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MORNING REPORT

Department of Internal Medicine

Christian University of Indonesia

October 23rd2014

TEAM 2

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Findings Assessment Therapy

Appearance: mild illness, GCS : E4V5M6, BP: 160/90 mmHg, PR : 88x/min (adequate, regular) RR : 28 x/min, T: 36,5C

Eye : conjunctiva not pale, Sclera icteric -/-

Ear, Nose, Throat: normalNeck : lymph nodes did not enlarged, venous distention

THORAXInsp : symmetric, ictus cordis (-)

Pal : vf symmetric, ictus cordis palpable

Per : symmetric, sonor sound

RHB ICS V lin. sternal dext, LHB ICS V lin.

Midclavicula sin

Aus : vesicular rh -/-,wh-/-

S1 single, S2 single, murmur (-), gallop (-)

ABDOMINAL

Ins : stomach looks flatAusc : bowel sounds + 4x

Palp : Pressure Pain - - -

Undulation(-),Per : timpany, pain in percussion (-), - -Extremitas : warm acral, CR

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Subjective DataName : Mrs. D

Address : Kramat JatiTC : Thursday/23rdOctober 2014

CC : Feeling hot all over the body

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Anamnesis

Main symptom : Feeling hot all over the body

Additional symptom : Decreasing appetite, nauseous, stomachache

Patient came because she was feeling hot all over her body for the pa

days. The complaint felt over and over again and she already took medicine to

the complaint but it didnt work. Patient couldnt remember why she

complaint on the first place. Because of that, she also felt nauseous after eati

made her eat less than usual. She also feeling stomached. Complaint of fe

denied, complaint of vomit was denied too. Patient said that the complaint ha

her unable to do her everyday activities properly.

History of hypertension was denied. History of high blood sugar was d

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Past Medical History and Treatment

(denied)

Family History

(denied)

Social HistorySmoking (-), Alcohol (-), Drug induced (-),

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Objective Data

LOC : E4V5M6 ; Compos mentis

Appearance : mild illBP : 160/90 mmHg

PR : 88 x/min (adequate, regular)

RR : 28 x/min

Temp : 36,50C

HEAD & EYE : pale conjungtiva -/- ; ict -/-

THORAX :Heart

Ins : IC invisible

Pal : IC palpable

Per : RHB ICS V lin. sternal dext, LHB ICS V lin. Midclavicula

Ausc : S1 single, S2 single, regular, murmur (-) gallop (-)

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PULMO

Insp : Static and dynamic symmetric

Pal : VF right and left symmetric

Perc : Sonor symmetric

Ausc : BBS vesicular, Rhonki -/-, Wheezing -/-

ABDOMEN

Insp : Stomach looks flat

Ausc : Bowel sound (+)

Pal : undulation (-), pressure pain (-)

Perc : timpany, pain in percussion (-)

EXTREMITIES

Edema (-); warm (+); capp. Refill

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Assessment

Dyspepsia

Oral intake difficult

Hypertension grade II

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Therapy

IVFD: II Futrolit/24 hours

Diet: smooth do not stimulateMm:

Omeprazole 1x40 mg IV

Sucralfat 3x1

Ondacentron 2x2 mg IV

Alprazolam 1x0,5 mg POAmlodipin 1x5 mg PO

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Planning

- Complete perifer blood- GDS

- ECG

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Thank You

Department of Internal Medicine

Christian University of Indonesia