Department of Internal

Medicine
Christian University of Indonesia

MORNING REPORT
March 19rd 2015
TEAM 2

Mr. S (76 yo )
32-47-06-00
Findings

Assessment

Therapy

Cough with white phlegm

and shortness of breath for 3
days
Fever that worsen at night for
3 days,cold sweat (-)
Diarrhea (-)
nausea -, vomit -, T: 37,6C,
BP: 130/80 mmHg, Pul:
80x/minute, RR: 26x/minute
Thorax:
Symmetric, Vocal Fremitus
symmectric, Sonor Sound
Symmetric, BND vesical, wh
-/-, rh -/Abdomen:
Flat, Bowel Sound + 5x/min,
Tenderness -, tympanic sound,
pressure pain -

Bronchopneumonia
Clinical thyphoid

Initial Therapy (ER) :

IVFD : Ringer Lactate
II Kolf / 24 hrs
MM :
Levofloxacin 1x500
mg(iv)
Paracetamol 3x500
mg (po)
Ambroxol syr 3x1C

Planning
Further planning :
Pro hospitalized
Diet : soft non
stimulating food
Thorax AP Rontgen
Check lab:
Complete blood
count
Blood glucose
Widal test

Subjective Data
Name
: Mr. P
Address : Kampung Melayu
TC : Wednesday / 11 March 2015
CC
: Epigastric pain since one week

Anamnesis
Main symptom
: Episgastric pain in one week
Additional symptom : nausea
Patient came to the hospital with epigastric pain for 1 week. The
pain is dull and intermittent. The patient also experienced nausea
and vomiting . Before admission he had been throing up for 3 times.
No other symptom was found. Bowel activity is normal and so does
urinary activity, no fever was found . History of hypertension was
denied, History of high blood sugar was confirmed

Past Medical History and Treatment

(denied)

Family History
(denied)

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

Objective Data
LOC
: E4V5M6 ; Compos mentis
Appearance : mildly ill
BP
: 150/80 mmHg
PR
: 77 x/min (adequate, regular)
RR
: 20 x/min
Temp
: 36.40C
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 (-)

Objective Data
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 (+) 8x/m
Pal : undulation (-), pressure pain (+) in epigastrium
Perc
: timpany, pain in percussion (-)
EXTREMITIES
Edema (-); warm (+); capp. Refill <2 seconds

Assessment
Dyspepsia syndrome
DM type 2

Therapy
Initial Therapy (ER) :
IVFD : Ringer Lactate II Kolf /
24 hrs

MM :
Ranitidine
2x1 amp(iv)
Ondancentrone
2x4mg (iv)
Metformin
3x500mg (po)

Planning
Further planning :
Pro hospitalized
Diet : soft non stimulating food
Thorax AP Rontgen
Random glucose test/24 hour
Check lab: H2TL, GDS

Department of Internal
Medicine
Christian University of Indonesia

Thank You