8/17/2019 Morpot 01 Maret 2016 Kelompok 1

1/11

MORNING REPORT

Department of InternalMedicineChristian University of Indonesia

March, 1 st 2015TEAM 1

8/17/2019 Morpot 01 Maret 2016 Kelompok 1

2/11

Findings Assesment Therapy

• Dyspneu since 4 days ago, cough with mucus,blood (-),fever (+)

• GC ! "4#$%&, 'D! * *, .! /* 0, ' ! &,& oC, ..! 140"ye ! ale Con2ungtiva - -, clera icteric - -'3' ! ormal

ec5 ! 6# distended, 7ymph odes not "nlarged6# ! -THORAX

8 ! ymmetrical chest wall movement, ictus cordis (-)al! ymmetrical #ocal fremitus, ictus cordis ! palpableer! onor onor

9us! :asic breath sound vesical, ronchi - -, whee;ing + +< and 1 reguler, gallop (-), murmur (-)

ABDOMEN8ns ! flat9us ! :owel sound (+) &0 minute

al ! ressure pain (-)<er ! 'ymphani, percussion tenderness (-)

Extremitas ! pitting oedem (-), warm acral, C.' = 1>

• neumonia•9sma :ronchiale•3istory of'uberculosis pulmo

%%7evoflo0acin 0$**mg drip

anmol 0$** mgalbutamol 0 1mg (po)

?%@ 101* mg (po)9;ytromycin 0 tab

ucralfat 0 C (po)

3os88 .

eb:loo'hor

Mr. Sahr ni!"" # Diarrhea

8/17/2019 Morpot 01 Maret 2016 Kelompok 1

3/11

Subjecti e DataName :Mrs Sahroni, 53 ears O!d

CM : TC : Monday, Mar"h # st $%#&!! " D#spneu

8/17/2019 Morpot 01 Maret 2016 Kelompok 1

4/11

8/17/2019 Morpot 01 Maret 2016 Kelompok 1

5/11

Past Medi"a! 4istory and TreatmentTuberculosis Pulmo (+) and got a medicine 5 yeras ago,

Diabetes mellytus (+), asma bronchiale (+)

ami!y 4istory

denied

So"ia! 4istorySmoking (+), consuming alcoholic beverages (-)

8/17/2019 Morpot 01 Maret 2016 Kelompok 1

6/11

$bjecti e Data• 6''earan"e : Moderate I!!ness• GCS E+M&75• 8P : #3%9 % mmh-,• RR: 3%;9 min(te,• T : 3&.

8/17/2019 Morpot 01 Maret 2016 Kelompok 1

7/11

• Thora;. – I : Symmetri"a! "hest *a!! movement, I"t(s "ordis 0 2

– Pa!: Symmetri"a! 7o"a! fremit(s, i"t(s "ordis : 'a!'a !e – Per: Sonor9Sonor – 6(s: 8asi" reath so(nd vesi"a!, ron"hi 9 , *hee@in- 191. S# and S$ re-(!er,

-a!!o' 0 2, m(rm(r 0 2

• 6 domen. – I : Aat – 6(s : o*e! so(nd 012 , & ; 9 min(te – Pa! : Press(re 'ain 0 2, !iver en!ar-ement 0 2 – Per : tiym'hani, 'er"(ssion tenderness 0 2

• E;tremityBarm a"ra!Ca'i!!ary re !!in- time D$ se"ondEdema 0 2

8/17/2019 Morpot 01 Maret 2016 Kelompok 1

8/11

Assessment

• neumonia•9sma :ronchiale•3istory of 'ubercolusis ulmo

8/17/2019 Morpot 01 Maret 2016 Kelompok 1

9/11

Therap#• 7evoflo0acin 0$**mg drip

• anmol 0$** mg• albutamol 0 1mg (po)

• ?%@ 101* mg (po)

• 9;ytromycin 0 tab

• ucralfat 0 C (po)

8/17/2019 Morpot 01 Maret 2016 Kelompok 1

10/11

%lannin&

3ospitali;ed88 .7 14 hours

ebuli;er :lood laboratorium'hora0 rontgen

8/17/2019 Morpot 01 Maret 2016 Kelompok 1

11/11

Than' (ou

Department of Internal

MedicineChristian University of Indonesia