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Morning ReportJune 13th, 2016

Dept. of internal medicineG24

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DA!AR "# $%!&R%A!n. Joe'oef ( )"*D+"*! -am/am .2 %. ulu #adriah $ Mar5ah 1

!n. amian7!, 8iperalemia Gone

!n. idi 8 Mar5ah 10

%. Reo5ati 7omiting RJ

%. u5arni D'pep'ia RJ

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$dentit%ame 9 Mr. JAge 9 :4 ear' old

"ccupation 9 %one

Addre'' 9 (R upratman ; R!6 R(1arangpacar #oonegoro

Admi''ion 9 June 12 th, 2016 at 16936 *M

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)hief )omplaint

*re'ent hi'tor

)ough

*atient felt cough 'ince 1 month ? colored green. *atient al'o felt 'hortne'' of

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*a't hi'tor of $llne''

amil hi'tor

8! deniedDM deniedA'thma 'ince 13, e@erda u'e 'almoterol puC 2

No familial related

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ocial hi'tor

moe =>? one pac per da. a't 'moe 1 month ago

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7ital ign'#*14E+:3 mm8g

*ul'e:: +min, 'trong, reguler

!emp36,:0)

RR

33 +min

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A9 clear, gargling =?, 'noring =?, 'peaFuentl =>?, potential o+>, a"2 2 5ithout "2'upport 100 5ith "2 %RM : lpm.

)9 etremit (DR, )R! H2I, % ::+min, #*14E+:3 mm8g

D9 G) 4E6, lat , *#$ 3mm+ 3mm, * >+>&9 temp 36,: )

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G&%&RA !A!

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General condition 9 5ea

A5arene'' 9 compo' menti'

G) 9 4E6

8+% 9 a +i+c+d>

lmph node enlargement at nec =? J7* 5ithin normal limit

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!hora

$n'pectionmmetrical, retraction

*alpation!hrill =?, fremitu' (%

*ercu''ionung'9 'onor + 'onor

)or9 %

Au'cultationung'9 @e' +@e', rh +, 5h >+>

)or9 12 'ingle, M , gallop

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A

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&tremitie'$n'pection)lu

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)& A%D )&

Male, :E ear' oldD'pneu)ough =>?ung au'cultation9 5h >+>

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*lanning Diagno'e

D

&lectrolte 'erum

&)G

!hora A*GDA

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A''e'ment)"*D

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a

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&G

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Ro !hora

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ReA''e'ment)"*D8ponatremi

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*lanning !herap

"2 %RM : lpm

$nf. RA 1.E00cc+24 hour'

$n. %a Metami/ole 31gr i.@.

$n. Ranitidine 2E0mg i.@.

%e #i'ol@on 1E drop'+12 hour'

$n. Methpredni'olon 3 62,E mg i@

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*A%%$%G M"%$!"R$%G

7ital ign'

*atientI' complaint

Ad@er'e eCect

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*A%%$%G &D)A!$"%

&plain to the patient and hi' famil a