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