Department of Internal Medicine

Christian University of Indonesia

MORNING REPORT

January 25th 2016

TEAM 3
Mr I / 25 YO
CC : Fever

Findings Assesment Therapy Planning

Fever for 3 days
GCS: E4V5M6, BP: 120/80mmHg, PR : 76x, T : 38,8oC, RR:18x 1.Viral Infection dd MM: Hospitalized
Eye : Pale Conjungtiva +/+, Sclera icteric -/- Dengue Fever, Sanmol 3x500 mg IVFD : II RL/24 hour
THT : Normal Dengue Topazol 1x1 amp (IV)
Neck : Lymph Nodes not Enlarged Haemorragic Fever Domperidone 3x10 mg
JVP : vein not distended
THORAX
I : intercostal retraction and movement simetric
Pal: Vocal fremitus simetric
Per: right lung-sonor , left lung-sonor
Aus: Basic breath sound vesiculer , ronchi -/-, wheezing -/-. S1 and S2
reguler, gallop (-), murmur (-)
ABDOMEN
Ins : Flat
Aus : Bowel sound (+) 5x/minute
Per : Tympani
Pal : Pressure pain (+) on umbilical region
SKIN : normal
Extremitas : oedema (-), warm acral, CRT < 2, turgor normal
Subjective Data
Name : Mr. I / 25 YO
TC : Monday, January 25th 2016
Anamnesis
Main symptom : Fever
Additional symptom : Watery Stool

The patient came to Emergency Room Hospital UKI with fever

complaints since 3 days ago. The fever has been going on for 3
days and the temperature's stays continously. Patient also have
watery stools, nausea, headache, and cough complaints.
Past Medical History and Treatment
(-)

Family History
(-)

Social History
(-)
Objective Data
Appearance : Moderate Illness
GCS E4M6V5
BP : 120/80mmHg,
RR: 18x/ minute,
T : 38,8C
Pulse : 76 x/minute.
Eye: Pale conjunctiva +/+ , sclera icteric -/-
Ear, Nose, throat : normal
JVP : vein not distended
Objective Data
THORAX
I : intercostal retraction and movement simetric
Pal: Vocal fremitus simetric
Per: right lung-sonor , left lung-sonor
Aus: Basic breath sound vesiculer , ronchi -/-, wheezing -/-. S1 and S2 reguler, gallop (-), murmur (-)
ABDOMEN
Ins : flat
Aus : Bowel sound (+) 5x/minute
Per : tympani.
Pal : Pressure pain (+) on umbilical region, liver and spleen enlargement (-)
SKIN : normal
Extremitas : oedema (-), warm extremities, CRT < 2, turgor normal
Clinical Laboratory
Monday, 25 January 2016
Hematologi
Hemoglobin : 15,5 gr/dl
Leukosit : 5.000 /ul
Hematokrit : 47 %
Trombosit : 157 rb/ul
Assessment
1.Viral Infection dd. Dengue Fever, Dengue
Haemorragic Fever
Therapy
MM:
Sanmol 3x500 mg
Topazol 1x1 amp (IV)
Domperidone 3x10 mg
Planning
Hospitalized
Check Lab H2TL/day
IVFD : II RL/24 jam
Diet: Non-stimulating soft diet
 Department of Internal Medicine
Christian University of Indonesia

Thank You