7/21/2019 Morpot 31 Oct 2014

1/11

MORNING REPORT

Department of Internal

MedicineChristian University of Indonesia

October 31th2014TEAM 2

7/21/2019 Morpot 31 Oct 2014

2/11

Findings Assessment Therap

Appearance : moderate illnessGCS : E4V5M6BP: 120/0 mm!"# P$ :100 %/min &ade'(ate# re"(lar) $$ : 2 %/min# *:

+6#5CE,e : con-(nti.a not pale# Slera icteric /Ear# ose# *roat: normalec : l,mp nodes did not enlar"ed# .eno(s distention

THORAXInsp : symmetric, icts cordis p!sation in intercosta ",

midc!avic!a sinistra !inePa! : vf symmetric, icts cordis pa!pa#!ePer : symmetric, sonor sond $!B 3CS V lin sternal de%t# !B 3CS V lin Midcla.ic(la sin

$s : #ronchia!e rh %&%, "h#$# S1 sin"le# S2 sin"le# prolon"ed e%piration# m(rm(r &)

"allop &)

ABDOMINAL

Ins : stomac loos latA(sc : 7o8el so(nds 9 5%Palp : Press(re Pain

nd(lation&)#Per : timpan,# pain in perc(ssion &)#E%tremitas : 8arm acral# C$ ;2

7/21/2019 Morpot 31 Oct 2014

3/11

+,b-ecti.e DataName : Mr' $

$ddress : Ci(antn)TC : *riday&+thOcto#er -./

// reathless

7/21/2019 Morpot 31 Oct 2014

4/11

AnamnesisMain smptom : 0reath!ess

Additional smptom : Co)h

Patient came 1ith #reath!ess' The symptom 1as fe!t sdays a)o, acta!!y in co!d condition and very tired' 2e is ta3i

4ometimes he sed inha!er 1hen re!apse' 0t no1, he st#reath!ess even sed inha!er' 2e a!so co)h 1hen #rea

attac5' There6s no dyspnea d6e7ort, chest pain, paro3

noctrna! dyspnea' The symptom didn6t depend on activity'

7/21/2019 Morpot 31 Oct 2014

5/11

Past Medica! 2istory and Treatment

Ventolin inaler

*ami!y 2istory

&denied)

4ocia! 2istorySmoking (+), Alcohol (-), Drug induced (-),

7/21/2019 Morpot 31 Oct 2014

6/11

Ob-ecti.e Data

=C : E4V5M6 > Composmentis

Appearance : moderate illnessBP : 120/0 mm!"

P$ : 100 %/min &ade'(ate# irre"(lar)

$$ : 2 %/min

*emp : +6#50C

HEAD & EYE : pale con-(n"ti.a / > ict /

THORAX :Heart

3ns : 3C .isi7le in an intercosta V# midcla.ic(la sinistra line

Pal : 3C palpa7le

Per: $!B 3CS V lin sternal de%t# !B 3CS V lin Midcla.ic(la sin

A(sc : S1 sin"le# S2 sin"le# re"(lar# m(rm(r &) "allop &)

7/21/2019 Morpot 31 Oct 2014

7/11

PULMO

3nsp : tora% mo.ement s,mmetric

Pal : V? ri"t and let s,mmetric

Perc : Sonor s,mmetric

A(sc : BBS .esic(lar# $oni /# @eein" 9/9

ABDOMEN

3nsp : Stomac loos lat A(sc : Bo8el so(nd &9)

Pal : (nd(lation &)# press(re pain &)

Perc : timpan,# pain in perc(ssion &)

EXTREMITIES

Edema &)> 8arm &9)> capp $eill ;2 seconds

Ob-ecti.e Data

7/21/2019 Morpot 31 Oct 2014

8/11

Assessment

$4T2M$ 0RONC2I$8E

7/21/2019 Morpot 31 Oct 2014

9/11

7/21/2019 Morpot 31 Oct 2014

10/11

!lanning% Not hospita!i9ed% Mm&: % sa!#tamo! +3- m) ;"