Department of Internal

Medicine
Christian University of Indonesia

MORNING REPORT
March, 1st 2015
TEAM 1

Mr. Sahroni,
CC : Diarrhea
Findings

Dyspneu since 4 days ago, cough with mucus,blood (-),

fever (+)
GCS: E4V5M6, TD: 130/70, PR: 90 x, T : 36,6oC, RR: 24x
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 (+) 6x/minute
Pal : Pressure pain (-).
Per : Tymphani, percussion tenderness (-)
Extremitas : pitting oedem (-), warm acral, CRT < 2

Assesment
Pneumonia
Asma Bronchiale
History of
Tuberculosis pulmo

Therapy
MM/
Levofloxacin 1x500mg drip
Sanmol 3x500 mg
Salbutamol 3 x 2mg (po)
OMZ 2x20 mg (po)
Azytromycin 1x1 tab
Sucralfat 3x1C (po)

Planning
Hospitalized
II RL / 24 hours
Nebulizer
Blood Laboratorium
Thorax Rontgen

Subjective Data
Name
CM
TC
CC

:Mrs Sahroni, 53 Years Old

:
: Monday, March 1st 2016
: Dyspneu

Anamnesis
Main symptom
Additional symptom

: dyspneu
:

Patient arrived to UKI hospital with main

complain dyspneu since 4 days before
admission,
complaints
continuously
throughout the day. Since one week ago, he
got a cough, mucus (+), blood (-), fever (+) 4
days ago.

Past Medical History and Treatment

Tuberculosis Pulmo (+) and got a medicine 5 yeras ago,
Diabetes mellytus (+), asma bronchiale (+)

Family History
denied

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

Objective Data

Appearance : Moderate Illness

GCS E4M6V5
BP : 130/70 mmhg,
RR: 30x/ minute,
T : 36.7C
Pulse : 90x/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 (+) , 6 x / minute
Pal : Pressure pain (-), liver enlargement (-)
Per : tiymphani, percussion tenderness (-)

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

Assessment
Pneumonia
Asma Bronchiale
History of Tubercolusis Pulmo

Therapy
Levofloxacin 1x500mg drip
Sanmol 3x500 mg
Salbutamol 3 x 2mg (po)
OMZ 2x20 mg (po)
Azytromycin 1x1 tab
Sucralfat 3x1C (po)

Planning

Hospitalized
II RL / 24 hours
Nebulizer
Blood laboratorium
Thorax rontgen

Department of Internal
Medicine
Christian University of Indonesia

Thank You