MORNING REPORT

DECEMBER 5, 2017
DEPT OF INTERNAL MEDICINE
M28
OB LIST INTERNA
Nama Diagnosis Ruangan
Ny Tonajah SH Marwah 11
Tn Sapran TB paru Arofah 5
Tnabdul halim Sepsis Igd
Ny Sumarsi Asma Igd
IDENTITY
Name : Mrs T
Age : 59 years old
Address : Tunggulan Lamongan
Admission : Dec 4th, 2017 at 20.00 PM
 Abdominal pain

The abdominal pain was felt since 2 months before admitted

to emergency departement. patient complained that the pain
getting worse last 2 days, patient felt the pain in all region
of abdomen, continuously. The pain was accompanied by
enlargement of abdomen and also felt fullness. Patient also
complain that the skin colour was change yellow since a
month ago. Bloody defecate- Nausea – Vomit – Fever –
Dyspneu-
Past history of Illness

Treatment History :
Examined at RS Suyudi  ascites punction two times @ 200 cc
DM is denied
HT + controlled

Family history

Family history : no similar complain

Social history

This patient work as housewife

VITAL SIGNS
BP
 173/95 mmHg

Pulse
 80 x/min

Temp
 36,3º C

RR
 22 x/min
A: clear, gargling (-), snoring (-), speak fluently (+), potential obstruction (-)
B: spontan, RR 22x/min, ves / ves, rh -/-, wh -/-, SaO2 96% with no oxygen support
C: acral  warm, dry, pale, CRT <2, pulse 80 bpm, BP 173/95 mmHg
D: GCS 456, lateralization -, Pupil : round 3mm/ 3mm, Light perception +/+
E: temp 36,3C
GENERAL STATUS
General condition : weak
Awareness : compos mentis
GCS : 456
H/N : a +/i+/c-/d-
THORAX
Inspection
 Symmetrical, retraction -

Palpation
 Thrill (-), fremitus WNL

Percussion
 Lungs: sonor +/+
 Cor: N

Auscultation
 Lungs: ves /ves, rh -/-, wh -/-
 Cor: S1S2 single, M -, gallop -
ABDOMEN
Inspection
 Distended, colateral vein +, spider nervi -, skin mark +

Auscultation
 Met -, bowel sound WNL

Palpation
 Pain (+) all region
 Liver/Spleen hard to evaluated
 Undulation test+

Percussion
 shiffting dulness+
EXTREMITIES
Inspection
 Clubbing fingers (+), icteric (+), cyanosis (-), edema (-)

Palpation
 Warm and dry pale, CRT <2’
CLUE AND CUE
Female, 59 years old
Abdominal pain
Abdominal enlarged
Abdominal fullness
Anemia
Jaundice
Colateral vein+
Clubbing finger+
Shifting dullness+,
PLANNING DIAGNOSE

Chest radiography
Complete blood count
ASSESMENT
SH
anemia
LABORATORY FINDINGS
• Eritrosit. 3.62 (3.8-5.3) GDA 119
• Hb. 8.8 (13 – 18)
Albumin 4.0
• LED1. 52
• LED2. 72 SGOT 21 (0-35)
• Limposit. 6,6
SGPT 10 (0-35)
• Basofil. 1.5
• Eosinopil. 4.7 (1-2)
• Hematokrit. 27.7
• Leukosit 6.3
• Neutropil. 86.7
• MCHC 31.80
• MCH 24.30
• MCV 76.50
• Monosit 3.3
• MPV 6
• RDW 15
• Trombosit 192
RO THORAX
PLANNING THERAPY

Inf. PZ 500 cc / 24 hours

Inj. Na metamizol 3x1 gr i.v.
Inj. Ondancentron 3x 8mg

Consult Internist
PLANNING MONITORING
Vital Signs
Patient’s complaint