Department of Internal Medicine

Christian University of Indonesia

MORNING REPORT

August, 10th 2015
TEAM 5

IVFD : inj. Mm: THT: Normal infection Difenhidramin 10 mg (IV) Ceftriaxone 1 x 2 gr IV  ST Neck: Lymph Nodes not Enlarged Sanmol 3 x 500 mg JVP: vein not distended Difenhidramin 3 x 10 mg (IV) THRORAX Metilprednisolon 1 x 125 mg I : Symmetrical chest wall movement. ictus cordis : palpable Urispas 2 x1 (PO) Per: Sonor/Sonor . TD: 120/80. ictus cordis (-) (IV) Pal: Symmetrical Vocal fremitus . turgor normal . Consult with dermatologist ABDOMEN Ins : flat Aus : Bowel sound (-) Pal : Pressure pain (-). gallop (-). wheezing -/-. S1 and S2 reguler. SGPT. Infus I RL/ 24 Hours Eye: Pale Conjungtiva (-). RR: 18x urticaria 2. creatinin amforik -/-. T : 38oC. ronchi -/-. SGOT. fever • Late onset 1. MM/: 2. Hospitalized GCS: E4V5M6. Per : Timpani.Mrs. electrolit. plug 1. ureum. cardiac englargement (-) 4. warm acral. murmur (-) 5. CRT < 2”. PR : 84x. P/ 76 YO CC : itchy Findings Assesment Therapy Planning • Itchy. Sclera icteric (-) • Urinary tract Metilprednisolon 125 mg (IV) 3. percussion tenderness (-) Extremitas : pitting oedem (-). Aus: Basic breath sound vesical.

10th 2015 CC : itchy .Subjective Data Name : Mrs. 76 Years Old CM : TC : August. P.

and betamethasone but the itch not decrease.Anamnesis Main symptom : Itchy Additional symptom : Fever Patient arrived to UKI hospital with main complain itchy in whole body since a week ago. Patient feel itchy after painting her hair 2 weeks before hospitalize. Patient went to the doctor and took some medicine are paracetamol. Patient also feel fever. cetirizine. .

Past Medical History and Treatment denied Family History denied Social History Smoking (-). consuming alcoholic beverages (-) .

• Eye: Pale conjunctiva (-) . sclera icteric (-) • Ear. lymph nodes not enlarged . • T : 38°C • Pulse : 84x/minute.Objective Data • Appearance : Moderate Illness • GCS E4M6V5 • BP : 120/80 mmhg. throat : normal • JVP : normal . • RR: 18x/ minute. 5-2 cm. Nose.

gallop (-). wheezing -/-. Capillary refilling time <2 second . Edema (-) .• Thorax. S1 and S2 irreguler. percussion tenderness (-) • Extremity . ronchi -/-. Turgor normal . – I : Symmetrical chest wall movement. Warm acral . murmur (-) • Abdomen. Ictus cordis (-) – Pal: Symmetrical vocal fremitus. ictus cordis : palpable – Per: Sonor/Sonor. liver enlargement (-) – Per : timpani. – I : flat – Aus : bowel sound (+) – Pal : Pressure pain (-). cardiac englargement (-) – Aus: Basic breath sound vesical.

Clinical Laboratory 10/08/2015 H2TL – Hb : 12.9 g/dl – White Blood Cell : 23.000/uL .000 /uL – Hematocrite : 37.1 % – Trombosite : 555.

Urine Tests .

Assessment •Late onset urticaria •Urinary Tract Infection .

plug 2. IVFD : inj. Therapy 1. MM/: Metilprednisolon 125 mg (IV) Difenhidramin 10 mg (IV) .

Mm: Ceftriaxone 1 x 2 gr IV  ST Sanmol 3 x 500 mg Difenhidramin 3 x 10 mg (IV) Metilprednisolon 1 x 125 mg (IV) Urispas 2 x1 (PO) 4. SGOT. Hospitalized 2. ureum. electrolit.Planning 1. Consult with dermatologist . SGPT. creatinin 5. Infus I RL/ 24 Hours 3.

Department of Internal Medicine Christian University of Indonesia Thank You .