Department of Internal

Medicine
Christian University of Indonesia

MORNING REPORT
July 19th 2015
TEAM 2

Mr. FT , 69 YO
CC : Diarrhea
Findings
Diarrhea, vomiting, weakly, cold sweating,
GCS: E4V5M6, TD: 160/90, PR : 80x, T : 36,4oC, RR: 28x
Eye : Pale Conjungtiva +/+, Sclera icteric -/THT : Normal
Neck : Lymph Nodes not Enlarged
JVP : 5-2cmH2O
THRORAX

: intercostal movement simetric

Pal: Vocal fremitus simetric
Per: right lung-dall , left lung-dall
Aus: Basic breath sound vesicular , ronchi -/-, wheezing -/-. S1
and S2 reguler, gallop (-), murmur (-)
ABDOMEN
Ins : flat
Aus : Bowel sound (+) 4x/minute
Pal : Pressure pain (-) hepar and lien normal
Per : tympani
Extremitas : pitting oedem ekstremitas (-), cold warm, CRT <
2, turgor decrease.

Assesment
-GEA with
mild
dehidration
-Hiponatrem
ia
-Hipocalemi
a
-Hipertensi

Therapy
MM/
Ciprofloxacine 2x200mg (iv) ST
OMZ 1x40mg (PO)
Domperidone 3x10mg (PO)
KSR 3x1tab
Amlodipine 1x5mg (morning-PO)

Planning
Pro Hospitalized
Diet : soft, low salt
IVFD 2 Line : I NS 3% / 24h
II RL / 24h
Px: SGOT/SGPT, DPL, Ur, Cr,
Electrolite.

Subjective Data
Name
: Mr.FT, 69 years old
CM
:
TC
: Sunday, July 19th 2015
CC
: Diarrhea

Anamnesis
Main symptom
: Shortness of breath
Additional symptom : Patient came to UKI hospital with complain
shortness of breath since 1 day ago.
Shortness of breath is felt constantly.
complain increase when patient lie down, to
decreasing the complain, patien sit. The
patient havent treat the pain. History of
trauma (-) Nausea (+), vomitting (-), stomach
ache (-), decrease in weight (-), cough (+)
since 1 week ago.

Past Medical History and Treatment

Post Masektomi, CA Mamae, CHF

Family History

(-)
Social History
Smoking (-)

Objective Data

Appearance : Moderate Illness

GCS E4M6V5
BP : 100/90 mmhg,
RR: 31x/ minute,
T : 37,5C
Pulse : 100 x/minute.
Eye: Pale conjunctiva -/- , sclera icteric -/Ear, Nose, throat : normal
JVP : vein undistended

THRORAX
I : intercostal movement simetric
Pal: Vocal fremitus simetric
Per: right lung-dall , left lung-dall
Aus: Basic breath sound vesicular , ronchi -/-, wheezing -/-. S1 and S2 reguler,
gallop (-), murmur (-)
ABDOMEN
Ins : flat
Aus : Bowel sound (+) 4x/minute
Pal : Pressure pain (-) hepar and lien normal
Per : tympani
Extremitas : pitting oedem ekstremitas (+), cold warm, CRT < 2, turgor normal

Clinical Laboratory

Hematologi
Hemoglobin : 9,5 gr/dl
Leukosit : 9,2rb/ul
Hematokrit : 29,1 %
Trombosit : 563 rb/ul
Ureum : 67 mg/dl
GDS : 118 mg/dl

ekg

Assessment
- Efusi pleura
- Post masektomi (Ca Mamae)
- CHF
- Anemia

Therapy
MM/
Furosemid 3x1ampul (iv)
Aspilet 1x80mg (PO)
Sulfas ferous 3x1 tab
Laxadine 1x15cc (PO)
ISDN 3x5mg (PO)

Planning
Pro Hospitalized
Diet : soft
Inject plug
Px: Lab. Interna Sederhana

Department of Internal
Medicine
Christian University of Indonesia

Thank You