morep 25 juli
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Morning Report
July 25th 2014
Interna Group - Marwah
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Identity
Patient identity
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History Taing
!hie" !o#plaint
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Pre$iously
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Physi%al e&a#ination'ital (ign
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Head ) ne% * ane#ia +-)-, .aundi%e +-)-, %yanosis +-)-, dyspneu +-,
Thora& * /or#al %hest "or# I!( retra%tion +-, sy##etri%al %hest wall#o$e#ent
ungs P* (te# "re#itus* )
P * (onor)(onor (y##etri%
3 * $es )$es Rh -)- h -)-
RR * 24&)#inutes
!or P * ull
3 * (1-(2 #ur#ur +-, gallop +-,
36do#en I * "lat %aput #edusa +-,
P * (oe"l li$er and spleen not palpa6le (hi"ting dullness-
7pigastri% pain
P *ty#pani
3* 8owel sound +, /or#al
7&tre#ity * ar# dry and red
RT* T(3 d6n Mu%osa*so"t 3#pula didn9t %olaps Pain- H(-
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!lue and %ue
:e#ale ;0 years old
8loody stool without
#u%ous
:e$er /ausea
Pain in sto#a%h
7pigastri% pain
M #ore than 5
years
Taing her6al
#edi%ine 6ut sin%egot M stop
3l#ost e$ery 2 days
taes pil "or #ae her
6ody "eel good
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3sses#ent
He#ato%he
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Planning diagnosis
(G=T)(GPT
R:T
G3
H631!
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Laboratory Findings
i"" %ount * 2)1)>4)?);
He#ato%rite* 45@ A
H6 * 15 #g)dl
7 * @@)50
euo%ytes* 20200 Tro#6osite * 20;000
(G=T * 20
(GPT *21
3l6u#in * @?
Glo6ulin * @
(! * 14
Brea* 5C
Bri% a%id* 5@
!holesterol* 154
* >0C
TG* 14;
G3* 1;2
H631!* ??
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7DG
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Reasses#ent
G73
(epti%e#ia
M Type II
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Planing therapy
E I': Ring3s 1500%%)24.a#
E In. #eta#i#g prn
E in. !e"ota&i# @&1 g
E !)(pP
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Planning #onitoring
TT'
(u6.e%t %o#plain
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Prognosis
u6ia ad
6ona#
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7"e%ti$e %o##uni%ati$e edu%ation
Tae a planty o" rest
Tell the patient a6out the diseaseprognosis and #edi%ine that the patient9s
taing
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