contoh morning report mr. yafet.pptx

7/27/2019 CONTOH MORNING REPORT mr. yafet.pptx

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CASE REPORT

Department of Internal Medicine

Christian University of Indonesia

October 25th 2013



Findings Assessmen

t

Therapy Planning

- Fever

- Nausea

- Constipation

- History travel from Jayapura 1 month before admit

to hospital

Appearance: moderate illness, GCS : E4V5M6, BP:110/60 mmHg, PR : 82 x/min (adequate, regular) RR :

20 x/min, T: 37,7° C

Eye : pale conjunctiva -/- sclera icteric -/-,

THT : normal

Neck : lymph nodes not enlarged

THORAX PulmoInsp : symmetric

Pal : vf symmetric

Per : symmetric, sonor sound

Aus : vesicular, wheezing -/-, ronkhi -/-

Heart Sound S1 S2 N, murmur – gallop -

Abdominal

Insp : flat

Ausc : bowel sounds + 2x/m

Per : Tympani, shifting dullness -

Palp : Pressure Pain -, hepar and lien not palpable

Extremitas : warm acral, CR<2”, edema

LAB FINDING :

Hemoglobin : 12,7 g/dLHematocrit : 39 %

Leucocyte : 11.000 /uL

Thyfoid fever

DD/ Malaria

Pro Hospitalized

Diet : soft meal

IVFD : I RL/24

hours

Mm/Levofloxacin 1 x

500 mg

Omeprazole 2 x

20 mg

Domperridon 3 x

10 mgParacetamol 3 x

500 mg

Px/

-Parasitology

Lab for

Malaria

Mr. Y, 33 y.o.

East Jakarta

CC : fever since 1 week before admit to hospital

Saturday, 26th October 2013 , 05:03

-- --



Subjective Data

Name : Mr. Y

Address : East Jakarta

TC : Friday, 26 oct 2013/ 05.03

CC : fever



AnamnesisMain symptom : fever

Additional symptom : constipation, nausea

33 y/o male patient came with chief complaints of fever since one week

before admission to hospital. Fever intermitten but more severe at night. Patient has

been consume paracetamol but not getting better. Patient felt nausea but novomitting. Patient compaint that no defecation for 4 days before go to hospital.

Patient has a history travel from Jayapura 1 month before admit to Hospital. Patient

has a roommate that have a same fever and sign like him.



Past Medical History and Treatment

-

Family History

-

Social HistorySmoking (+) , Alcohol (+)



Objective Data

LOC : E4V5M6 ; Composmentis

Appearance : moderate ill

BP : 110/60 mmHg

PR : 82 x/min (adequate,regular)

RR : 20 x/minTemp : 37,70C

EYE : hiperemic conjungtiva -/- ; icteric -/-

THORAX :

Heart

Ins : IC visible

Pal : IC palpable

Per : RHB ICS V line Parasternal dext, LHB ICS V lin. Midclavicula sin

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



PULMOInsp : Chest movement symmetric

Pal : VF right and left symmetric

Perc : Sonor symmetric

Ausc : Vesicular, wheezing -/-, ronkhi -/-

ABDOMEN

Insp : flat

Ausc : bowel sounds + 2x/m

Per : Tympani, shifting dullness -

Palp : Pressure Pain -, hepar and lien not palpable

Objective Data



EXTREMITIEEdema (-); warm acral,crt <

2’’

Objective Data



Assessment

Thyfoid fever

DD/ Malaria



Therapy

Pro HospitalizedDiet : soft meal

IVFD : I RL/24 hours

Mm/Levofloxacin 1 x 500 mg

Omeprazole 2 x 20 mg

Domperridon 3 x 10 mg

Paracetamol 3 x 500 mg



Planning

- Parasitology Lab for Malaria



Thank You

Department of Internal Medicine

Christian University of Indonesia

October, 26th 2013

contoh morning report mr. yafet.pptx

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