MORNING REPORT

Department of Internal MedicineChristian University of Indonesia

Juny 6th 2015 TEAM 3

Findings Assesment Therapy Planning

Cough Blood GCS: E4V5M6, TD: 120/70, PR : 84x, T : 38,8oC, RR: 34xEye : Pale Conjungtiva -/-, Sclera icteric -/-THT : NormalNeck : Lymph Nodes not EnlargedJVP : 5 - 2 cmH2OTHRORAX

I : Intercostal movement simetric

Pal: Vocal fremitus simetricPer: Sonor right = left Aus: Basic breath sound vesiculer , ronchi -/-, wheezing -/-. S1

and S2 reguler, gallop (-), murmur (-) ABDOMENIns : flatAus : Bowel sound (+) 4x/minutePal : Pressure pain (-)Per : tympaniExtremitas : pitting oedem (-), cold warm, CRT < 2”, turgor

normal

Hemoptoe et causa Suspect Lungs TB

MM/Ceftizoxime 2c1 gr Asam Traneksamat 3x1 gr VIT K 3x1 Ambroxol 3x1Paracetamol drip extra

Pro HospitalizedDiet Lunak TKTR IVFD : -II Futrolit /24jam -I RL / 24 jam Periksa Sputum BTA 3 kaliPeriksa GDS + elektrolit + Ureum/Creatinin Foto thorax ada di puskesmas

Tn RJ 24 YOCC : Cough Blood

Subjective DataName : Tn . J, 24 years oldCM : TC : Saturday, June 6th 2015

CC : Cough Blood

AnamnesisMain symptom : Cough BloodAdditional symptom : -

Shortness of breath constantly and felt worse while the patient is lying down and using 2 pillows patient or the patient is sitting, the patient feels better. patients have difficulty sleeping and restless. A year ago the patient had experienced Similar complaints and Patients treated in RSU UKI by dr. Robert Saragih. Patients then stop control since 6 months agoHistory of trauma (-) Nausea (-), vomiting (-), abdominal pain (-), weight loss (-) Asthma (-) History of uncontrolled hypertension.

Past Medical History and Treatment •A year ago the patient had experienced similar complaints and patients treated in RSU UKI by dr. Robert Saragih. patients then stop control since 6 months ago

Family History

(-)

Social History(-)

Objective Data

• Appearance : Moderate Illness• GCS E4M6V5• BP : 200/140 mmhg, • RR: 48x/ minute, • T : 37,1°C• Pulse : 110 x/minute.• Eye: Pale conjunctiva -/- , sclera icteric -/-• Ear, Nose, throat : normal• JVP : 5 + 4 cmH2O

• Thorax– I : intercostal movement simetric

– Pal: Vocal fremitus simetric– Per: Sonor right = left – Aus: Basic breath sound vesiculer , ronchi -/-, wheezing -/-. S1 and S2 reguler, gallop (-), murmur (-)

• Abdomen.– I : flat– Aus : bowel sound (+) 8x/minute– Per :timpani, percussion tenderness (-)– Pal : abdominal tenderness (-), liver and spleen enlargement (-)

• Extremity- Warm- Capillary refilling time <2 second- Edema (-)- Turgor normal

Clinical Laboratory

• Hematologi– Hemoglobin : 13,8 gr/dl– Leukosit : 11.5 rb/ul– Hematokrit : 43,6 %– Trombosit : 219 rb/ul– GDS : 115 mg/dl

X-Ray

ekg

Assessment

Congestif Heart Failure et causa Hypertension Heart Disease

TherapyFurosemide 2x1 amp Captopril 3x25 mg Aspilet 1x80 mgLaxadine 1x15ccAlprazolam 1x0.5 mg

Planning

Fluid balance intake Check lab : Blood Count, Urine complete, Ur/Cr, Electrolite, SGOT/SGPT Diet : Heart III

Thank You

Department of Internal MedicineChristian University of Indonesia