Format Morport Interna

5/27/2018 Format Morport Interna

1/12

MORNING REPORT

Department of Internal Medicine

Christian University of Indonesia

December 8th2013


2/12

Findings Assessment Therapy Pla

Appearance: moderate illness, GCS : E4V5M6, BP:

110/70 mmHg, PR : 78 x/min (adequate,regullar) RR :53 x/min, T: 37C

Eye : conjuntiva anemis -/-, Sklera icteric -/-

Ear, Nose, Throat: normal

Neck : lymph nodes did not enlarged, venousdistention -

THORAXInsp : symmetric, ictus cordis (-)

Pal : vf right >left

Per : right


3/12

Subjective DataName : Mrs S

Address :CM : 31.20.02.00

TC : Sunday/6thapril 2014

CC : dypsneu


4/12

Anamnesis

Main symptom : dypsneu

Additional symptom : Cough, hemaptoe, Night sweating

24 years old female patient came to hospital with complaint dyspne

three day before admission. The complaint perceived continously and incr

severe. The complain started with coughing first. Before that, patient alread

to clinic and received some medicine, she ate it but the complaint wasntde

yet. The other complaints she had were productive cough, hemamptoe an

sweating.

Patient has no history of hypertension, but no history ofdiabetes mellit

heart disease. The patient denied any complaints on the urination and defecat

The patient denied history of allergy.


5/12

Past Medical History and Treatment

(denied)

Family History

(denied)

Social HistorySmoking (-) , Alcohol (-), Drug induced (-),

Tatoo (-), Free sex (-), Sport (-)


6/12

Objective Data

LOC : E4V5M6 ; Composmentis

Appearance : moderate illBP : 100/70 mmHg

PR : 78 x/min (adequate,regular)

RR : 53x/min

Temp : 370C

EYE : anemic conjungtiva -/- ; ict -/-

THORAX :Heart

Ins : IC not visible

Pal : IC palpable

Per : RHB ICS V lin. sternal dext, LHB ICS V lin. Midclavicula

Ausc : S1 single, S2 single, regular, murmur (-) gallop (-)


7/12

PULMO

Insp : Static and dynamic symmetric

Pal : VF right >left symmetric

Perc : Sonor right < left

Ausc : BBS Vesicular, Rhonci +/+, Wheezing -/-

ABDOMEN

Insp : Stomach looks flat

Ausc : Bowel sound (+) 4 x/min

Pal : Pressure Pain (-) in epigastrium

Perc : Timpany; Percussion Pain (-) in epigastrium

EXTREMITIES

Edema (-); warm (+); capp. Refill


8/12

Clinical Laboratory

Hb : 12,2 gr/dl

Leu : 20.900/ul

Ht :36,7%

Tro : 497000/ul

gds:130mg/dl


9/12

Assessment

Susp.TB


10/12

Therapy

Pro HospitalizedIVFD : II RL / 24 hours

Diet : Normal

Mm/ Levofloxacin 1x500mg (iv)

Vit K 3x1 (iv)

Omeprazole 2x40mgFlumucyl 3x200mg

Obh Syr 3x1C

As Traknesamat 2x1

Inhalation with Fentolin+pulmicort in

ER


11/12

Planning

Complete perifer blood per day Sputum FAB day I-III


12/12

Thank You

Department of Internal Medicine

Christian University of Indonesia

Documents

Format Morport Interna