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MORNING REPORT

Department of Internal

MedicineChristian University of Indonesia

 January, 29th 2016TEAM 2

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Findings Assesment Therapy

• Dyspnoe, coughing 2 mounths ago, nausea and vomiting, appetite

decrease, night sweat

• GCS :E4V5M, !": #5$%&$, "' (& ), * : +,5 oC, '': +2)

Eye : "ae Con-ungtiva .%., Scera icteric .%.

*/* : 0orma

 0ec1 : ymph 0odes not Enarged

3V" : distended ., 5.2 cm/26

THORAX

7 : Symmetrica chest wa movement, ictus cordis . , retraction intercosta8"a: Voca 9remitus asimetric

"er: Da %Sonor

us: !asic ;reath sound vesica, ronchi

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Su!ecti"e DataName : Mr. A, 5 years o!d

 TC : "riday , #an$ary %&th %'()CC : Shortness o9 ;reath

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Anamne#i#

•Main sym*tom : Shortness o9 ;reath

•Additiona! sym*tom :

•"atient was came with headache since 5 days

 ;e9ore admittance to hospita8 "atients compain

o9 headache suddeny8 0ausea

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•Past Medi+a! istory and Treatment

-

•"ami!y istory

-

•-o+ia! istory-

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$!ecti"e Data

• A**earan+e : Mi!d I!!ness

• GCS :E4V5M

• !": #5$%&$

• "' (& )

• * : +,5oC

•'': +2)

• Eye: Pa!e +on$n+tiva /0/ , s+!era i+teri+

• Ear, Nose, throat : norma!

• Ne+1 : !ym*h nodes not en!ar2ed

• 3V" : distended ., 5.2 cm/26

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•  Thora3.

7 : Symmetrica chest wa movement, ictus cordis . , retraction intercosta8

"a: Voca 9remitus asimetric"er: Da %Sonor

us: !asic ;reath sound vesica, ronchi

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A##e##ment

• E9usion peura et causa *! pumona

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Therapy

• MM%

#8Ce9ti=o)ime 2)# gr iv

286!/ +)# C po

+8'anitidine 2)# iv

48!8 Comp 2)# po

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%lannin&• "eura punction

• Diet : high caories high protein

• 62 0B +.4 pm

• 7V>D : 7 '< 7 >utroit % 24 hours

• Chec1 !*, ED, SG6*%SG"*, reum, Creatinin

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Than' (ou

Department of Internal

MedicineChristian University of Indonesia