morpot interna
DESCRIPTION
morning reportTRANSCRIPT
MORNING REPORT
Department of Internal MedicineChristian University of Indonesia
Juny 6th 2015 TEAM 3
Findings Assesment Therapy Planning
Cough Blood GCS: E4V5M6, TD: 120/70, PR : 84x, T : 38,8oC, RR: 34xEye : Pale Conjungtiva -/-, Sclera icteric -/-THT : NormalNeck : Lymph Nodes not EnlargedJVP : 5 - 2 cmH2OTHRORAX
I : Intercostal movement simetric
Pal: Vocal fremitus simetricPer: Sonor right = left Aus: Basic breath sound vesiculer , ronchi -/-, wheezing -/-. S1
and S2 reguler, gallop (-), murmur (-) ABDOMENIns : flatAus : Bowel sound (+) 4x/minutePal : Pressure pain (-)Per : tympaniExtremitas : pitting oedem (-), cold warm, CRT < 2”, turgor
normal
Hemoptoe et causa Suspect Lungs TB
MM/Ceftizoxime 2c1 gr Asam Traneksamat 3x1 gr VIT K 3x1 Ambroxol 3x1Paracetamol drip extra
Pro HospitalizedDiet Lunak TKTR IVFD : -II Futrolit /24jam -I RL / 24 jam Periksa Sputum BTA 3 kaliPeriksa GDS + elektrolit + Ureum/Creatinin Foto thorax ada di puskesmas
Tn RJ 24 YOCC : Cough Blood
Subjective DataName : Tn . J, 24 years oldCM : TC : Saturday, June 6th 2015
CC : Cough Blood
AnamnesisMain symptom : Cough BloodAdditional symptom : -
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 agoHistory 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 : 37,1°C• Pulse : 110 x/minute.• Eye: Pale conjunctiva -/- , sclera icteric -/-• Ear, Nose, throat : normal• JVP : 5 + 4 cmH2O
• Thorax– I : 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.– 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
TherapyFurosemide 2x1 amp Captopril 3x25 mg Aspilet 1x80 mgLaxadine 1x15ccAlprazolam 1x0.5 mg
Planning
Fluid balance intake Check lab : Blood Count, Urine complete, Ur/Cr, Electrolite, SGOT/SGPT Diet : Heart III
Thank You
Department of Internal MedicineChristian University of Indonesia