morpot 9 sep,kel 5
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8/18/2019 Morpot 9 sep,kel 5
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MORNING REPORT
Department of Internal
MedicineChristian University of Indonesia
December 21h 2015
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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()#$#t < 1C
10 +!me)i+!n < 10 mg
11R#niti+ine 2
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Subjective DataNae ! Mr" Ohara #ian$unta%& ' year
od TC ! *ednesday& #epte+er ,th ./'
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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"
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Past Medica ;istory and Treatent
(Controed NI00M& T: )
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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
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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
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ECG
Th
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ThoraDIa2in2
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Assessment
nte)i!) STEM-, #(ute g#st)itis, T. !n te)#", -DDM"!n#t)emi#, "!(#$emi#
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herapyMM>!
1TG +)i 5 mi()!/%#m
2si$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
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!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
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han# $ou
Department of Internal
MedicineChristian University of Indonesia
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