Department of Internal

Medicine
Christian University of Indonesia

MORNING REPORT
March, 05th 2015
TEAM 4

Mr. P , 32 YO
CC : Shortness of breath
Findings
Shortness of breath
Cough and fever
GCS: E4V5M6, TD: 110/70, PR 89x, T : 37oC, RR: 30x
Eye : Pale Conjungtiva -/-, Sclera icteric -/THT : Normal
Neck : Lymph Nodes not Enlarged
JVP : not distended
THRORAX
Insp: Symmetris
Pal: Vocal fremitus sound symmetris dextra = Sinistra
Per : Symmetric sonor sound
Aus : Basic sound of breath vesical, wheezing -/-, ronchi +/+
ABDOMEN
Ins : bulging
Aus : Bowel sound (+) 4x/minute
Pal : Pressure pain (-)
Per : tympani
Extremitas : pitting oedem (-), warm acral, CRT < 2, turgor
normal

Assesment
Pneumonia
dd/ Suspect
TB

Therapy
MM/
Antibiotic : Cephalosporin 1 x 2 gr
Mucolitic : Ambroxol syr 3 x 1 c
Antipiretic : Paracetamol tab 3 x 500 mg

Planning
Pro Hospitalized
O2 mask 4-5 lpm
Check lab : H2TL, LED
Sputum test (AFB)
IVFD : RL/ 24 hours
X-ray thorax

Subjective Data
Name
CM
TC
CC

: Mr. P
:
: Thursday, March 05th 2015
: Shortness of breath

Anamnesis
Main symptom
breath
Additional symptom

: Shortness of
: cough, fever

Patient came to UKI hospital with shortness of

breath since about 1 week ago. The patient
felt this all day. Before admition, pasien had
coughed for about 1 month, phlegm (+),
blood (-). The patient havent treat the pain.
The patient also complain that he had fever
especially at night. Nausea (-), vomitting (-),
decreased in appetite, stomach ache (-),
decrease in weight (+).

Past Medical History and Treatment

denied

Family History
denied

Social History
Smoking denied

Objective Data

Appearance : Moderate Illness

GCS E4M6V5
BP : 110/70 mmhg,
RR: 30x/ minute,
T : 37C
Pulse : 89x/minute.
Eye: Pale conjunctiva -/- , sclera icteric -/Ear, Nose, throat : normal
JVP : not distended

 Thorax.

I : symmetrical, non-visible ictus cordis

Pal: symmetrical vocal fremitus, ictus cordis : unpalpable
Per: Sonore, cardiac englargement (-)
Aus: Basic breath sound vesical, ronchi +/+, wheezing -/-. Normal heart sound, gallop (-), murmur
(-)

Abdomen.

I : flat
Aus : bowel sound (+) 4x/minute
Per :timpani, percussion tenderness (-)
Pal : abdominal tenderness (-), liver and spleen enlargement (-)

Extremity
-

Warm
Capillary refilling time <2 second
Edema (-)
Turgor normal

Clinical Laboratory

Assessment
Pneumonia dd/ suspect TB

Therapy
O2 mask 4-5 lpm
IVFD: RL/24 hour
Drugs:
Antibiotic : Cephalosporin 1 x
2 gr
Mucolitic : Ambroxol syr 3 x 1c
Antipiretic : Paracetamol tab 3
x 500 mg

Planning
Pro hospitalized
H2TL, LED
Sputum test (AFB)
X-ray thorax

Department of Internal
Medicine
Christian University of Indonesia

Thank You