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  • Morning Report: 2 5 February 2015

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    farahansuah
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    I Nyoman Suaba, a 46-year-old Hindu man from Tabanan, Indonesia, presented to the emergency department with a three-day fever as high as 39°C that was unrelieved by paracetamol. A physical examination was performed and blood work was ordered. The patient's medical history, past illnesses, family history, and social history were not yet documented. An assessment was made and a treatment plan was to be determined.

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    Morning Report

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    I Nyoman Suaba, a 46-year-old Hindu man from Tabanan, Indonesia, presented to the emergency department with a three-day fever as high as 39°C that was unrelieved by paracetamol. A physical examination was performed and blood work was ordered. The patient's medical history, past illnesses, family history, and social history were not yet documented. An assessment was made and a treatment plan was to be determined.

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    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
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    8 views13 pages

    Morning Report: 2 5 February 2015

    Uploaded by

    farahansuah
    I Nyoman Suaba, a 46-year-old Hindu man from Tabanan, Indonesia, presented to the emergency department with a three-day fever as high as 39°C that was unrelieved by paracetamol. A physical examination was performed and blood work was ordered. The patient's medical history, past illnesses, family history, and social history were not yet documented. An assessment was made and a treatment plan was to be determined.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
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    of 13

    MORNING REPORT

    25TH FEBRUARY 2015

    PATIENTS IDENTITY

    Name: I Nyoman Suaba


    Age
    : 46 years old
    Gender : Male
    Religion : Hindu
    Address : Dusun Kantimemes Sudimara, Tabanan

    ANAMNESIS
    Chief Complaint: Fever
    Present Illness: Patient has come to the emergency

    department with the main complaint of having fever


    since 3 days ago. The fever is said to occur suddenly
    and has been quite high since. The temperature
    taken reached up to 39C. Patient has taken
    Paracetamol for his fever and the fever did reduce
    but it relaps again.

    ANAMNESIS
    Medical History

    ANAMNESIS
    Past Illness History

    Family History

    Social History

    PHYSICAL EXAMINATION
    General appearance
    Level of consciousness
    GCS
    Vital Signs :

    BP
    RR
    PR
    Tax

    Body weight
    Height
    BMI

    PHYSICAL EXAMINATION
    Eyes :
    ENT
    Neck

    PHYSICAL EXAMINATION
    Thorax

    Cor
    Inspection
    Palpation
    Percussion
    Auscultation

    Po
    Inspection
    Palpation
    Percussion
    Auscultation

    PHYSICAL EXAMINATION
    Abdomen
    Extremities
    Inspection
    Auscultation
    Percussion
    Palpation

    Complete blood count

    ASSESMENT

    PLANNING

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