morpot 31 agustus 2015 kelompok 1
TRANSCRIPT
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MORNING REPORT
Department of Internal
MedicineChristian University of Indonesia
August, 31st2015TEAM 1
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Findings Assesment Therapy
Diarrhea
GCS: E4V5M6, TD: 140/90, PR 116 x, T : 36,6oC, RR: 24x
Eye : Pale Co!"#$i%a &/&, S'lera i'$eri' &/&
T(T : )or*al
)e'+ : VP -i.$e-e-, y*h )o-e. o$ Elar#e-
VP : &
THORAX
: Sy**e$ri'al 'he.$ all *o%e*e$, i'$". 'or-i. &Pal: Sy**e$ri'al Vo'al re*i$"., i'$". 'or-i. : alale
Per: Soor/Soor
7".: 8a.i' rea$h .o"- %e.i'al, ro'hi &/&, heei# &/& S1 a-
S2 re#"ler, #allo &, *"r*"r &
ABDOMEN
. : la$
7". : 8oel .o"- ; 4x/*i"$e
Pal : Pre.."re ai &
Per : Ti*ai, er'"..io $e-ere.. &
Extremitas: i$$i# oe-e* &, ar* a'ral, CRT < 2=
Ga.$roe$eri$i.
(yo'ale*ia
MM/
)e -ia$a 2 $a. e%ery -iarrhea
e%oloxa'i 1 x 500 *# -ri
Do*eri-oe 3 x 1 $a
(o
R
Par
Mrs. Nawa !" #O
$$ % Diarrhea
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Subecti!e DataName :Mrs Nawa, 72ears O!d
CM :TC : Monday, "#$#st %&st2'&(
"" # Diarr$ea
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AnamnesisMain s%mptom : diarrhea
Additional s%mptom :
Patient arrived to U)I hos*ita! with main+om*!ain diarrhea sin+e 2 days efore
admission, +om*!aints +ontin#o#s!y
thro#$ho#t the day, 2- % times a day. /rown
dro**in$s, m#+#s 0-1, !ood 0-1, na#sea 01 &wee3 a$o, heada+he, a**etite red#+ed.
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Past Medi+a! 4istory and Treatment
Vertigo (+), hypertension (+)
5ami!y 4istory
denied
6o+ia! 4istorySmoking (-), consuming alcoholic beverages (-)
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&becti!e Data
"**earan+e : Moderate I!!ness
GC6 EM89(
/P : &';' mmh$,
RR: 2
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Thora
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Assessment
Ga.$roe$eri$i.
(yo'ale*ia
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T$erap% )e -ia$a 2 $a e%ery -iarrhea
e%oloxa'i 1 x 500 *# -ri
Do*eri-oe 3 x 1 $a
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'lanning
(o.i$alie-
R / 24 ho"r. ; >Cl 25 *E?
Para.i$e .$ool exa*ia$io
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T$an( )ou
Department of Internal
MedicineChristian University of Indonesia