Morpot Interna
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Transcript of Morpot Interna
MORNING REPORT
Department of Internal MedicineChristian University of Indonesia
Mei, 28th 2013
2
Findings Assessment Therapy Planning
- Epigastric Pain- Nausea- Vomiting
BP : 120/80 mmhgPR : 78x/minute, adequate, regularRR : 20x/minuteTemp : 36°c
LAB FINDING From UKI:Hemoglobin : 14,1 g/dl (12 – 14)Leukosit : 8,7 ribu/ul (5 – 10)Trombosit : 224 ribu/ul (150 – 400)Hematokrit : 42,0 % (37 – 43)
USG Findings :Resume : CholelithiasisHepatomegali non spesific.Splen and renal normal
Susp cholelithiasis
Diit : lunak tidak merangsangIVFD : Ranitidine 2x50 mg I RL+ 2 tramadol/24jamMM/: ceftriaxone 1x2grRanitidine 2x1ampAntasid 3x2 cth
Lab : SGPT SGOTBilirubin total I and II
Ms,Siti Aisyah 31YOcipayung kp. Melayu
TC : Saturday /08 June 2013/23.16CM : 73-59-04-00
3
Subjective DataName : Mrs. Sitanggang Chandra Feri , 27 YO
Address : Raya Cendar no8 RT09/05
CM : 47-56-04-00
TC : Tuesday/28 may 2013/23:32
CC : Fever
Anamnesis
Main Complaint
• Fever since 7 days ago
Additional Complaints
Nausea, Vomiting and Headache
Autoanamnesis dan Alloanamnesis on the date 28 May 2013, Time
23.32 WIB
5
Anamnesis
Patient admitted to UKI Hospital with a complain of a fever that has been felt for seven days, the fever is fluctuative, the highest temperatur that the patient felt was 41°C, patient told that the fever mostly occur at night time. Before the complain occur, patient recently traveled to the island of Borneo. Other than that, Patient also complain of nausea, vomitting and also low appetite. A day before admitted at RS UKI, patient was admitted at RSIA Restu Kasih and was diagnosed malaria, but from microscopic examination, there has not been found any paracyte.
04/17/23
Past Medical History and Treatment
Hypertension (-)History of Diabetes Melitus (-)Operative History (-)History of trauma (-)
Family History(-)
Social HistorySmoking (+) , Alcohol (-)
Objective DataAppearance : moderate
illness
LOC : E4V5M6;
CM
BP : 120/70mm
Hg
HR : 80x /menit
(adequate, reguler)
RR : 24x /menit
Temp : 37,7°C
Objective Data Head :Normocephali
Konjunctiva anemic -/-
Sklera Ikterik -/-
ThoraxPulmonal Left Right
Inspeksi FrontStatic and dynamic symmetric Static and dynamic symmetric
backStatic and dynamic symmetric Static and dynamic symmetric
Palpasi Front VF symmetricVF symmetric
BackVF symmetric VF symmetric
Perkusi Front Sonor Sonor
Back Sonor Sonor
Auskultasi Front BBS Vesicular, Rhonci -/-,
Wheezing -/-
BBS Vesicular, Rhonci -/-,
Wheezing -/-
Back BBS Vesicular, Rhonci -/-,
Wheezing -/-
BBS Vesicular, Rhonci -/,
Wheezing -/-
Inspection Looks iktus cardiac pulsation in ICS VI
Palpation Iktus cardiac pulsation palpable 1 finger left anterior linea axillaris anterior in IC 6
Percussion
Right limit ICS 4 linea right sternal
Left limit ICS 6, 2 finger lateral linea left midclavicularis
Auscultation BJ I reguler and BJ II regular, murmur (-), Gallop (-)
Abdomen
Inspeksi:
stomach looks flat
Palpasi:
Liver–Spleen impalpable ; ball -/-;Pressure Pain -
Perkusi:
Tympani; Percussion Pain -
Auskultasi:
Bowel sound (+)
Lower Extremities
Kanan Kiri
Muscle
Tonus Normotonus Normotonus
Massa Normal Normal
Joint in all directions in all directions
Move in all directions in all directions
Power +5 +5
Akral Warm Warm
Edema - -
13
Upper Extremities
Kanan Kiri
Muscle
Tonus Normotonus Normotonus
Massa Normal Normal
Joint in all directions in all directions
Move in all directions in all directions
Power +5 +5
Akral Warm Warm
Edema - -
LABORATORIUM
HEMATOLOGI HASIL NILAI RUJUKAN
Malaria antigen + Negatif
Widal
Salmonela typhi OSalmonela Paratyphi OASalmonela Paratyphi OBSalmonela Paratyphi OCSalmonela Thypi HSalmonela Parathypi HASalmonela Paratyphi HBSalmonela Paratyphi HC
+ 1/80+ 1/80+ 1/80
-+ 1/80
-+ 1/80
-
NegatifNegatifNegatifNegatifNegatifNegatifNegatifNegatif
RSIA 28/5/2013
LABORATORIUM
HEMATOLOGI HASIL NILAI RUJUKAN
Hemoglobin 12,6 g/dl 12-14 g/dL
Leukosit 16,3 ribu/UL 5-10 ribu/UL
Hematokrit 35,6 % 40-48 %
Trombosit 95 ribu/uL 150-400 ribu/uL
CLINICAL CHEMISTRY HASIL NILAI RUJUKAN
Ureum 24 H 15-45 mg/dl
Creatinin 0,97 H 0.70-1.10 mg/dl
28/5/2013
16
Assessment
• Suspect Malaria DD DHF
17
TherapyIVFD : RL 30 drop/mntMM/ :Sanmol 3x500gOndancentron 4mg injection 2x1 ampOmeperazole drip 2x1Diet : Pure
18
Planning•Pro Hospitalized•bed rest•H2TL/ 12 jam•Malaria Blood: Blood for examination taken when fever occured
19
Department of Internal MedicineChristian University of Indonesia
Juni, 03th 2013