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Morning Report

July 25th 2014

Interna Group - Marwah

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Identity

Patient identity

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History Taing

!hie" !o#plaint

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Pre$iously

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Physi%al e&a#ination'ital (ign

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Head ) ne% * ane#ia +-)-, .aundi%e +-)-, %yanosis +-)-, dyspneu +-,

Thora& * /or#al %hest "or# I!( retra%tion +-, sy##etri%al %hest wall#o$e#ent

ungs P* (te# "re#itus* )

P * (onor)(onor (y##etri%

3 * $es )$es Rh -)- h -)-

RR * 24&)#inutes

!or P * ull

3 * (1-(2 #ur#ur +-, gallop +-,

36do#en I * "lat %aput #edusa +-,

P * (oe"l li$er and spleen not palpa6le (hi"ting dullness-

7pigastri% pain

P *ty#pani

3* 8owel sound +, /or#al

7&tre#ity * ar# dry and red

RT* T(3 d6n Mu%osa*so"t 3#pula didn9t %olaps Pain- H(-

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!lue and %ue

:e#ale ;0 years old

8loody stool without

#u%ous

:e$er /ausea

Pain in sto#a%h

7pigastri% pain

M #ore than 5

years

Taing her6al

#edi%ine 6ut sin%egot M stop

3l#ost e$ery 2 days

taes pil "or #ae her

6ody "eel good

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3sses#ent

He#ato%he

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Planning diagnosis

(G=T)(GPT

R:T

G3

H631!

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Laboratory Findings

i"" %ount * 2)1)>4)?);

He#ato%rite* 45@ A

H6 * 15 #g)dl

7 * @@)50

euo%ytes* 20200 Tro#6osite * 20;000

(G=T * 20

(GPT *21

3l6u#in * @?

Glo6ulin * @

(! * 14

Brea* 5C

Bri% a%id* 5@

!holesterol* 154

* >0C

TG* 14;

G3* 1;2

H631!* ??

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7DG

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Reasses#ent

G73

(epti%e#ia

M Type II

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Planing therapy

E I': Ring3s 1500%%)24.a#

E In. #eta#i#g prn

E in. !e"ota&i# @&1 g

E !)(pP

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Planning #onitoring

TT'

(u6.e%t %o#plain

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Prognosis

u6ia ad

6ona#

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7"e%ti$e %o##uni%ati$e edu%ation

Tae a planty o" rest

Tell the patient a6out the diseaseprognosis and #edi%ine that the patient9s

taing