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MORNING REPORT
Department of Internal
MedicineChristian University of Indonesia
July, 22th2015TEAM 1
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Findings Assesment Therapy
Fever
GCS: E4M6V5, TD: 100/70, PR 78x, T : 38,3 oC, RR: 18x
Eye : Pale Co!"#$%va &/&, S'lera %'$er%' (/(
T)T : *or+al
*e' : -y+. *oe o$ Elar#e
2VP : o$ %$ee
THRORAX
I : %$er'o$al re$ra'$%o a +ove+e$ y+e$r%'Pal: Vo'al re+%$" y+e$r%', %'$" 'or% : .al.ale
Per: oor, 'ar%a' elar#+e$ (
": a%' rea$ o" ve%'al, ro'% (/(, 9ee%# (/(; S1 a
S< %rre#"ler, #allo. (, +"r+"r (
ABDOMEN
= : la$
" : o9el o" & 5x/+%"$e
Pal : Pre"re .a% % e.%#a$r%"+&
Per : $y+.a%
Extremitas: .%$$%# oee+ (, 'ol a'ral, CRT >
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Subecti!e DataName 1 Mrs2 M3 4 years o(d
TC 1 5ednesday3 6,(y3 ##th#$*"" # $e!er
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Anamne%i%Main %ymptom 1 7ever
Additional %ymptom 1 Na,sea3 8omitin%
Patient "ame to U9I hospita( :ith 7ever sin"e
$ days ;efore "ame to hospita(2 Patients a(so
"omp(ain of na,sea and vomitin% sin"e * days2
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Past Medi"a( 0istory and Treatment
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7ami(y 0istory
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+o"ia( 0istory
+mo
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&becti!e Data
Appearan"e 1 Moderate I((ness
GC+ E/M48*
=P 1 $$>?$ mmh%3
RR1 @!> min,te3
T 1 )@3)C
P,(se 1 ?@!>min,te2 Eye1 Pa(e "onB,n"tiva > 3 s"(era i"te
Ear3 Nose3 throat 1 norma(
68P 1 norma(
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Thora!2
I : =$er'o$al re$ra'$%o a +ove+e$ y+e$r%'
Pal: Vo'al re+%$" y+e$r%', %'$" 'or% : .al.ale
Per: oor, 'ar%a' elar#+e$ (
": a%' rea$ o" ve%'al, ro'% (/(, 9ee%# (/(; S1 a S< %rre#"ler, #allo. (, +"
A;domen2
I 1 at
A,s 1 ;o:e( so,nd &' *!>min,te
Per 1timpani3 per",ssion tenderness &-'
Pa( 1 a;domina( tenderness &'3 (iver and sp(een en(ar%ement &-'
E!tremity
- Co(d
- Capi((ary re((in% time # se"ond
- Edema &-'
- T,r%or norma(
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"linical 'aboratory
##>$?>#$* #$1/*
0#TL
0; 1 F3? %>d( &Lo:'
Le,"osite 1 /2#$$>,L &0i%h'
0emato"rite 1 #@3/ &Lo:'
Trom;osite 1 *)2$$$>,L
GD+ 1 F* m%>d(
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Na 1 )/ mmo(>L
9 1 F3* mmo(>L
C( 1 $# mmo(>L
+2Thypose 0 1 >)#$
+2 Thypose o 1 > 4$
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A%%e%%ment
Thypoid fe!er, anemia,
dy%pep%ia
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Therapy
Levoo!a"in # ! #$$ m% &iv'
Para"etamo( )! *$$m%
+,"ra(fat )!"
Omepra.o(e !/$m%
0emafort )!
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(lannin) Pro )o.%$al%e
=VFD : == "$rol%$/
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Than* +ou
Department of Internal
MedicineChristian University of Indonesia
