Department of Internal

Medicine
Christian University of Indonesia

MORNING REPORT
Juny 6th 2015
TEAM 3

Tn RJ 24 YO
CC : Cough Blood
Findings
Cough Blood
GCS: E4V5M6, TD: 120/70, PR : 84x, T : 38,8oC, RR: 34x
Eye : Pale Conjungtiva -/-, Sclera icteric -/THT : Normal
Neck : Lymph Nodes not Enlarged
JVP : 5 - 2 cmH2O
THRORAX

: Intercostal movement simetric

Pal: Vocal fremitus simetric
Per: Sonor right = left
Aus: Basic breath sound vesiculer , ronchi -/-, wheezing -/-. S1
and S2 reguler, gallop (-), murmur (-)
ABDOMEN
Ins : flat
Aus : Bowel sound (+) 4x/minute
Pal : Pressure pain (-)
Per : tympani
Extremitas : pitting oedem (-), cold warm, CRT < 2, turgor
normal

Assesment
Hemoptoe et
causa
Suspect
Lungs TB

Therapy
MM/
Ceftizoxime 2c1 gr
Asam Traneksamat 3x1 gr
VIT K 3x1
Ambroxol 3x1
Paracetamol drip extra

Planning
Pro Hospitalized
Diet Lunak TKTR
IVFD :
-II Futrolit /24jam
-I RL / 24 jam
Periksa Sputum BTA 3 kali
Periksa GDS + elektrolit +
Ureum/Creatinin
Foto thorax ada di puskesmas

Subjective Data
Name
CM
TC
CC

: Tn . J, 24 years old
:
: Saturday, June 6th 2015
: Cough Blood

Anamnesis
Main symptom
Additional symptom

: Cough Blood
:-

Shortness of breath constantly and felt worse while

the patient is lying down and using 2 pillows patient
or the patient is sitting, the patient feels better.
patients have difficulty sleeping and restless. A year
ago the patient had experienced Similar complaints
and Patients treated in RSU UKI by dr. Robert
Saragih. Patients then stop control since 6 months
ago
History of trauma (-) Nausea (-), vomiting (-),
abdominal pain (-), weight loss (-) Asthma (-) History
of uncontrolled hypertension.

Past Medical History and Treatment

A year ago the patient had experienced similar
complaints and patients treated in RSU UKI by dr. Robert
Saragih. patients then stop control since 6 months ago

Family History

(-)
Social History
(-)

Objective Data

Appearance : Moderate Illness

GCS E4M6V5
BP : 200/140 mmhg,
RR: 48x/ minute,
T : 37,1C
Pulse : 110 x/minute.
Eye: Pale conjunctiva -/- , sclera icteric -/Ear, Nose, throat : normal
JVP : 5 + 4 cmH2O

 Thorax
I

Abdomen.

: intercostal movement simetric

Pal: Vocal fremitus simetric
Per: Sonor right = left
Aus: Basic breath sound vesiculer , ronchi -/-, wheezing -/-. S1 and S2 reguler, gallop (-), murmur (-)

I : flat
Aus : bowel sound (+) 8x/minute
Per :timpani, percussion tenderness (-)
Pal : abdominal tenderness (-), liver and spleen enlargement (-)

Extremity
-

Warm
Capillary refilling time <2 second
Edema (-)
Turgor normal

Clinical Laboratory

Hematologi

Hemoglobin : 13,8 gr/dl

Leukosit : 11.5 rb/ul
Hematokrit : 43,6 %
Trombosit : 219 rb/ul
GDS : 115 mg/dl

X-Ray

ekg

Assessment
Congestif Heart Failure et causa Hypertension Heart Disease

Therapy
Furosemide 2x1 amp
Captopril 3x25 mg
Aspilet 1x80 mg
Laxadine 1x15cc
Alprazolam 1x0.5 mg

Planning
Fluid balance intake
Check lab : Blood Count, Urine complete, Ur/Cr,
Electrolite, SGOT/SGPT
Diet : Heart III

Department of Internal
Medicine
Christian University of Indonesia

Thank You