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MORNING REPORT

Tuesday, June 8th 2016


Doctor in Charge :
DR.dr. Muh Darwin P Sp.PD-KHOM

Patient Identity
Name
Sex
Age
Address
Occupation

: Mr. I
: Male
: 74 y.o
: Jl.Alalak Dalam Banjarmasin
: Swasta

Summary of Data Base


Chief Complaint (Autoanamnesis): Dispneu
Patient complained about dispneu since 2 days ago.
Patient also felt nausea and vomit. He got fever
and cough. The skin looked pale and there was a
wound in the part of his lower back. He also got a
weakness of the legs and left leg edema. The patient
felt like increased of the appetite and drinking, increased
the number of urination, and the weight loss.
History of illness: uncontrolled DM (+).
History of family illness: DM(+) Hipertensi (-)

Physical Examination
General
Appearance

Moderately ill

Blood Pressure

110/60 mmHg,

Pulse Rate

87 x/m, regular, strong

Respiration
Rate

29 x/m

Temperature

36,6o C

Skin

nodul (-)

General
Appearance

Physical Examination
Head

Pale conjunctiva (-/-), Jaundice sclera (-/-), decreased visual acuity (-/-), Edema palpebra
(-/-), Diplopia (-), discharge (-/-), anemic konjungtiva (+/+)

Neck

Lympatic node swelling (-)

Chest Heart

Inspection : ictus invisible


Palpation : palpable in MCS ICS V
Right margin : Right : ICS II-III L.Ster (D).
Cardiac waist : (n)
Auscultation : S1 > S2 single, murmur (-) gallop (-)

Lung

Inspection : Symmetric, barrel chest (-)


Palpation : FV symmetric
Percussion :
Auscultation :
S | S
BV | BV
S | S
BV | BV
S | S
BV | BV
Wheezing (-), Ronchi (-)

Abdomen

Bowel sound (+), bruit sound (-).


Percussion:
T | T |T
T | T |T
T | T |T
Hepatomegali(-)
ren/ Spleen/ was difficult to evaluate

Extremities

Superior D & S : Edema (-), Pain (-), Weakness (-)


Inferior D & S : Edema (-/+), Pain (-), Weakness (-)

Laboratory Result, june 6th 2016

Sponsored by XXVI-I

Laboratory Result, June 6th 2016

No. Problems

Data Support

1.

Pneumonia with sepsis

Cough
Fever, which may be mild or high
Shortness of breath
Auscultation :
BV | BV
BV | BV
BV | BV
Wheezing (-), Ronchi (-)

2.

Normocytic
normoochromic Anemia et
chronic imflamatory

Hb 8,5
MCV normal
MCH Normal
MCHC Normal

3.

History of Hypoglikemia:

GDS 300

Dm tipe II

153

Problem Oriented Medical Record


No

1.

Problem

Pneumonia
with sepsis

P.Dx

-CXR
-Blood test

P.Tx

Ceftriaxon

P.Mo
-General
state
-Complaint
-Vital sign

P.E

(-)

Problem Oriented Medical Record


No

2.

No

Problem

P.Dx

Normocytic
normoochromi
Liver fungtion
c Anemia et
Renal fungtion
chronic
imflamatory

Problem

Azotemia
Renal :
3.
-DM nefrotik
-Sepsis

P.Dx

-Ureum
-Creatinin

P.Tx
Transfusi prc
Zat besi
Eritropoitin

P.Tx

P.Mo
-General
state
-Complaint
-Vital sign

P.E

(-)

P.Mo

-General
state
-Complaint
-Vital sign

P.E

(-)

Problem Oriented Medical Record


No

4.

No

5.

Problem

P.Dx

P.Tx

History of
Hypoglikemia: -GDI
-GDII
Dm tipe II

Problem

Pansitopenia
+ Leukositosis

P.Dx

HB
Trom
BMP

P.Tx

P.Mo

P.E

-General
state
-Complaint
-Vital sign

-Lifestyle
Modification
-Medication
compliance

P.Mo

P.E

-General
state
-Complaint
-Vital sign

THANK YOU

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