MORNING REPORT

Department of Internal Medicine Christian University of Indonesia

October 3rd 2013

Subjective Data
Name: MR. Immanuel, 52 YO Address: East Jakarta CC : Bloody cough TC: Tuesday/ 3rd October 2013 / 15:15

Anamnesis

Autoanamnesis on the date 3rd October 2013, Time 15.15 WIB

Main Complaint

Bloody cough since 3 hours before addmited

Additional Complaints

Weight loss

Anamnesis
Patient came to the hospital with main complaints bloody cough since 3 hours before hospital admission. The blood that came out is a fresh red blood mixed with mucus as much as a quarter of Aqua glass. Before patients are in the early phase of tuberculosis treatment for 1 week. Patient also complain of unexplained weight loss is pretty much for 1 month, from 79kg to 62kg. nausea (-), vomit (-), intake (+).

Past Medical History and Treatment

History of trauma (-) Rifampisin 450mg, INH 300mg, Pirazinamid 1000mg, Etambutol 1000mg

Family History (-), smoking (-)

12/4/2013

Objective Data
Appearance : moderate illness

awareness : E4V5M6; CM

TD : 120/80mmHg

HR : 86x /menit (adequate, reguler)

RR : 22x /menit

Temp : 37C

Objective Data
Head :Normocephali Konjunctiva anemic +/+ Sklera Ikterik -/-

Thorax
Pulmonal Inspeksi Front back Palpasi Front Left Static and dynamic symmetric Static and dynamic symmetric VF symmetric VF symmetric Right Static and dynamic symmetric Static and dynamic symmetric VF symmetric

Back

VF symmetric

Perkusi

Front
Back

Sonor
Sonor BBS Vesicular, Rhonci

Sonor
Sonor -/-, BBS lost, Rhonci -/-, Wheezing -/-

Auskultasi

Front

Wheezing -/-

Back

BBS

Vesicular,

Rhonci

-/-, BBS Vesicular, Rhonci -/-, Wheezing -

Wheezing -/-

/-

Abdomen
Inspeksi: stomach looks flat

Palpasi:
LiverSpleen impalpable ; ball -/;Pressure Pain ,Acites Auskultasi:

Perkusi: Tympani; Percussion Pain -

Bowel sound (+) 4x/minutes

Upper Extremities
Kanan Muscle Tonus Massa Joint Move Power Akral Edema Normotonus Normal in all directions in all directions +5 Warm Normotonus Normal in all directions in all directions +5 Warm 10

Kiri

Lower Extremities
Kanan Muscle Tonus Normotonus Normotonus Kiri

Massa
Joint Move Power Akral Edema

Normal
in all directions in all directions +5 Warm -

Normal
in all directions in all directions +5 Warm -

LABORATORIUM
HEMATOLOGI HASIL NILAI RUJUKAN

Hemoglobin
Leukosit Hematokrit Trombosit

10,3
8,6 37,4% 362

12-14 g/dL
5-10 ribu/UL 37-47 % 150-400 ribu/uL

Assessment
Diagnose: Lung Tuberculosis in therapy

13

Therapy
IVFD : I RL / 24 hours
MM/ : Rifampisin 450mg INH 300mg Pirazinamid 1000mg Etambutol 1000mg Kalnex 3x1 amp Vit K 3x1 amp

14

Planning
Pro Hospitalized

15

Department of Internal Medicine Christian University of Indonesia

THANK YOU

16