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MORNING REPORT
Social History
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Objective Data
Appearance : Mild Illness
GCS :E4V5M6
BP: 150/80
PR 78 x
T : 36,5oC
RR: 32x
Eye: Pale conjunctiva -/- , sclera icteric -/-
Ear, Nose, throat : normal
Neck : lymph nodes not enlarged
JVP : distended (-), 5-2 cmH2O
Thorax.
I : Symmetrical chest wall movement, ictus cordis (-) , retraction intercosta.
Pal: Vocal fremitus asimetric
Per: Dal /Sonor
Aus: Basic breath sound vesical, ronchi +/+, wheezing -/-. S1 and S2 reguler, gallop (-), murmur (-)
Abdomen.
- Ins Ins : Flat
- Aus : Bowel sound (+) 3times/minute
- Per : Timpani on 9 regions, percussion tenderness (-)
- Pal : Supel, Pressure pain (-)
Extremity
- Pitting oedem (-), warm acral, CRT < 2
Assessment
Efusion pleural et causa TB pulmonal
Therapy
MM/
1.Ceftizoxime 2x1 gr (iv)
2.OBH 3x1 C (po)
3.Ranitidine 2x1 (iv)
4.B. Comp 2x1 (po)
Planning
Pleural punction
Diet : high calories high protein
O2 NK 3-4 lpm
IVFD : I RL+ I Futrolit / 24 hours
Check BTA, LED, SGOT/SGPT, Ureum, Creatinin
Department of Internal Medicine
Christian University of Indonesia
Thank You