CONTOH MORNING REPORT mr. yafet.pptx
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Transcript of CONTOH MORNING REPORT mr. yafet.pptx
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CASE REPORT
Department of Internal Medicine
Christian University of Indonesia
October 25th 2013
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Findings Assessmen
t
Therapy Planning
- Fever
- Nausea
- Constipation
- History travel from Jayapura 1 month before admit
to hospital
Appearance: moderate illness, GCS : E4V5M6, BP:110/60 mmHg, PR : 82 x/min (adequate, regular) RR :
20 x/min, T: 37,7° C
Eye : pale conjunctiva -/- sclera icteric -/-,
THT : normal
Neck : lymph nodes not enlarged
THORAX PulmoInsp : symmetric
Pal : vf symmetric
Per : symmetric, sonor sound
Aus : vesicular, wheezing -/-, ronkhi -/-
Heart Sound S1 S2 N, murmur – gallop -
Abdominal
Insp : flat
Ausc : bowel sounds + 2x/m
Per : Tympani, shifting dullness -
Palp : Pressure Pain -, hepar and lien not palpable
Extremitas : warm acral, CR<2”, edema
LAB FINDING :
Hemoglobin : 12,7 g/dLHematocrit : 39 %
Leucocyte : 11.000 /uL
Thyfoid fever
DD/ Malaria
Pro Hospitalized
Diet : soft meal
IVFD : I RL/24
hours
Mm/Levofloxacin 1 x
500 mg
Omeprazole 2 x
20 mg
Domperridon 3 x
10 mgParacetamol 3 x
500 mg
Px/
-Parasitology
Lab for
Malaria
Mr. Y, 33 y.o.
East Jakarta
CC : fever since 1 week before admit to hospital
Saturday, 26th October 2013 , 05:03
-- --
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Subjective Data
Name : Mr. Y
Address : East Jakarta
TC : Friday, 26 oct 2013/ 05.03
CC : fever
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AnamnesisMain symptom : fever
Additional symptom : constipation, nausea
33 y/o male patient came with chief complaints of fever since one week
before admission to hospital. Fever intermitten but more severe at night. Patient has
been consume paracetamol but not getting better. Patient felt nausea but novomitting. Patient compaint that no defecation for 4 days before go to hospital.
Patient has a history travel from Jayapura 1 month before admit to Hospital. Patient
has a roommate that have a same fever and sign like him.
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Past Medical History and Treatment
-
Family History
-
Social HistorySmoking (+) , Alcohol (+)
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Objective Data
LOC : E4V5M6 ; Composmentis
Appearance : moderate ill
BP : 110/60 mmHg
PR : 82 x/min (adequate,regular)
RR : 20 x/minTemp : 37,70C
EYE : hiperemic conjungtiva -/- ; icteric -/-
THORAX :
Heart
Ins : IC visible
Pal : IC palpable
Per : RHB ICS V line Parasternal dext, LHB ICS V lin. Midclavicula sin
Ausc : S1 single, S2 single, regular, murmur (-) gallop (-)
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PULMOInsp : Chest movement symmetric
Pal : VF right and left symmetric
Perc : Sonor symmetric
Ausc : Vesicular, wheezing -/-, ronkhi -/-
ABDOMEN
Insp : flat
Ausc : bowel sounds + 2x/m
Per : Tympani, shifting dullness -
Palp : Pressure Pain -, hepar and lien not palpable
Objective Data
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EXTREMITIEEdema (-); warm acral,crt <
2’’
Objective Data
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Assessment
Thyfoid fever
DD/ Malaria
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Therapy
Pro HospitalizedDiet : soft meal
IVFD : I RL/24 hours
Mm/Levofloxacin 1 x 500 mg
Omeprazole 2 x 20 mg
Domperridon 3 x 10 mg
Paracetamol 3 x 500 mg
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Planning
- Parasitology Lab for Malaria
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Thank You
Department of Internal Medicine
Christian University of Indonesia
October, 26th 2013