Morning Report

Morning ReportIdentityName: Mrs.SAge: 58 years oldAddress: Cipinang GalurDate of enterance: 12th july 2013Name: Mrs. SAge: 58 years oldDate of entrance: July 12th 2013FindingsAssessmentTherapyPlanningDyspneu since 4 days ago.Nokturnal cought with green mucusNausea and vomiting

Temperature: 36.50 CBP: 130/90 mmHgPulse: 74 x/mntRR : 27 x/mnt

Thoraks:Auscultation:Ronkhi +/+Wheezing +/+Asthma bronchiale mild persisten e.c pneumonie dd susp. New TBCHypertension grade 1DyspepsiaNIDDMCanul O2 2 lpmInhalation (fulmicord + ventolin) 3x1Erytromycin 2x500 mgRanitidine 2x150 mgCaptopril 3x1Metformin 3x1Complete internal of medicine laboratorium testRandom blood sugar tesBTA sputumSpirometriThoraks photoTime of entrance : 23.30Address : Cipinang GalurMR: 42.45.04.00Main Symtom : Dyspneu since 4 days agoAnother symptoms : Nokturnal cought with green mucus, nausea and vomiting

Recent Symptomps Chronology:56 y/o patient came with 4 days onset of dyspneu. History : Hypertension (+)Diabetes melitus (+)Asthma (+)

Family Illness Chronology :-Physical ExaminationGeneral Qualitative : Compos Mentis

Temperature: 36,5o CBP: 130/90 mmHgPulse: 74x/mntRR: 27/xmntPhysical ExaminationEyes: Conjutiva anemis -/- Sklera Ikterik -/-

ThoraksInspection: no abnormality foundPalpation: Fremitus WNLPercussion: CTP BilaterallyAuscultaion: Normal S1/S2 wheezing +/+ ronkhi +/+

Physical ExaminationAbdominalInspection : BulgingAuscultation: BO (+) 9x/mntPercution: Thymphani, Pain (-)Palpation: Pain (+)

Udem: -Nail: CR > 2/ > 2 LabsComplete Blood Count:Hemoglobin: 12,5 gr/ dlLeukosit: 9.900 /ulHemotokrit: 36.7 %Trombosit: 406.000/ulWORKING DIAGNOSISAsthma bronchiale mild persisten e.c pneumonie dd susp. New TBC

Hypertension grade 1

Dyspepsia

NIDDMTherapyIVFD:II RL/days

Canul O2 2 lpmInhalation (fulmicord + ventolin) 3x1Erytromycin 2x500 mgRanitidine 2x150 mgCaptopril 3x1Metformin 3x1