+ 1/80

-

NegatifNegatifNegatifNegatifNegatifNegatifNegatifNegatif

RSIA 28/5/2013

LABORATORIUM

HEMATOLOGI HASIL NILAI RUJUKAN

Hemoglobin 12,6 g/dl 12-14 g/dL

Leukosit 16,3 ribu/UL 5-10 ribu/UL

Hematokrit 35,6 % 40-48 %

Trombosit 95 ribu/uL 150-400 ribu/uL

CLINICAL CHEMISTRY HASIL NILAI RUJUKAN

Ureum 24 H 15-45 mg/dl

Creatinin 0,97 H 0.70-1.10 mg/dl

28/5/2013

16

Assessment

• Suspect Malaria DD DHF

17

TherapyIVFD : RL 30 drop/mntMM/ :Sanmol 3x500gOndancentron 4mg injection 2x1 ampOmeperazole drip 2x1Diet : Pure

18

Planning•Pro Hospitalized•bed rest•H2TL/ 12 jam•Malaria Blood: Blood for examination taken when fever occured

19

Department of Internal MedicineChristian University of Indonesia

Juni, 03th 2013