Morning Report

July 11 , 2016
th

Dept. of internal medicine

G24
DAFTAR OB INTERNA
 Tn. Joko Suwarno 44 th Abdominal Pain RJ
 Ny. Hindun 63 th Dispepsia RJ
 Ny. Kris Maeny 43 Dispepsia RJ
 Tn. Mujud 50 Hiccup Multazam 6
 Ny. Solfi 27 GEA Arofah 1
 Tn. Ujud Hemoptoe Arofah 3
Identity
 Name : Tn. M
 Age : 50 years old
 Occupation : Shopkeeper
 Address : Sedayulawas Lamongan
 Admission: July 11 th, 2016 at 16.23
 Chief Complaint

Hiccup
 Present history

Patient felt hiccup since 3 days before admission. Hiccup

intermittent, appear after drink medicine from dentist (ibuprofen,
amoxicillin). 1 day before admission, patient treated from internist
(dr. BEW) got Fluoxetin, glimepirid but complaint didn’t diminished.
 Past history of Illness

•DM +
•HT denied

 Family history

No familial related
 Social history

No social history related

Vital Signs
 BP
 143/93 mmHg
 Pulse
 97 x/min, strong, reguler
 Temp
 36 0 C
 RR
 20 x/min
 A: clear, gargling (-), snoring (-), speak fluently (+),
potential obstruction (-)
 B: spontan, RR 20x/min, ves (weak) / ves, rh -/-, wh -/-,
SaO2 97% without O2 support
 C: extremity WDR, CRT <2’, N 97x/min, BP 143/93
mmHg
 D: GCS 456, lat -, PBI 3mm/ 3mm, LP +/+
 E: temp 36 C
GENERAL STATUS
 General condition : weak
 Awareness : compos mentis
 GCS : 456
 H/N : a -/i-/c-/d-
lymph node enlargement at neck (-)
JVP within normal limit
 Thorax
 Inspection
 Symmetrical, retraction -
 Palpation
 Thrill (-), fremitus WNL
 Percussion
 Lungs: sonor / sonor
 Cor: N
 Auscultation
 Lungs: ves /ves, rh -/-, wh -/-
 Cor: S1S2 single, M -, gallop -
 Abdomen
 Inspection
 flat
 Auscultation
 Met -, bowel sound WNL
 Palpation
 Liver/Spleen within normal limit
 Percussion
 Tymphany
 Extremities
 Inspection
 Clubbing fingers (-), icteric (-), cyanosis (-), edema (-)
 Palpation
 Warm and dry, CRT <2’
CLUE AND CUE
 Male, 50 years old
 Hiccup
Planning Diagnose
DL
ECG
Assesment
 Hiccup
 Laboratory Findings

 GDA 396  Monosit 4.7

 Eritrosit 4.31  Neutropil 78.9
 Hb 12.4  Trombosit 340
 Limposit 26.2  Bilirubin direct 1.67
 Basofil 0.6  Bilirubin total 2.30
 Eosinopil 1.1  SGOT 21
 Hematokrit 40.3  SGPT 10
 Leukosit 7.2  Urea 31
 MCH 29.90
 Serum creatinin 0.7
 MCV 93.50
 MCHC 32.00
Re-Assesment
 Hiccup
 Hiperglycemia
 Planning Therapy

Inf. Loading 500 cc Asering  Maintenance 1500 cc/24 jam

Inj. Santagesic 1 gr prn
Inj. Acran 2x50 mg
Inj. Ceteron 8 mg prn
RCI 2x4 iu  check GDA every 1 hour  Maintenance 3x6 iu
P.O Chlorpromazine 25 mg 2x1
PLANNING MONITORING
 Vital Signs
 Patient’s complaint
 Adverse effect
PLANNING EDUCATION
 Explain to the patient and his family about the disease, cause,
complication, intervention of the therapy and prognosis.