Department of Internal Medicine

Christian University of Indonesia

MORNING REPORT

February, 13th 2016

TEAM 2
Mr. M. 42 YO
CC : right flank pain

Findings Assesment Therapy Planning

Right flank pain and fever since 1 week ago, fever up and down, Tractus MM/ Diet : lunak tidak merangsang
epigastrium pain, nausea +, vomiting + 1x, urinarius 1. Levofloxacin 1x IVFD : I RL+ I Futrolit / 24
GCS :E4V5M6, BP: 110/70, PR 88 x, T : 37,4 oC, RR: 25x infection 500mg (iv) hours.
Eye : Pale Conjungtiva -/-, Sclera icteric -/-
2. Paracetamol 3x500mg
THT : Normal
3. OMZ 1x40mg (iv)
Neck : Lymph Nodes not Enlarged
4. Ondancentron 3x10mg
JVP : distended (-), 5-2 cmH2O
5. Sucralfat 3x1C
THORAX
I : Symmetrical chest wall movement, ictus cordis (-).
Pal: Vocal fremitus simetric
Per: Sonor /Sonor
Aus: Basic breath sound vesical, ronchi -/-, wheezing -/-. S1 and S2 reguler,
gallop (-), murmur (-)
ABDOMEN
Ins : Flat
Aus : Bowel sound (+) 4 times/minute
Per : Timpani on 9 regions, percussion tenderness (+) epigastrium
Pal : Supel, Pressure pain (+) epigastrium
Extremity : pitting oedem (-), warm acral, CRT < 2
 Subjective Data
Name : Mr. M, 42 years old
TC : Saturday , february 13th 2016
CC : Right flank pain
 Anamnesis
Main symptom : Shortness of breath
Additional symptom :
Patient was came with headache since 5 days
before admittance to hospital. Patients complain
of headache suddenly. Nausea (+), vomiting (-),
urinate has normal, Not defecate since 5 days
ago. cough (-), fever ( -).
Past Medical History and Treatment
-
Family History
-

Social History
-
 Objective Data
Appearance : Mild Illness
GCS :E4V5M6
BP: 150/80
PR 78 x
T : 36,5oC
RR: 32x
Eye: Pale conjunctiva -/- , sclera icteric -/-
Ear, Nose, throat : normal
Neck : lymph nodes not enlarged
JVP : distended (-), 5-2 cmH2O
 Thorax.
I : Symmetrical chest wall movement, ictus cordis (-) , retraction intercosta.
Pal: Vocal fremitus asimetric
Per: Dal /Sonor
Aus: Basic breath sound vesical, ronchi +/+, wheezing -/-. S1 and S2 reguler, gallop (-), murmur (-)
Abdomen.
- Ins Ins : Flat
- Aus : Bowel sound (+) 3times/minute
- Per : Timpani on 9 regions, percussion tenderness (-)
- Pal : Supel, Pressure pain (-)
Extremity
- Pitting oedem (-), warm acral, CRT < 2
 Assessment
Efusion pleural et causa TB pulmonal
 Therapy
MM/
1.Ceftizoxime 2x1 gr (iv)
2.OBH 3x1 C (po)
3.Ranitidine 2x1 (iv)
4.B. Comp 2x1 (po)
 Planning
Pleural punction
Diet : high calories high protein
O2 NK 3-4 lpm
IVFD : I RL+ I Futrolit / 24 hours
Check BTA, LED, SGOT/SGPT, Ureum, Creatinin
Department of Internal Medicine
Christian University of Indonesia

Thank You