Department of Internal Medicine

Christian University of Indonesia

MORNING REPORT

August, 10th 2015

TEAM 5
Mrs. P/ 76 YO
CC : itchy

Findings Assesment Therapy Planning

Itchy, fever Late onset 1. IVFD : inj. plug 1. Hospitalized
GCS: E4V5M6, TD: 120/80, PR : 84x, T : 38oC, RR: 18x urticaria 2. MM/: 2. Infus I RL/ 24 Hours
Eye: Pale Conjungtiva (-), Sclera icteric (-) Urinary tract Metilprednisolon 125 mg (IV) 3. Mm:
THT: Normal infection Difenhidramin 10 mg (IV) Ceftriaxone 1 x 2 gr IV ST
Neck: Lymph Nodes not Enlarged Sanmol 3 x 500 mg
JVP: vein not distended Difenhidramin 3 x 10 mg (IV)
THRORAX Metilprednisolon 1 x 125 mg
I : Symmetrical chest wall movement, ictus cordis (-) (IV)
Pal: Symmetrical Vocal fremitus , ictus cordis : palpable Urispas 2 x1 (PO)
Per: Sonor/Sonor , cardiac englargement (-) 4. SGOT, SGPT, electrolit,
Aus: Basic breath sound vesical, ronchi -/-, wheezing -/-, ureum, creatinin
amforik -/-. S1 and S2 reguler, gallop (-), murmur (-) 5. Consult with dermatologist
ABDOMEN
Ins : flat
Aus : Bowel sound (-)
Pal : Pressure pain (-).
Per : Timpani, percussion tenderness (-)
Extremitas : pitting oedem (-), warm acral, CRT < 2, turgor
normal
Subjective Data
Name : Mrs. P, 76 Years Old
CM :
TC : August, 10th 2015
CC : itchy
Anamnesis
Main symptom : Itchy
Additional symptom : Fever

Patient arrived to UKI hospital with main complain itchy

in whole body since a week ago. Patient feel itchy after
painting her hair 2 weeks before hospitalize. Patient went
to the doctor and took some medicine are paracetamol,
cetirizine, and betamethasone but the itch not decrease.
Patient also feel fever.
Past Medical History and Treatment
denied

Family History
denied

Social History
Smoking (-), consuming alcoholic beverages (-)
Objective Data
Appearance : Moderate Illness
GCS E4M6V5
BP : 120/80 mmhg,
RR: 18x/ minute,
T : 38C
Pulse : 84x/minute.
Eye: Pale conjunctiva (-) , sclera icteric (-)
Ear, Nose, throat : normal
JVP : normal , 5-2 cm, lymph nodes not enlarged
 Thorax.
I : Symmetrical chest wall movement, Ictus cordis (-)
Pal: Symmetrical vocal fremitus, ictus cordis : palpable
Per: Sonor/Sonor, cardiac englargement (-)
Aus: Basic breath sound vesical, ronchi -/-, wheezing -/-. S1 and S2 irreguler, gallop (-), murmur (-)
Abdomen.
I : flat
Aus : bowel sound (+)
Pal : Pressure pain (-), liver enlargement (-)
Per : timpani, percussion tenderness (-)
Extremity
- Warm acral
- Capillary refilling time <2 second
- Edema (-)
- Turgor normal
Clinical Laboratory
10/08/2015

H2TL
Hb : 12,9 g/dl
White Blood Cell : 23.000 /uL
Hematocrite : 37,1 %
Trombosite : 555.000/uL
Urine Tests
Assessment

Late onset urticaria

Urinary Tract Infection
 Therapy
1. IVFD : inj. plug
2. MM/: Metilprednisolon 125 mg (IV)
Difenhidramin 10 mg (IV)
Planning
1. Hospitalized
2. Infus I RL/ 24 Hours
3. Mm: Ceftriaxone 1 x 2 gr IV ST
Sanmol 3 x 500 mg
Difenhidramin 3 x 10 mg (IV)
Metilprednisolon 1 x 125 mg (IV)
Urispas 2 x1 (PO)
4. SGOT, SGPT, electrolit, ureum, creatinin
5. Consult with dermatologist
Department of Internal Medicine
Christian University of Indonesia

Thank You