Emergency Unit

MORNING REPORT
December 21st, 2016
TEAM 4
 SUBJECTIVE DATA
• Patient Name : Mrs. Carolina Katherina
• TC : Wednesday, December 21st
2016
• CC : Fever
Patient came to emergency unit with fever since
1 day before hospitalized. Fever noticeably from
the afternoon till night with temperature 38oC.
Patients are suffering coughing by plain phlegm
since 1 week before hospitalized. Patients
already have gone to Polyclinic and the drugs
are Paracetamol , Ambroxol, and Imboost but
fever happened again this afternoon. Headache
(+), nausea (+) , vomiting (-), sore and muscle
pain (+).
 PHYSICAL EXAMINATION
• General appearance : Severe illnes
• GCS : E4M6V5
• Vital signs
BP : 120/70 mmHg
RR : 22 x/minute
Temp : 38,4 ˚C
Pulse : 68 x/minute
• Eye : Anemic conjunctiva -/- ,
icteric sclera -/-
• ENT : Normal
• Neck : Lymph nodes not enlarged
 PHYSICAL EXAMINATION
Thorax
- I: Symmetrical chest wall movement, ictus
cordis (-)
- P: Symmetrical Vocal Fremitus
- P: Sonor/sonor , Right=left
- A: Basic breath sound vesicular, ronchi -/-,
wheezing -/-, S1 and S2 normal, gallop (-),
murmur (-).
Abdomen
- I : Flat
- A : Bowel sound (+) 3x/minute
- P : Soepel, pressure pain (-), hepar/Lien not
enlarged
- P : Timpani, percussion tenderness (-)
Extremity
- Warm acral
- CRT <2 second
- Edema (-)
- Turgor normal
 CLINICAL LABORATORY
• H2TL • Widal
- Hb 10,7 g/dl - S.THYPOSE H (-)
- L 9,0 ribu/ul - S. PARATYPHI A H (-)
- Ht 49,9 % - S. PARATYPHI B H (-)
- T 101.000 /uL - S. PARATYPHI C H (-)
- S.TYPHOSE O (+) 1/80
- S. PARATYPHI A O (-)
- S. PARATYPHI B O (+) 1/80
- S. PARATYPHI CO (-)
 ASSESSMENT
• Dengue Haemorrhagic Fever
 THERAPY
• IVFD : IV RL/24 hours

• Mm : Sanmol 3x1 (PO)

Omeprazole 2x1 amp
Sucralfat 3x1 (PO)
Ceftriaxone 1x2 gr
Sanmol drip 3x1 amp