Morning Report

Dept of internal medicine

F24

Identity
Name

: Mrs. D
Age
: 72 years old
Occupation : Address
: Lamongan

Chief Complaint

Hard to breathe
Present history

Patient came as out of breathe since 21 hours ago. Rarely

cough with mucus, felt better while sitting. Chest pain (-)
Fever (+). Back pain (-). Loss of appetite, nausea and no
vomitting.
Urinary and defecation were normal.

Past history of Illness

HT (-)
Decomp cordis (-)
DM (-)

Family history

No familial related

Social history
Cigarrete (-)
Coffe (-)
Alcohol (-)

Vital Signs
Pulse
140x/min

BP
136/82mmHg

Temp
36 C

RR
32x/min

A: clear, gargling (-), snoring (-), speak

fluently (+), potential obstruction (-)

B: spontan, RR 22x/min, ves / ves, rh -/-, wh
-/-, Sa O2 97 % without O2 support 99%
with O2 nasal 3 3lpm
C: extremity WDR, CRT <2, N 91x/min, TD
136/82 mmHg
D: GCS 456, lat -, PBI 3mm/ 3mm, LP +/+
E: temp 36C

GENERAL STATUS

General condition

: well
Awareness
: compos mentis
GCS
: 456
H/N
: a -/i-/c-/d+

Thorax
Inspection
Symmetrical, retraction +

Palpation
Fremitus WNL, thrill (-)

Percussion
Lungs: sonor +/+
Cor: N

Auscultation
Lungs: ves /ves, rh -/-, wh -/Cor: S1 S2 single, mur -, gall-

Abdomen

Inspection

Flat, collaterral veins (-), inflammation signs (-)

Auscultation
Met -, gut noise WNL

Palpation
Epigastric pain (-)
Mc burneyTurgor WNL
Liver/Spleen is untouchable

Percussion
tymphany

Extremities
Inspection
Clubbing fingers (-), icteric (-), cyanosis (-)

Palpation
Warm and dry, CRT <2

CLUE AND CUE

Female 72 years old
Dyspnea

Planning Diagnose
SE
LFT
RFT
BGA
ECG
Ro Thorax

Assesment
Hypokalemia
Pneumonia

Laboratory Findings
Diffcount Eo 3.5/

Ba 4.2, Lim 23.2/

Neu 54.4/ Mo 14.7
Hct 23.8
Hb 7.8
Leukosit 4.100
Trombosit 201.000
Eritrosit 2.51
GDA 110

SGOT 34 (N 31 U/l)
SGPT 29 (N 31 U/l)
Cl 101
K 4.16
Na 135
Creatinine serum 6.0
Urea 64

BGA:
K 4.16
Na 137
Be 1.0
Beecf 0.7
HCO3 25.3
Cl 103,8
Hct 26
PCO2 32.3
pH 7.491 (7.350-

7.450)

pO2 77.0 (83.0-100 mmHg)

SO2

96.4

ctHb 8,9

Planning Therapy
Bed rest
O2 NRM 10 lpm 97% O2 nasal 3 lpm 99%
Inf.PZ life line 500cc/24 jam
Inf. KCL premix 25 meq 500 cc/24 jam
Inj. Lasix 2 amp 3x1 amp
Inj. Levofloxacyn 1x 750 mg iv
Inj. Hexilon 2x 62.5 mg iv
consult to internist

PLANNING MONITORING
Vital Signs
Blood glucose level
SE
Patients complaint

PLANNING EDUCATION
Explain to the patien and his family about the

disease, cause, stadium of the disease,

complication, intervention of the therapy and
prognosis.