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MORNING REPORT
Department of Internal MedicineChristian University of Indonesia
February 3rd 2015 TEAM 3
Findings Assessment Therapy Planning
Appearance: moderate illness, GCS : E4V5M6, BP: 110/60 mmHg, HR : 100x/min RR : 28 x/min, T: 39° CEye : conjuntiva not pale, Sklera icteric -/-Ear, Nose, Throat: normalNeck : lymph nodes did not enlarged, venous distention -THORAX Insp : symmetric, ictus cordis (-)Pal : vf symmetric, ictus cordis palpablePer : symmetric, sonor sound RHB ICS V lin. sternal dext, LHB ICS V lin. Midclavicula sinAus : bronchovesicular rh -/-,wh-/- S1 single, S2 single, prolonged expiration, murmur (-) gallop (-)ABDOMINALIns : stomach looks flatAusc : bowel sounds + 5xPalp : Soepel, pain in all field of abdomenPer : timpany, pain in percussion (-), Extremitas : warm acral, CR <2”, edema - - - -
1. Thypoid Fever Hospitalized -Diet : soft diet with low fiber-IVFD : I Futrolit/ 24 hours III RL/ 24 hours-Mm/ Levofloxacin 1x500mg IVSucralfat syr 3x1C POOndancetron 3x8mg IVOmeprazole 1x40mg IVParacetamol 3x500mg PO
Check Routine blod test daily
Mr. SN
CC : Nausea
Subjective DataName : Mr. SNTC : Friday/30th January 2015CC : Nausea
AnamnesisMain symptom : NauseaAdditional symptom : Shortness of breath, fever
Patient came to IGD RSU UKI with Nausea and vomitting for approximately 4 days ago. Patient vomitting for ten times yesterday, and it contains with food, no blood and no slime. Before that, patient got a fever, and the fever already last for 6 days before the patient came to hospital. The fever is on and off and also increasing at evening and came down in the morning. Patient was already had come to hospital at 26 – 2015 and declared as dengue fever but the patient refuse to be hospitalized and go home. The patient also have headache (+), myalgia (+), weakness (+), and loss of apetite (+)
Past Medical History and Treatment
Family History(denied)
Social History Smoking (-), Alcohol (-), Drug induced (-),
Objective DataLOC : E4V5M6 ; ComposmentisAppearance : moderate illBP : 110/80 mmHgPR : 88x/minRR : 20 x/minTemp : 37,40CHEAD & EYE : pale conjungtiva -/- ; ict -/-THORAX :
HeartIns : IC invisiblePal : IC isn’t palpablePer : RHB ICS V lin. midsternal dext, LHB ICS V lin. Axilla anterior IC 6 sinAusc : S1 single, S2 single, regular, murmur (-) gallop (-)
PULMOInsp : Static and dynamic symmetricPal : VF right and left symmetricPerc : Sonor symmetric Ausc : BBS bronchial, Rhonki -/-, Wheezing -/-
ABDOMEN
Insp : Flat Ausc : Bowel sound (+) 5x/min
Pal : undulation (-), pressure pain (+) shifting dullness (-)
Perc : timpany, pain in percussion (-)
EXTREMITIESEdema - - warm (+); capp. Refill <2 seconds - -
Objective Data
Laboratorium Findings
• Hb: 14,7• Leukocyte: 8,5• Hematocrite:
45,6• Trombocyte:
158• Ureum: 123• Kreatinin: 2,22• GDS: 113
• Na : 137• K :4,3• Cl : 104
Thorax photo
Assessment
CHFAsitesCephalgia chronicAKI dd CKD
Therapy
Hospitalized
-Diet : soft diet with low fiber
-IVFD : I Futrolit / 24 hours III RL / 24 hours
-Mm/ • Levofloxacin 1x500mg IV• Sucralfat syr 3x1C PO• Ondancetron 3x8mg IV• Omeprazole 1x40mg IV• Paracetamol 3x500mg PO
Planning
Thank You
Department of Internal MedicineChristian University of Indonesia