MORNING REPORT

Department of Internal Medicine

Christian University of Indonesia
October 23
rd
2014
TEAM 2
Findings Assessment Therapy Planning



Appearance: mild illness, GCS : E4V5M6, BP: 160/90 mmHg, PR : 88
x/min (adequate, regular) RR : 28 x/min, T: 36,5 C
Eye : conjunctiva not pale, Sclera 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 : vesicular rh -/-,wh-/-
S1 single, S2 single, murmur (-), gallop (-)

ABDOMINAL
Ins : stomach looks flat
Ausc : bowel sounds + 4x
Palp : Pressure Pain - - -
Undulation(-),
Per : timpany, pain in percussion (-), - -
Extremitas : warm acral, CR <2, edema
Dyspepsia
Hypertension grade II
Pro: Hospitalized
IVFD: II Futrolit/24 hours
Diet: smooth do not stimulate
Omeprazole 1x40 mg IV
Sucralfat 3x1
Ondacentron 2x2 mg IV
Alprazolam 1x0,5 mg PO
Amlodipin 1x5 mg PO

Complete perifer blood
GDS
ECG
Mrs. D (74 YO)



CC : feeling hot all over the body
Subjective Data
Name : Mrs. D
Address : Kramat Jati
TC : Thursday/23
rd
October 2014
CC : Feeling hot all over the body

Anamnesis

Main symptom : Feeling hot all over the body
Additional symptom : Decreasing appetite, nauseous, stomachache

Patient came because she was feeling hot all over her body for the past three
days. The complaint felt over and over again and she already took medicine to reduce
the complaint but it didnt work. Patient couldnt remember why she had the
complaint on the first place. Because of that, she also felt nauseous after eating. That
made her eat less than usual. She also feeling stomached. Complaint of fever was
denied, complaint of vomit was denied too. Patient said that the complaint had made
her unable to do her everyday activities properly.
History of hypertension was denied. History of high blood sugar was denied.
Past Medical History and Treatment
(denied)

Family History
(denied)

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


Objective Data
LOC : E4V5M6 ; Compos mentis
Appearance : mild ill
BP : 160/90 mmHg
PR : 88 x/min (adequate, regular)
RR : 28 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 vesicular, Rhonki -/-, Wheezing -/-

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

Dyspepsia
Oral intake difficult
Hypertension grade II

Therapy
IVFD: II Futrolit/24 hours
Diet: smooth do not stimulate
Mm:
Omeprazole 1x40 mg IV
Sucralfat 3x1
Ondacentron 2x2 mg IV
Alprazolam 1x0,5 mg PO
Amlodipin 1x5 mg PO
Planning











- Complete perifer blood
- GDS
- ECG
Thank You
Department of Internal Medicine
Christian University of Indonesia