Department of Internal Medicine

Christian University of Indonesia

MORNING REPORT

May 14th 2015

TEAM 4
Mr. A, YO
CC : Shortness of breath

Findings Assesment Therapy Planning

Shortness of breath Suspect MM/ Pro Hospitalized
GCS: E4V5M6, TD: 180/100, PR : 120x, T : 36,1oC, RR: 32x spontan cefixozime 2x1 gr (IV) Skin test
Eye : Pale Conjungtiva -/-, Sclera icteric -/- hemineumo Metronidazole 3x500mg (PO) Lasix bolus 4 amp with drip 10
THT : Normal thoraks Ketorolac 3x1 amp mg/hour
Neck : Lymph Nodes not Enlarged SInistra Check lab : Complete Blood Count,
JVP : SGOT SGPT, Ur/Cr, Electrolite
THRORAX Check EKG
I : intercostal retraction and movement in the left lung lagging Check Thoraks X-Ray
Pal: Vocal fremitus simetric IVFD : I RL/ 24 hours
Per: right lung-dullness , left lung-sonor
Aus: Basic breath sound vesiculer , ronchi +/-, wheezing -/-. S1 WSD
and S2 reguler, gallop (-), murmur (-)
ABDOMEN
Ins : flat
Aus : Bowel sound (+) 3x/minute
Pal : Pressure pain (-)
Per : tympani
Extremitas : pitting oedem (-), cold warm, CRT < 2, turgor
normal
Subjective Data
Name : Mr. A,34years old
CM :
TC : Thursday, May 14th 2015
CC : Shortness of breath
Anamnesis
Main symptom : Shortness of breath
Additional symptom :-

Patient came to UKI hospital with complain shortness of

breath since 4 hours ago. Shortness of breath is felt
constantly. complain increase when patient lie down, to
decreasing the complain, patien sit. The patient havent
treat the pain. History of trauma (-) Nausea (-), vomitting
(-), stomach ache (-), decrease in weight (-).Patient has
history of asthma
Past Medical History and Treatment
asthma

Family History
asthma

Social History
Smoking (+) and 2 times per week
Objective Data
Appearance : Moderate Illness
GCS E4M6V5
BP : 130/90 mmhg,
RR: 26x/ minute,
T : 36,8C
Pulse : 80 x/minute.
Eye: Pale conjunctiva -/- , sclera icteric -/-
Ear, Nose, throat : normal
JVP : vein undistended
 Thorax.
I : intercostal retraction and movement in the left lung lagging
Pal: Vocal fremitus of left thoraks loss, ictus cordis : palpable
Per: right lung-sonor , left lung-hipersonor
Aus: Basic breath sound vesical in right lung and loss in the left lung,
ronchi -/-, wheezing -/-. S1 and S2 irreguler, gallop (-), murmur (-)

Abdomen.
I : flat
Aus : bowel sound (+) 5x/minute
Per :timpani, percussion tenderness (-)
Pal : abdominal tenderness (-), liver and spleen enlargement (-)
Extremity
- Warm
- Capillary refilling time <2 second
- Edema (-)
- Turgor normal
Clinical Laboratory
14/05/2015
AGD & Electrolit
Blood pH : 7,437
PCO-2 : 37,3mmHg
PO-2 : 51,8 mmHg (Low)
O2 Saturation : 88,1 %
Base Excess : 2.0 mmol/L
HCO3 : 25.4 mmol/L (High)
TCO2 : 26.6 mmol/L
O2 Concentration : 19,7 VOL %
X-Ray

Lung Collapse
ekg
Assessment

Suspect Spontan
Hemipneumothoraks Sinistra
Therapy
cefixozime 2x1 gr (IV) Skin test
Metronidazole 3x500mg (PO)
Ketorolac 3x1 amp
 Planning
Pro Hospitalized
Lasix bolus 4 amp with drip 10 mg/hour
Check lab : Complete Blood Count,
SGOT SGPT, Ur/Cr, Electrolite
Check EKG
Check Thoraks X-Ray
IVFD : I RL/ 24 hours
WSD
Department of Internal Medicine
Christian University of Indonesia

Thank
You