Vous êtes sur la page 1sur 12

Department of Internal

Medicine
Christian University of Indonesia

MORNING REPORT
July 2th 2015
TEAM 1

Tn N, 54 YO
CC : unwell abdominal
Findings
Unwell abdominal, anuria, fever

GCS: E4V5M6, TD: 190/90, PR 114x, T : 39,1oC, RR: 23x


Eye : Pale Conjungtiva -/-, Sclera icteric -/THT : Normal
Neck : Lymph Nodes not Enlarged
JVP : distended and increased
THRORAX

: intercostal retraction and movement are simetric


Pal: Vocal fremitus simetric
Per: right lung-sonor , left lung-sonor
Aus: Basic breath sound vesical in left and right lung , ronchi -/-,
wheezing -/-. S1 and S2 reguler, gallop (-), murmur (-)
ABDOMEN
Ins : flat
Aus : Bowel sound (+) 4x/minute
Pal : Pressure pain (+), swelling at left hypokondrika
Per : tympani
Extremitas : pitting oedem (-), warm acral, CRT < 2, turgor
normal

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

: Tn. N, 54 years old


: Thursday, July 2th 2015
: unwell abdominal

Anamnesis
Main symptom
Additional symptom

: unwell abdominal
: anuria, fever

Patient came to UKI hospital with unwell


abdominal since 5 days ago. Unwell
abdominal is felt in the morning. Patient came
to clinic and got medicine but no
improvement. Nausea (-), vomitting (-), anuria
(+), fever (+).

Past Medical History and Treatment


Asma
Uncontrolled hypertension

Family History
-

Social History
-

Objective Data

Appearance : Moderate Illness


GCS E4M6V5
BP : 190/90 mmhg,
RR: 23x/ minute,
T : 39,1C
Pulse : 114x/minute.
Eye: Pale conjunctiva -/- , sclera icteric -/Ear, Nose, throat : normal
JVP : vein undistended

Thorax.

I : intercostal retraction and movement are simetric


Pal: Vocal fremitus simetric
Per: Right lung-sonor , left lung-sonor
Aus: Basic breath sound vesical, ronchi -/-, wheezing -/-. S1 and S2 reguler, gallop (-), murmur (-)

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

IVFD : III RL/24 hours

Department of Internal
Medicine
Christian University of Indonesia

Thank You