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Morning Report

September 16 , 2017
th

Dept. of internal medicine


H27
List Interna Medicine New Patients
1. Tn M : Lungs TB + Chronic Hepatitis B + Cirrhosis
hepatis + Ascites Arofah 4
2. Tn A : Lungs TB + Pleural effusion RJ
3. Ny T: DM type 2+HT essential + Pneumonia + OF
Zamzam
4. Tn MA : HT + colic abdomen RJ
5. Sdr A: Myalgia RJ
6. Tn D : Dyspepsia RJ
Identity
Name : Mrs. MT
Age : 37 years old
Address : Dengok, Paciran
Admission: September 16th, 2017 at 17.50
Chief Complaint

Fever
Present history

The patient complained fever since 15 days before


admission. He felt fever countinously, getting worse
when afternoon until evening. Fever accompanied with
productive cough, but its hard to spit out the sputum
and cold. He felt it when walk less than 3 m and felt
better when take a rest.
Past history of Illness

HT -, Controlled DM+ with glimepirid since 2 years a go, Pleural


Effusion since 2 years ago anf thoracosintesis in RS Sutomo 3 times. ,
Cirrhosis Hepatis, Chronis hep B
Didnt have history of allergy before

Family history

Family history:-
Social history

No social history related


Vital Signs
BP
120/82mmHg
Pulse
122x/min, strong, reguler
Temp
37,50 C
RR
48 x/min
A: clear, gargling (-), snoring (-), speak fluently (+),
potential obstruction (-)
B: spontan, RR 48x/min, ves / ves, rh +/+ basal wh -/+
expiratory, SaO2 77% without O2 support
C: extremity WDR, CRT <2, N 122x/min, BP
1120/81mmHg
D: GCS 456, lat -, PBI 3mm/ 3mm, LP +/+
E: temp 37,5 C
GENERAL STATUS
General condition : weak
Awareness : compos mentis
GCS : 325
H/N : a -/i+/c-/d+
lymph node enlargement at neck (-)
JVP within normal limit
Thorax
Inspection
Symmetrical, retraction + subcostal
Palpation
Thrill (-), fremitus WNL
Percussion
Lungs: sonor / sonor
Cor: N
Auscultation
Lungs: ves /ves, rh +/+, wh -/+ expiratory
Cor: S1S2 single, M -, gallop -
Abdomen
Inspection
Flat, Plak eritematous +, vena colateral +
Auscultation
Meteorismus -, bowel sound WNL
Palpation
Liver WNL, spleen WNL
Percussion
dulness
Extremities
Inspection
Anemis -, icteric (-), cyanosis (-), eritema palmaris +
Palpation
Warm and dry, CRT <2
CLUE AND CUE
Male. 37 y.o
Fever
Cough
Dyspnea +, subcostal retraction
Rales +
Wheezing +
Vena colateral +
Dulness
Planning Diagnosis
DL
ECG
Thorax photo
Assesment

SH
Chronic hep B
Laboratory Findings
GDA 73 Eritrosit 4,6(3,8-5,3)
Kalium serum 3,8 (3,6-5,5) Hb 12,5 (P 13-18 L 14-18)
Natrium serum 142,9 (135-155) Hct 39,8 (L 40-54 P 35-47)

Clorida serum 117,3 ( 70-108) MCV 86.50 (87.00-100)

Urea 30 (10-50) MCH 27.20 (28.00-36.00)


MCHC 31.80(31.00-37.00)
Serum creatinin 0.7(P 0,7-1,2 L 0,8-1,5)
RDW 11 (10-16,5)
SGOT 171( L 37, P 31)
Trombosit 197(150-450)
SGPT 91 (L 41, P 31)
MPV 5(5-10)
Leukosit 7.8 (4-11)
LED 1 : 87 (0-1)
Neutropil 68,9(49-67)
LED 2 : 100(1-7)
Limfosit 16.4(25-33)
Monosit 12 (3-7)
Metode I Non reaktif
Eosinophil 2,3(1-2)
Basofil 0.4(0-1)
Re-Assesment

Lungs TB
Cirrhosis Hepatis
Chronis hep B
Planning Therapy
O2 mask 10 lpm
Nebul velotin + bisolvon 10 drops 3x1
Inf. PZ 500cc/24h
Inj ceftriaxone 2x1gr
Inj Na Metamizole 3x1 prn
Inj Pantoprazole 2x1
Consul with internist
PLANNING MONITORING
Vital Signs
Patients complaint
Adverse effect
PLANNING EDUCATION
Explain to the patient and his family about the disease, cause,
complication, intervention of the therapy and prognosis.

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