Morpot 9 sep,kel 5

8/18/2019 Morpot 9 sep,kel 5

1/14

MORNING REPORT

Department of Internal

MedicineChristian University of Indonesia

December 21h 2015


2/14

Findings Assesment Therapy

GCS: E4V5M6, TD: 120/80 mmHg, PR : 96 times/minute, T :

6,5!C, RR:

E"e : P#$e C!n%ungti '/', S($e)# i(te)i( */*RPD: (!nt)!$e+ -DDM, T.

THT : !)m#$

e( : "m !+es n!t En$#)ge+

3VP : vein not distended

THRORAX

I : T!)#s sinist)# #n+ +est)# simet)i(P#$: V!(#$ )emitus simet)i(

Pe): Rigt $ung's!n!) , $et $ung's!n!)

us: .#si( )e#t s!un+ &esi(u$e) , )!n(i '/', 7eeing '/'S1 #n+ S2 )egu$e), g#$$! ';, mu)mu) ';

ABDOMEN

-ns : $#t

us : .!7e$ s!un+ *; 89 Su()#$#t < 1C

10 +!me)i+!n < 10 mg

11R#niti+ine 2


3/14

Subjective DataNae ! Mr" Ohara #ian$unta%& ' year

od TC ! *ednesday& #epte+er ,th ./'


4/14

Anamnesis

Main symptom ! A)d(minal pain

Additional symptom ! -

The patient cae to IG0 R#U U1I *ith aincopaints of a+doina pain since days +eforeenterin2 the hospita" Pain is fet in a re2ionespeciay in the epi2astriu re2ion" 3ethar2y (4)&nausea (4)& voitin2 (4) tie ( yeo* i5uid ) &

constipation " 6+out 7 onth patient had pe2cou2h in 2reen coour&oss *ei2ht 8 %2& fever (-)&ni2ht s*eats& decreased appetite and hard to+reathe"

There is a /year history of NI00M *ith the dru22i+encaide ' 2 and in ..' patient su9er fro

T: and has +een cured"


5/14

Past Medica ;istory and Treatent

(Controed NI00M& T: )


6/14

Objective Data

• 6ppearance ! Moderate Iness

• GCS: E4V5M6, TD: 10/90, PR : 84


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• Th(rax

I : T!)#s sinist)# #n+ +est)# simet)i(P#$: V!(#$ )emitus simet)i(

Pe): Rigt $ung's!n!) , $et $ung's!n!)

us: .#si( )e#t s!un+ &esi(u$e) , )!n(i '/', 7eeing '/' S1 #n+ S2 )egu$e), g

• ABDOMEN

-ns : $#t

us : .!7e$ s!un+ *; 8


8/14

Cinica 3a+oratory

• *ednesday& #epte+er ,th ./'

;eatoo2i

– ;eo2o+in ! /&/ 2r>d (N ! /-/ 2r>d)

– 3eu%osit ! 7& r+>u (N ! '-/. r+>u)

– ;eato%rit ! /&/ ? (N ! .-@ ?)

– Tro+osit ! A r+>u (N ! /'.-.. r+>u)

– G0# ! /.. 2>d (N ! B..)

– Natriu ! /8 o>3 (N ! /78-/' o>3)

– Caiu ! & o>3 (N ! 7&' '&/ o>3)

– Corida !/.A o>3 (N ! ,, /// o>3)

EC


9/14

ECG

Th


10/14

ThoraDIa2in2


11/14

Assessment

nte)i!) STEM-, #(ute g#st)itis, T. !n te)#", -DDM"!n#t)emi#, "!(#$emi#


12/14

herapyMM>!

1TG +)i 5 mi()!/%#m

2si$et 1 < 80 mg

C$!i+!g)e$ 1 < ?5 mg

4.is!)!$!$ 1 < 2,5 mg

5 $!&en!< 2 < 0,6

6Simst#tin 1 < 20 mg

?C#n+es#)t#n 1 < 4 mg

8Cet)i#

9Su()#$#t < 1C

10 +!me)i+!n < 10 mg

11R#niti+ine 2


13/14

!lannin"1 Ce( H2T, GDS, e$e(t)!$"te

2 T!)#< im#ging ECG

4 @2 n#s#$ (#nu$e PM

5 P)! -CA

6 -VBD : - S 0,9 * 5 me C$ / 12 !u)

? Diet e#)t ---

8 Ce( u)e#, ()e#tinine, SG@T, SGPT, $!!+ g$u(!se/+#", (#)+i

i!m#)e)s in te )!!m


14/14

han# $ou

Department of Internal

MedicineChristian University of Indonesia

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Morpot 9 sep,kel 5