Department of Internal Medicine Christian University of Indonesia

MORNING REPORT
December 8th 2013

Mrs.S(24 YO)

Findings
CC : Shortness of breathe
Cough, night sweating, hemaptoe

Assessment
Susp TB

Therapy
Pro Hospitelize IVFD : II RL /24Hour Diet :normal Mm/ Levofloxacin 1x500mg (iv) Vit K 3x1 (iv) Omeprazole 2x40mg Flumucyl 3x200mg Obh Syr 3x1C As Traknesamat 2x1

Planning
Complete perifer blood per day Sputum FAB day IIII Consultation to Dr Yohanes Sp.P

Appearance: moderate illness, GCS : E4V5M6, BP: 110/70 mmHg, PR : 78 x/min (adequate,regullar) RR : 53 x/min, T: 37 C Eye : conjuntiva anemis -/-, Sklera icteric -/Ear, Nose, Throat: normal Neck : lymph nodes did not enlarged, venous distention THORAX Insp : symmetric, ictus cordis (-) Pal : vf right >left Per : right<left, sonor sound RHB ICS V lin. sternal dext, LHB ICS V lin. Midclavicula sin Aus : bronchial rh +/+,wh -/S1 single, S2 single, regular, murmur (-) gallop (-) ABDOMINAL Ins : stomach looks flat Ausc : bowel sounds + 4x/m, Palp : Pressure Pain (-) Undulation(-) Per : timpany, shifting dulness (-), Extremitas : warm acral, CR<2, edema
LAB FINDING: Complete Perifer Blood : Hb : 12,2 gr/dl Leu : 20.900/ul ; Ht :36,7% Tro : 497000/ul gds:130mg/dl

Inhalation with Fentolin+pulmicort in ER

Subjective Data
Name Address CM TC CC : Mrs S : : 31.20.02.00 : Sunday/6th april 2014 : dypsneu

Anamnesis
Main symptom Additional symptom : dypsneu : Cough, hemaptoe, Night sweating
24 years old female patient came to hospital with complaint dyspneu since three day before admission. The complaint perceived continously and increasingly severe. The complain started with coughing first. Before that, patient already came to clinic and received some medicine, she ate it but the complaint wasnt decreased yet. The other complaints she had were productive cough, hemamptoe and night sweating. Patient has no history of hypertension, but no history ofdiabetes mellitus, and heart disease. The patient denied any complaints on the urination and defecation. The patient denied history of allergy.

Past Medical History and Treatment (denied)

Family History
(denied)

Social History
Smoking (-) , Alcohol (-), Drug induced (-), Tatoo (-), Free sex (-), Sport (-)

Objective Data
LOC Appearance BP PR RR Temp EYE THORAX Heart
Ins Pal Per Ausc

: E4V5M6 ; Composmentis : moderate ill : 100/70 mmHg : 78 x/min (adequate,regular) : 53x/min : 370C : anemic conjungtiva -/- ; ict -/:
: IC not visible : IC palpable : RHB ICS V lin. sternal dext, LHB ICS V lin. Midclavicula sin : S1 single, S2 single, regular, murmur (-) gallop (-)

Objective Data
PULMO Insp Pal Perc Ausc ABDOMEN Insp Ausc Pal Perc : Static and dynamic symmetric : VF right >left symmetric : Sonor right < left : BBS Vesicular, Rhonci +/+, Wheezing -/-

: Stomach looks flat : Bowel sound (+) 4 x/min : Pressure Pain (-) in epigastrium : Timpany; Percussion Pain (-) in epigastrium
EXTREMITIES Edema (-); warm (+); capp. Refill <2 seconds

Clinical Laboratory
Hb : 12,2 gr/dl Leu : 20.900/ul Ht :36,7% Tro : 497000/ul gds:130mg/dl

Assessment

Susp.TB

Therapy
Pro Hospitalized IVFD : II RL / 24 hours Diet : Normal Mm/ Levofloxacin 1x500mg (iv) Vit K 3x1 (iv) Omeprazole 2x40mg Flumucyl 3x200mg Obh Syr 3x1C As Traknesamat 2x1 Inhalation with Fentolin+pulmicort in ER

Planning
Complete perifer blood per day Sputum FAB day I-III

Department of Internal Medicine Christian University of Indonesia

Thank You