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MORNING REPORT
Family History
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Social History
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Objective Data
Appearance : Mild Illness
GCS E4M6V5
BP : 100/70 mmhg,
RR: 18x/ minute,
T : 36,2C
Pulse : 60x/minute.
Eye: Pale conjunctiva -/- , sclera icteric -/-
Ear, Nose, throat : normal
lymph nodes not enlarged
Thorax.
- I : Symmetrical chest wall movement, ictus cordis (-)
- Pal: Symmetrical Vocal fremitus, ictus cordis : palpable
- Per: Sonor/Sonor
- Aus: basic breath sound vesical, rhonchi -/-, wheezing -/-. S1 and S2 regular, gallop (-), murmur (-)
Abdomen.
- Ins : flat
- Aus : Increasing bowel sound (+) 5 times/minute
- Pal : Pressure pain (+) epigastic region
- Per : Timpani on 9 regions
Extremity
- Warm acral
- Capillary refilling time <2 second
- Edema (-)
- Turgor normal
Clinical Laboratory
Hb : 12,8 g/dl
White Blood Cell : 10.900 (H) /uL
Hematocrite : 38,9%
Trombosite : 191.000/uL
Electrolytie
Natrium : 136 mmol/L
Kalium : 2,7 (L) mmol/L
Chloride : 118 (H) mmol/L
GDS : 94 mg/dL
Assessment
IVFD :
- I RL ( 200cc Loading)
- II RL /24 jam
Department of Internal Medicine
Christian University of Indonesia
Thank You