MORNING REPORT

Department of Internal MedicineChristian University of Indonesia

July 19th 2015 TEAM 2

Findings Assesment Therapy Planning

Diarrhea, vomiting, weakly, cold sweating, GCS: E4V5M6, TD: 160/90, PR : 80x, T : 36,4oC, RR: 28xEye : Pale Conjungtiva +/+, Sclera icteric -/-THT : NormalNeck : Lymph Nodes not EnlargedJVP : 5-2cmH2OTHRORAXI : intercostal movement simetricPal: Vocal fremitus simetricPer: right lung-dall , left lung-dallAus: Basic breath sound vesicular , ronchi -/-, wheezing -/-. S1

and S2 reguler, gallop (-), murmur (-) ABDOMENIns : flatAus : Bowel sound (+) 4x/minutePal : Pressure pain (-) hepar and lien normalPer : tympaniExtremitas : pitting oedem ekstremitas (-), cold warm, CRT <

2”, turgor decrease.

-GEA with mild dehidration-Hiponatremia-Hipocalemia-Hipertensi

MM/Ciprofloxacine 2x200mg (iv) STOMZ 1x40mg (PO)Domperidone 3x10mg (PO)KSR 3x1tabAmlodipine 1x5mg (morning-PO)

Pro HospitalizedDiet : soft, low saltIVFD 2 Line : I NS 3% / 24h II RL / 24hPx: SGOT/SGPT, DPL, Ur, Cr, Electrolite.

Mr. FT , 69 YOCC : Diarrhea

Subjective DataName : Mr.FT, 69 years oldCM : TC : Sunday, July 19th 2015CC : Diarrhea

AnamnesisMain symptom : Shortness of breathAdditional symptom : -

Patient came to UKI hospital with complain shortness of breath since 1 day ago. Shortness of breath is felt constantly. complain increase when patient lie down, to decreasing the complain, patien sit. The patient haven’t treat the pain. History of trauma (-) Nausea (+), vomitting (-), stomach ache (-), decrease in weight (-), cough (+) since 1 week ago.

Past Medical History and Treatment Post Masektomi, CA Mamae, CHF

Family History

(-)Social History

Smoking (-)

Objective Data

• Appearance : Moderate Illness• GCS E4M6V5• BP : 100/90 mmhg, • RR: 31x/ minute, • T : 37,5°C• Pulse : 100 x/minute.• Eye: Pale conjunctiva -/- , sclera icteric -/-• Ear, Nose, throat : normal• JVP : vein undistended

THRORAXI : intercostal movement simetricPal: Vocal fremitus simetricPer: right lung-dall , left lung-dallAus: Basic breath sound vesicular , ronchi -/-, wheezing -/-. S1 and S2 reguler,

gallop (-), murmur (-) ABDOMENIns : flatAus : Bowel sound (+) 4x/minutePal : Pressure pain (-) hepar and lien normalPer : tympaniExtremitas : pitting oedem ekstremitas (+), cold warm, CRT < 2”, turgor normal

Clinical Laboratory

• Hematologi– Hemoglobin : 9,5 gr/dl– Leukosit : 9,2rb/ul– Hematokrit : 29,1 %– Trombosit : 563 rb/ul– Ureum : 67 mg/dl– GDS : 118 mg/dl

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Assessment

- Efusi pleura- Post masektomi (Ca Mamae)- CHF- Anemia

TherapyMM/Furosemid 3x1ampul (iv)Aspilet 1x80mg (PO)Sulfas ferous 3x1 tabLaxadine 1x15cc (PO)ISDN 3x5mg (PO)

Planning

Pro HospitalizedDiet : softInject plugPx: Lab. Interna Sederhana

Thank You

Department of Internal MedicineChristian University of Indonesia