Department of Internal Medicine

Christian University of Indonesia

MORNING REPORT
June, 19th 2014

TC
Findings
Fever
Weakness
Dizzy
Myalgia
LOC : E4M6V5, compos mentis
BP : 160/100 mmHg
PR : 94 x/minute, adequate, regular
RR : 26 x/minute
Temp : 36,50 C
Eye : Pale Conjungtiva -/-, SI -/Coated tounge (-)
Thoraks :
Ins : movement of chest wall symmetric
right = left, retraction (-)
Pal : vf symmetric, right=left
Per : sonor in all lung field
Aus : Basic breath sounds vesicular , Rh (-/-), Wh
(+/+) ; Heart sound 1 & Heart sound 2 reguler ,
murmur (-),gallop (-)
Abdoment :
Ins : stomach looks flat
Pal : Impalpable,pressure pain (-) epigastrium,
umbillicus, and suprapubic
Per : Tympany, percussion pain (-)
Aus: Bowel sound 4 times/minute
Extremity : cold (-), cappilary refill <2 , edema ()
Skin : Turgor elastic

Assessment
Asthma bronkiale

: Thursday /19 June 2014

Therapy
Medikamentosa :
Ceftriaxone 1x2g,
Dexamethasone 2x1,
Nebulizer (Ventolin +Fumicort),
Amlodipine 1x 10mg,
Salbutamol 3x1

Planning
-Pro hospitalized
Diet less sodium
IVFD: I RL + Aminofilin
/ 24 hours, I RL

LAB FINDING:
Hematology
Hb : 14,5 g/dl
Leu : 5,4 rb/uL
Ht : 42,8 %
Tro : 148.520 uL

11/9/2014

Subjective Data
Name: Tn. S, 66 YO
Address: Jakarta
TC: Thursday /19 June 2014/18:35

CC: Dyspneu

Anamnesis

Autoanamnesis
on the date 19 June 2014, Time
18.35 WIB

Main Complaint

Dyspneu since 3 days ago

Additional Complaints

Vomiting (+), productive cough

Anamnesis
Patient admitted to UKI Hospital with a complain of a
dyspneu that has been felt for 3 days. Dyspneu perceived
continously especially at night.Patient had another complain
such as productive cough since 1 week ago. Patient had
been medication in Puskesmas and he was given some
medicine but it wasnt help. Patient have some history of
sick such as hypertension but uncontrolled and asthma.

Family History
(-)

11/9/2014

Objective Data
Appearance :
moderate
illness
HR : 94x /minute
(adequate,
reguler)

LOC :
E4V5M6; CM

BP :
160/100mmH
g

RR : 26x
/minute

Temp :
36,5C

Objective Data
Head :Normocephali
Konjunctiva Anemis -/Sklera Ikterik -/Coated Tongue (-)

Thorax
Inspeksi

Front
back

Palpasi

Front

Auskultasi

Static and dynamic symmetric Static and dynamic symmetric

VF symmetric

VF symmetric

VF symmetric

VF symmetric

Front

Sonor

Sonor

Back

Sonor

Sonor

Front

BBS Vesicular, Rhonci -/-, BBS Vesicular, Rhonci -/-,

Back
Perkusi

Left
Right
Static and dynamic symmetric Static and dynamic symmetric

Wheezing +/+

Front

BJ I reguler and BJ II regular,

murmur (-), Gallop (-)

Wheezing +/+

Abdomen
Inspeksi:
stomach looks
flat

Perkusi:
Hipertympani;
Percussion
Pain (-)

Palpasi:
LiverSpleen
impalpable ;
ball -/-;
Pressure Pain
(-)
Auskultasi:

Bowel sound
(+)
4x/minute

Lower Extremities
Right

Left

Akral

Warm

Warm

Edema

Upper Extremities
Right

Left

Akral

Warm

Warm

Edema

13

LABORATORIUM
HEMATOLOGI

19/06/2014

HASIL

NILAI RUJUKAN

Hemoglobin

14,5 g/dl

14-16 g/dL

Leukosit

5400/UL

5-10 ribu/UL

Hematokrit

42,8 %

40-48 %

Trombosit

148.520/uL

150-400 ribu/uL

Assessment
Asthma Bronkiale

15

Therapy
Ceftriaxone 1x2g,
Dexamethasone 2x1,
Nebulizer (Ventolin +Fumicort),
Amlodipine 1x 10mg,
Salbutamol 3x1

16

Planning
Pro hospitalized
Diet less sodium
IVFD: I RL + Aminofilin / 24 hours, I RL)

17

18

THANK YOU