MORNING REPORT

JUNE 16, 2017

DEPT OF INTERNAL MEDICINE
G26
1. Tn. Supari/ MR + ALO + HF + Herpes zooster /
marwah 17
2. Ny. Ummi/ ISK + Nausea + Vomit/ Marwah 14
3. Ny. Sumira/melena / marwah 18
 IDENTITY

Name : Ny. U
Age : 48 years old
Occupation :-
Address : Solokuro, Lamongan
Admission : juni 16 2017 at 21.40 PM
 Chief Complaint

epigastric pain

Present history

Patient come to RSML with epigastric pain. Epigastric pain

since 1week ago. Patient feel fever continously. Patient also
feel of upper abdominal pain not radiating to the back.
headache + Nausea + and vomiting +. Defecation is within
normal limits . Urination is wiyhin lower limits and anyang-
anyangan . Decreased appetite since 1 week. Dyspneu (-)
 Past history of Illness

HT -
DM -
Gasrtitis
Leukhorrhea (since 2 months) +, fishy odor, many, itching

Family history

No familial related
 Social history

Cigarrete (-)
Coffe (-)
Alcohol (-)
 VITAL SIGNS

Pulse
109x/min
BP
106/65mmHg
Temp
37.8 C
RR
20x/min
 A: clear, gargling (-), snoring (-), speak fluently (+),
potential obstruction (-)
B: spontan, RR 20x/min, ves / ves, rh -/-, wh -/-, Sa
O2 100 % without O2 support
C: extremity WDR, CRT <2, N 109x/min, TD 106/65
mmHg
D: GCS 456, lat -, PBI 3mm/ 3mm, LP +/+
E: temp 37.8 C
GENERAL STATUS
 General condition : weak
Awareness : compos mentis
GCS : 456
H/N : a +/i-/c-/d-
 THORAX
Inspection
Symmetrical, retraction -
Palpation
Fremitus WNL, thrill (-)
Percussion
Lungs: sonor +/+
Cor: N
Auscultation
Lungs: ves /ves, rh -/-, wh -/-
Cor: S1 S2 single, mur -, gall-
 ABDOMEN
Inspection
Flat, collaterral veins (-), inflammation signs (-)
Auscultation
Met -, gut noise WNL
Palpation
soefl
Epigastric pain (+)
Liver/Spleen is unpalpable
Percussion
tymphany
 EXTREMITIES
Inspection
Clubbing fingers (-), icteric (-), cyanosis (-)
Palpation
Warm and dry, CRT <2
 CLUE AND CUE

Female 48 years old

Epigastric pain
Polikisuria
Fever
 PLANNING DIAGNOSE

CBC
LFT
Antibiotic sesitivity test
 LAB. EXAMINATION

Eritrosit 4.99 (3.80 5.30) Trombosit 266 (150-450)

Hemoglobin 1142 ( 14-18) GDA 110\
Hematokrit 35.3 (40.0-54) Urea 32
MCH 22.8 (28.00-36.00) Serum creatinin 1.4
MCHC 3.30 (31.00-37.00) SGOT 22
MCV 70.70 (87.00-100.00) SGPT 20
LED 1 91(0-1)
LED 2 105(1-5)
Limfosit 2.7 (25-33)
Monosit 3 (3.0-7.0)
Neutrofil 91.2(49.0-67.00)
Basofil 2.3 (0-1)
Eosinofil 2,9
Leukosit 18.8 ( 4.0-11.0)
 ASSESMENT

UTI
Septic shock
Nausea-vomit
 PLANNING THERAPY

Nasal O2 3-4 lpm

DK
Inf PZ loading 500cc maintenance 1500CC/24jam
Inj. Antrain 3x1gr iv pm
Inj. Ranitidin 2x50mg iv
Inj. Ceteron 2x1mg iv prn
Inj. Ceftriaxone 2x1 gr iv
 PLANNING MONITORING

Vital Signs
Patients complaint
Lab: Hb, trombosit
 PLANNING EDUCATION

Explain to the patien and his family about the

disease, cause, stadium of the disease,
complication, intervention of the therapy and
prognosis.