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Morning Report JUNE 16, 2017 G26: Dept of Internal Medicine
Morning Report JUNE 16, 2017 G26: Dept of Internal Medicine
Name : Ny. U
Age : 48 years old
Occupation :-
Address : Solokuro, Lamongan
Admission : juni 16 2017 at 21.40 PM
Chief Complaint
epigastric pain
Present history
HT -
DM -
Gasrtitis
Leukhorrhea (since 2 months) +, fishy odor, many, itching
Family history
No familial related
Social history
Cigarrete (-)
Coffe (-)
Alcohol (-)
VITAL SIGNS
Pulse
109x/min
BP
106/65mmHg
Temp
37.8 C
RR
20x/min
A: clear, gargling (-), snoring (-), speak fluently (+),
potential obstruction (-)
B: spontan, RR 20x/min, ves / ves, rh -/-, wh -/-, Sa
O2 100 % without O2 support
C: extremity WDR, CRT <2, N 109x/min, TD 106/65
mmHg
D: GCS 456, lat -, PBI 3mm/ 3mm, LP +/+
E: temp 37.8 C
GENERAL STATUS
General condition : weak
Awareness : compos mentis
GCS : 456
H/N : a +/i-/c-/d-
THORAX
Inspection
Symmetrical, retraction -
Palpation
Fremitus WNL, thrill (-)
Percussion
Lungs: sonor +/+
Cor: N
Auscultation
Lungs: ves /ves, rh -/-, wh -/-
Cor: S1 S2 single, mur -, gall-
ABDOMEN
Inspection
Flat, collaterral veins (-), inflammation signs (-)
Auscultation
Met -, gut noise WNL
Palpation
soefl
Epigastric pain (+)
Liver/Spleen is unpalpable
Percussion
tymphany
EXTREMITIES
Inspection
Clubbing fingers (-), icteric (-), cyanosis (-)
Palpation
Warm and dry, CRT <2
CLUE AND CUE
CBC
LFT
Antibiotic sesitivity test
LAB. EXAMINATION
UTI
Septic shock
Nausea-vomit
PLANNING THERAPY
Vital Signs
Patients complaint
Lab: Hb, trombosit
PLANNING EDUCATION