MORNING REPORT

Department of Internal MedicineChristian University of Indonesia

October 11th 2014 TEAM 2

Findings Assessment Therapy Planning

Appearance: moderate illness, GCS : E4V5M6, BP: 130/80 mmHg, PR : 80 x/min (adequate, regular) RR : 32 x/min, T: 36,5° CEye : conjuntiva not pale, Sklera icteric -/-Ear, Nose, Throat: normalNeck : lymph nodes did not enlarged, venous distention -THORAX Insp : symmetric, ictus cordis (-)Pal : vf symmetric, ictus cordis palpablePer : symmetric, sonor sound RHB ICS V lin. sternal dext, LHB ICS V lin. Midclavicula sinAus : bronchovesicular rh -/-,wh+/+ S1 single, S2 single, prolonged expiration, murmur (-) gallop (-)ABDOMINALIns : stomach looks flatAusc : bowel sounds + 5xPalp : Pressure Pain - Undulation(-), Per : timpany, pain in percussion (-), Extremitas : warm acral, CR <2”, edema - - - -

Anaphylactic reaction O2 nasal canule 3-4 LPMIVFD RL 500 ccMm:Dexamethasone 1 cc (IV)Icadryl 1 cc (IV)Loratadine 2x1Metil-prednisolone 2x4

Check blood gas analysis

Mrs. I (31 YO)

CC : difficulty breathing

Subjective DataName : Mrs. IAddress : PalembangTC : Saturday/11th October 2014CC : Difficulty breathing

AnamnesisMain symptom : Difficulty breathingAdditional symptom : -

Patient came with difficulty breathing. The symptom felt since thirty minutes after the patient eat prawns for dinner. Rash was denied, swelling on the lips or the palpebra denied, nausea and vomit were denied. Patient quickly came to the hospital after her symptoms develop.

Past Medical History and Treatment Allergic to antalgin, amoxycylin

Family History(denied)

Social History Smoking (-), Alcohol (-), Drug induced (-),

Objective DataLOC : E4V5M6 ; ComposmentisAppearance : moderate illBP : 130/80 mmHgPR : 80 x/min (adequate, irregular)RR : 32 x/minTemp : 36,50CHEAD & EYE : pale conjungtiva -/- ; ict -/-THORAX :

HeartIns : IC invisiblePal : IC palpablePer : RHB ICS V lin. sternal dext, LHB ICS V lin. Midclavicula sinAusc : S1 single, S2 single, regular, murmur (-) gallop (-)

PULMOInsp : Static and dynamic symmetricPal: VF right and left symmetricPerc : Sonor symmetric Ausc : BBS bronchovesicular, Rhonki -/-, Wheezing +/+ prolonged expiration

ABDOMENInsp : Stomach looks flat

Ausc : Bowel sound (+) Pal: undulation (-), pressure pain (-) Perc : timpany, pain in percussion (-)

EXTREMITIESEdema (-); warm (+); capp. Refill <2

seconds

Objective Data

Assessment

•Anaphylactic reaction

Therapy•O2 nasal canule 3-4 LPM•IVFD : RL 500 cc•Mm/

– Dexamethasone 1 cc (IV)– Icadryl 1 cc (IV)– Loratadine 2x1 (PO)– Metil-prednisolone 2x4 (PO)

Planning

- Check blood gas analysis- Complete leukocyte count

Thank You

Department of Internal MedicineChristian University of Indonesia