MORNING REPORT

Department of Internal Medicine

Christian University of Indonesia
October 11
th
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 C
Eye : conjuntiva not pale, Sklera icteric -/-
Ear, Nose, Throat: normal
Neck : lymph nodes did not enlarged, venous distention -
THORAX
Insp : symmetric, ictus cordis (-)
Pal : vf symmetric, ictus cordis palpable
Per : symmetric, sonor sound
RHB ICS V lin. sternal dext, LHB ICS V lin.
Midclavicula sin
Aus : bronchovesicular rh -/-,wh+/+
S1 single, S2 single, prolonged expiration, murmur (-)
gallop (-)
ABDOMINAL
Ins : stomach looks flat
Ausc : bowel sounds + 5x
Palp : Pressure Pain -
Undulation(-),
Per : timpany, pain in percussion (-),
Extremitas : warm acral, CR <2, edema - -

- -

Anaphylactic reaction O2 nasal canule 3-4 LPM
IVFD RL 500 cc
Mm:
Dexamethasone 1 cc (IV)
Icadryl 1 cc (IV)
Loratadine 2x1
Metil-prednisolone 2x4


Check blood gas analysis
Mrs. I (31 YO)



CC : difficulty breathing
Subjective Data
Name : Mrs. I
Address : Palembang
TC : Saturday/11
th
October 2014
CC : Difficulty breathing

Anamnesis

Main symptom : Difficulty breathing
Additional 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 Data
LOC : E4V5M6 ; Composmentis
Appearance : moderate ill
BP : 130/80 mmHg
PR : 80 x/min (adequate, irregular)
RR : 32 x/min
Temp : 36,5
0
C
HEAD & EYE : pale conjungtiva -/- ; ict -/-
THORAX :
Heart
Ins : IC invisible
Pal : IC palpable
Per : RHB ICS V lin. sternal dext, LHB ICS V lin. Midclavicula sin
Ausc : S1 single, S2 single, regular, murmur (-) gallop (-)
PULMO
Insp : Static and dynamic symmetric
Pal : VF right and left symmetric
Perc : Sonor symmetric
Ausc : BBS bronchovesicular, Rhonki -/-, Wheezing +/+
prolonged expiration
ABDOMEN
Insp : Stomach looks flat
Ausc : Bowel sound (+)
Pal : undulation (-), pressure pain (-)
Perc : timpany, pain in percussion (-)

EXTREMITIES
Edema (-); 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 Medicine
Christian University of Indonesia