MORNING REPORT

Department of Internal Medicine

Christian University of Indonesia
August, 25
th
2014
2
Findings Assessment Therapy Planning
Weakness
Lack of appetite
Fever

LOC : E4M6V5,compos mentis,being
sick
BP : 100/70 mmHg
PR : 86 x/minute, adequate,
regular
RR : 20 x/minute
Temp : 36
0
C
Eye : Pale Conjungtiva -/-, SI -/-
Coated tounge (-)

Thoraks :
Ins : movement of chest wall
symmetric
right = left, retraction (-)
Pal : vf symmetric, right=left
Per : sonor in all lung field
Aus : Basic breath sounds vesicular ,
Rh (-/-), Wh (-/-) ; Heart sound 1 &
Heart sound 2 reguler , murmur (-
),gallop (-)

-DHF grade I
-Tifoid Fever
Diet : Soft, not
stimulate
IVFD : III RL/24hours
Medikamentosa :
-Ciprofloxacin 2 x 200 mg
(IV)
-BD gard 2x1 (PO)
-PCT k/p 3 x 500 mg (PO)
-KSR 3 x 1 (PO)
-Ondancentron 2 x 8 mg (IV)
-Omeprazole 2 x 40 mg (IV)


Pro Hospitalized
simple check of
the internal lab
USG Thorax
Check H2TL/day


Miss. F 24 years Old
Jakarta
TC : Monday / 10.00 PM
Date : 25th/08th/2014
CC : Vomit and nausea



Abdoment :
Ins : stomach looks flat
Pal : Impalpable,pressure pain (+)
epigastrium
Per : Tympany, percussion pain (+)
Aus: Bowel sound 5 times/minute

Extremity : cold (-), cappilary refill <2
, edema (- )
Skin : Turgor elastic

LAB FINDING:
Hematology
Hb : 14,9 g/dl
Leu : 2.400/uL
Ht : 43 %
Tro : 57.000 uL
GDS : 83 mg/dl
Na : 139 mmol/L
K : 3,8 mmol/L
Cl : 100 mmol/L


WIDAL
S. Tiphose H : + 1/320
S. Paratiphy AH : -
S. Paratiphy BH : +1/320
S.Paratiphy CH : -
S. Tiphose O : + 1/320
S. Paratiphy AO : + 1/320
S. Paratiphy BO : -
S. Paratiphy CO : + 1/320
8/31/2014
4
Subjective Data
Name : Miss. F, 24 Years Old
Address : Jakarta
TC : Monday /25 August 2014/10.00 PM
CC : Vomit and Nausea

Anamnesis

Main Complaint
Vomit and nausea since 4 days ago
Additional Complaints
Weakness, Lack of Appetite, Fever


Autoanamnesis
on the date 25 August, Time 10.00
PM

6
Anamnesis

Patient came to emergency room with symptoms of nausea
and vomit since 4 days ago. One day before admitted to the
hospital, patient had already been vomiting for about 5
times that day and got worse. Patient also had fever since 4
days ago persistently alongside with the nausea and
vomiting. Patient already went to other doctor before, fever
already been treated but still nausea and vomiting. Other
symptoms are lack of appetite caused by frequent vomiting,
lightheaded, dizziness, weak, and muscle ache.

8/31/2014



Family History
(-)

Objective Data

Appearance :
moderate illness

LOC :
E4V5M6; CM

BP :
100/70mmHg

HR : 86x /minute
(adequate,
reguler)
RR : 20x
/minute
Temp : 36C
Objective Data
Head :Normocephali
Konjunctiva Anemis -/-
Sklera Ikterik -/-
Coated Tongue (-)


Thorax
Left Right
Inspeksi Front
Static and dynamic symmetric

Static and dynamic symmetric

back
Static and dynamic symmetric

Static and dynamic symmetric

Palpasi Front VF symmetric

VF symmetric

Back
VF symmetric

VF symmetric

Perkusi Front Sonor Sonor
Back Sonor Sonor
Auskultasi Front BBS Vesicular, Rhonci -/-,
Wheezing -/-

BBS Vesicular, Rhonci -/-,
Wheezing -/-

Front BJ I reguler and BJ II regular,
murmur (-), Gallop (-)




Abdomen
Inspeksi:
stomach looks
flat


Palpasi:
LiverSpleen
impalpable ; ball
-/-;
Pressure Pain (+)

Perkusi:
Hipertympani;
Percussion Pain
(+)

Auskultasi:
Bowel sound (+)
5x/minute

Lower Extremities

Right Left
Akral Warm Warm
Edema - -
Rumple Lead +
13

Upper Extremities
Right Left
Akral Warm Warm
Edema - -
LABORATORIUM
HEMATOLOGI HASIL NILAI RUJUKAN
Hemoglobin

14,9 g/dl 14-16 g/dL

Leukosit 2.400/UL 5-10 ribu/UL
Hematokrit 43 % 40-48 %
Trombosit 57.000/uL 150-400 ribu/uL
GDS 83 mg/dl <200 mg/dl
Natrium 139 mmol/L 136-145 mmol/L
Calium 3,0 mmol/L 3,5 5,1 mmol/L

Clorida 100 mmol/L 99 111 mmol/L

25/08/2014
WIDAL HASIL NILAI RUJUKAN
S.Tiphose H

+ 1/320 -
S.Paratiphy AH
- -

S.Paratiphy BH
+ 1/320

-

S.Paratiphy CH
- -

S. Tiphose O
+ 1/320

-

S. Paratiphy AO
+ 1/320

-

S. Paratiphy BO
- -

S.Paratiphy CO
+ 1/320

-

Assessment
- DHF grade I
- Tifoid Fever
16
Therapy


17
Diet : Soft, not stimulate
IVFD : III RL/24hours
Medikamentosa :
-Ciprofloxacin 2 x 200 mg (IV)
-BD gard 2x1 (PO)
-PCT k/p 3 x 500 mg (PO)
-KSR 3 x 1 (PO)
-Ondancentron 2 x 8 mg (IV)
-Omeprazole 2 x 40 mg (IV)
18
Planning




Pro Hospitalized
Simple check of the internal lab
USG Thorax
Check H2TL/day
19
THANK YOU