Department of Internal

Medicine
Christian University of Indonesia

MORNING REPORT
January, 11 th 2015
TEAM 4

Mr. Suwarno, 66 YO
CC : Fever
Findings
Fever
GCS: E4V5M6, TD: 80/60, PR 92x, T : 36,5oC, RR: 19x
Eye : Pale Conjungtiva +/+, Sclera icteric -/THT : Normal
Neck : JVP distended, Lymph Nodes not Enlarged
JVP : THORAX

I : Symmetrical chest wall movement, ictus cordis (-)

Pal: Symmetrical Vocal fremitus, ictus cordis : palpable
Per: Sonor/Sonor
Aus: Basic breath sound vesical, ronchi -/-, wheezing -/-. S1 and
S2 reguler, gallop (-), murmur (-)
ABDOMEN
Ins : flat
Aus : Bowel sound (+) 4x/minute
Pal : Pressure pain (-).
Per : Timpani, percussion tenderness (-)
Extremitas : pitting oedem (-), warm acral, CRT < 2

Assesment
Urinary tract
infection
CAD
Hipokalemia

Therapy
MM/
Levofloxacin 1 x 500 mg (IV)
Paracetamol 3 x 500 mg
Urispas 3 x 1
Miniaspi 1 x 80 mg
Aforvasfatin 1 x 20 mg
Bisoprolol 1 x 2,5 mg
Nitrogliserin 1 x 1
KSR 3 X 1

Planning
Hospitalized
IVFD : I RL / 24 hours

Subjective Data
Name
CM
TC
CC

:Mr. Suwarno, 66 Years Old

:
: Monday, January 11 th, 2016
: Fever

Anamnesis
Main symptom
Additional symptom

: Vomitting
:

Patient arrived to UKI hospital with main

complain fever since one day ago. Patient also
complain about pain at foot. Nausea (-),
vomitting (-)

Past Medical History and Treatment

Patient had a history of heart catheter 1 month ago

Family History
denied

Social History
Smoking (-), consuming alcoholic beverages (-)

Objective Data

Appearance : Moderate Illness

GCS E4M6V5
BP : 130/70 mmhg,
RR: 22x/ minute,
T : 37,9C
Pulse : 92x/minute.
Eye: Pale conjunctiva -/- , sclera icteric -/Ear, Nose, throat : normal
JVP : normal, lymph nodes not enlarged

Thorax.

Abdomen.

I : Symmetrical chest wall movement, Ictus cordis (-)

Pal: Symmetrical Vocal fremitus, ictus cordis : palpable
Per: Sonor/Sonor
Aus: Basic breath sound vesical, ronchi -/-, wheezing -/-. S1 and S2 reguler, gallop
(-), murmur (-)
I : flat
Aus : bowel sound (+) , 4 x / minute
Pal : Pressure pain (-), liver enlargement (-)
Per : timpani, percussion tenderness (-)

Extremity
- Warm acral
- Capillary refilling time < 2 second
- Edema (-)

Assessment
Urinary tract infection
CAD
Hipokalemia

Therapy
MM/
Levofloxacin 1 x 500 mg (IV)
Paracetamol 3 x 500 mg
Urispas 3 x 1
Miniaspi 1 x 80 mg
Aforvasfatin 1 x 20 mg
Bisoprolol 1 x 2,5 mg
Nitrogliserin 1 x 1
KSR 3 X 1

Planning
Hospitalized
IVFD : I RL / 24 hours

Department of Internal
Medicine
Christian University of Indonesia

Thank You