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Department of Internal Medicine Christian University of Indonesia MORNING REPORT June, 19th 2014 TC Findings Fever Weakness Dizzy Myalgia LOC : E4M6V5, compos mentis BP : 160/100 mmHg PR : 94 x/minute, adequate, regular RR : 26 x/minute Temp : 36,50 C Eye : Pale Conjungtiva -/-, SI -/Coated tounge (-) Thoraks : Ins : movement of chest wall symmetric right = left, retraction (-) Pal : vf symmetric, right=left Per : sonor in all lung field Aus : Basic breath sounds vesicular , Rh (-/-), Wh (+/+
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  MORNING REPORT   Department of Internal Medicine Christian University of Indonesia   June, 19 th  2014    2   Findings Assessment Therapy Planning Fever Weakness Dizzy Myalgia LOC : E4M6V5, compos mentis BP : 160/100 mmHg PR : 94 x/minute, adequate, regular RR : 26 x/minute Temp : 36,5 0 C Eye : Pale Conjungtiva -/-, SI -/- Coated tounge (-) Thoraks : Ins : movement of chest wall symmetric right = left, retraction (-) Pal : vf symmetric, right=left Per : sonor in all lung field Aus : Basic breath sounds vesicular , Rh (-/-), Wh (+/+) ; Heart sound 1 & Heart sound 2 reguler , murmur (-),gallop (-) Abdoment : Ins : stomach looks flat Pal : Impalpable,pressure pain (-) epigastrium, umbillicus, and suprapubic Per : Tympany, percussion pain (-) Aus: Bowel sound 4 times/minute Extremity : cold (-), cappilary refill <2 “, edema (- ) Skin : Turgor elastic Asthma bronkiale   Medikamentosa : Ceftriaxone 1x2g, Dexamethasone 2x1, Nebulizer (Ventolin +Fumicort), Amlodipine 1x 10mg, Salbutamol 3x1 - Pro hospitalized Diet less sodium IVFD: I RL + Aminofilin / 24 hours, I RL TC : Thursday /19 June 2014  LAB FINDING:   Hematology  Hb : 14,5 g/dl Leu : 5,4 rb/uL Ht : 42,8 % Tro : 148.520 uL 11/9/2014    4   Subjective Data   Name: Tn. S, 66 YO Address : Jakarta TC : Thursday /19 June 2014/18:35 CC Dyspneu
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