Professional Documents
Culture Documents
Medicine
Christian University of Indonesia
MORNING REPORT
July 2th 2015
TEAM 1
Tn N, 54 YO
CC : unwell abdominal
Findings
Unwell abdominal, anuria, fever
Assesment
Urinary
tract
infection
Therapy
IVFD : III RL/24 hours
MM/
Paracetamol 3 x 500mg
Ceftriaxone 1 x 2gr
Urispas tab 2x1
Sucralfat syr 3x1 C
Ranitidine 2x1gr
Planning
Pro Hospitalized
Check lab : H2TL, GDS, Ureum &
Creatinin
Subjective Data
Name
TC
CC
Anamnesis
Main symptom
Additional symptom
: unwell abdominal
: anuria, fever
Family History
-
Social History
-
Objective Data
Thorax.
Abdomen.
I : flat
Aus : bowel sound (+) 4x/minute
Per :timpani, percussion tenderness (-)
Pal : Pressure pain (+), swelling at left hypokondrika
Extremity
-
Warm
Capillary refilling time <2 second
Edema (-)
Turgor normal
Clinical Laboratory
2/07/2015
H2TL
Hb : 13,8 g/dl (Low)
Leucosite
: 3100/uL (Low)
Hematocrite
: 43,1 %
Trombosite
: 122.000/uL (Low)
GDS
: 61 mg/dl
Imunologi
S,typhose H
: 1/160
S, paratyphi A H
: negatif
S, paratyphi B H
: 1/320
S, paratyphi C H
: negatif
S, typhose
: 1/80
S, paratyphi A O
: 1/320
S, paratyphi B O
: 1/320
S, paratyphi C O
: 1/320
Assessment
Urinary tract infection
Therapy
Paracetamol 3 x 500mg
Ceftriaxone 1 x 2gr
Urispas tab 2x1
Sucralfat syr 3x1 C
Ranitidine 2x1gr
Planning
Pro Hospitalized
Check lab : H2TL, GDS, Ureum &
Creatinin
Department of Internal
Medicine
Christian University of Indonesia
Thank You