format morport interna
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internaTRANSCRIPT
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MORNING REPORT
Department of Internal Medicine
Christian University of Indonesia
December 8th2013
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Findings Assessment Therapy Pla
Appearance: moderate illness, GCS : E4V5M6, BP:
110/70 mmHg, PR : 78 x/min (adequate,regullar) RR :53 x/min, T: 37C
Eye : conjuntiva anemis -/-, Sklera icteric -/-
Ear, Nose, Throat: normal
Neck : lymph nodes did not enlarged, venousdistention -
THORAXInsp : symmetric, ictus cordis (-)
Pal : vf right >left
Per : right
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Subjective DataName : Mrs S
Address :CM : 31.20.02.00
TC : Sunday/6thapril 2014
CC : dypsneu
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Anamnesis
Main symptom : dypsneu
Additional symptom : Cough, hemaptoe, Night sweating
24 years old female patient came to hospital with complaint dyspne
three day before admission. The complaint perceived continously and incr
severe. The complain started with coughing first. Before that, patient alread
to clinic and received some medicine, she ate it but the complaint wasntde
yet. The other complaints she had were productive cough, hemamptoe an
sweating.
Patient has no history of hypertension, but no history ofdiabetes mellit
heart disease. The patient denied any complaints on the urination and defecat
The patient denied history of allergy.
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Past Medical History and Treatment
(denied)
Family History
(denied)
Social HistorySmoking (-) , Alcohol (-), Drug induced (-),
Tatoo (-), Free sex (-), Sport (-)
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Objective Data
LOC : E4V5M6 ; Composmentis
Appearance : moderate illBP : 100/70 mmHg
PR : 78 x/min (adequate,regular)
RR : 53x/min
Temp : 370C
EYE : anemic conjungtiva -/- ; ict -/-
THORAX :Heart
Ins : IC not visible
Pal : IC palpable
Per : RHB ICS V lin. sternal dext, LHB ICS V lin. Midclavicula
Ausc : S1 single, S2 single, regular, murmur (-) gallop (-)
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PULMO
Insp : Static and dynamic symmetric
Pal : VF right >left symmetric
Perc : Sonor right < left
Ausc : BBS Vesicular, Rhonci +/+, Wheezing -/-
ABDOMEN
Insp : Stomach looks flat
Ausc : Bowel sound (+) 4 x/min
Pal : Pressure Pain (-) in epigastrium
Perc : Timpany; Percussion Pain (-) in epigastrium
EXTREMITIES
Edema (-); warm (+); capp. Refill
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Clinical Laboratory
Hb : 12,2 gr/dl
Leu : 20.900/ul
Ht :36,7%
Tro : 497000/ul
gds:130mg/dl
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Assessment
Susp.TB
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Therapy
Pro HospitalizedIVFD : II RL / 24 hours
Diet : Normal
Mm/ Levofloxacin 1x500mg (iv)
Vit K 3x1 (iv)
Omeprazole 2x40mgFlumucyl 3x200mg
Obh Syr 3x1C
As Traknesamat 2x1
Inhalation with Fentolin+pulmicort in
ER
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Planning
Complete perifer blood per day Sputum FAB day I-III
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Thank You
Department of Internal Medicine
Christian University of Indonesia