Team 6s

Morning Report

Identity of the Patient :

Name : Ms. Dewita malango

Age : 23 years old
Sex : Female
Admission date : 15-02-17
Status : Hospitalized

Chronological order :

Patient comes with the complaint of sore while urinating since 3 days before entering
the hospital. The urine was sandy (-), bloody (-), pulpy (+), sore in right side of waist
(+) not spreading, unsmooth urinate (-). Urinating 7 times a day. Fever gone and back
since 2 days before entering the hospital. Has been given medicines by doctor,
however the complaints do not get any better. The history of whitish was (+) 1,5 years
ago since using spiral KB. History of menstrual period was on December 2016. Ht (-)
dm (-).

Physical Examination

General condition : Moderately sick

Awareness : E4M6V5 (Composmentis)
BP : 110/70 mmHg
HR : 116x/minute
RR : 20x/minute
Temp. : 38 0C

Head. : Normochepali
o Eyes : Anemic conjungtiva -/-, ichteric sclerae -/-
Neck. : No lymph node enlargements
Chest :
o Inspection : Symmetrical respiratory movements, no uneven rib
movement.
o Palpation : Symmetrical vocal fremitus
o Percussion : Sonor sounds all over lung platforms
o Auscultation : lung : Ronchi -/-, Wheezing -/-
Heart : Normal, murmur -, gallop -
Abdomen:
o Inspection : appeared flat
o Auscultation : Intestinal sounds + 4x/min
o Palpation : Pressure pain + (Regio Lumbalis, Regio Iliaca, Regio
Supra pubik)
o Percussion : tympanic, percussion pain

Ekstremity : warm acrals, CRT <2, oedema

Laboratorium

H2TL :
Hb 11,6 g/dl (N: 12-14 g/dl)
Leu 13700/l (N: 5.000-10.000/ l)
Ht 33,4% (N: 40-48%)
Tromb 272.000/l (N: 150.000-400.000/l)

Urinalisa :
Warna : Kuning keruh
pH : 5,5
Blood : +2
Leukosit esterase : +1
Leukosit : 6-8/LPB
Eritrosit : 20-25/ LPB
Epitel : +1
Bakteri :+
Silinder :-
Kristal :-

Assesment
Dx : Infeksi Saluran Kemih (ISK)

Therapy
Pro Hospitalised
Diet : Normal
IVFD:
o III RL/24hour
MM/
o Levofloxacin 1 x 500 mg (IV)
o Omeprazole 1 x 40 amp (IV)
o Paracetamol 3 x 500 mg (PO)
 Team 6s
Morning Report

Arranged by :

Jhonny Susanto (1161050033)

Ghrena Amadea M.A (1161050035)

Tiara Cintya (1161050097)

Lisa Puspita (1161050108)

 Angga Meda (1161050235)

Jessica Levina (1261050028)

Dwi Kartika H (1261050167)

Debora P.P Saragih (1261050257)

Rashellya R.R (1261050293)