MORNING REPORT

department of internal
medicine
05-12-2014
 DAFTAR OB IGD
Ny. Kumiatun Ensefalopaty hepatik
Tn. Aser TB paru +DM type 2
Ny. Kuswati DM type 2 + cellulitis
Ny. Surya mukti septicemia + OMI
inferior
Ny. Rejowati Hipertensi Esensial
 IDENTITY
Name : Mr. A
Age : 45 y.o
Sex : male
Adress : Lamongan
Date : Desember, 05th 2014
 SUMMARY OF DATABASE
CHIEF COMPLAINT: Chronic cough
PRESENT ILLNESS HISTORY :
Patients complaint of long cough since
approximately 3 months before admission.
Cough with phlegm white , there is a little blood.
Patients also complaint of dyspnea , shortness of
breath deteriorate if cough. sometimes night
sweats and weight loss (+). Pain in the left chest
since patients cough. Fever (+) since 2 days
before admission. Swelling in the legs since 4
days before admission. Headache (+) since 1
weeks before admission, abdominal pain
(+).defecation and niction within normal limit.
 PAST ILLNESS HISTORY: DM (+)
FAMILY ILLNESS HISTORY: the same
as the patient's complaints (-) since 1
years, regularly drink OAD, HT denial,
complete treatment of pulmonary
tuberculosis for 6 months
PERSONAL HISTORY, SOCIAL, and
ECONOMICS: -
 PHYSICAL EXAMINATION
VITAL SIGN :
GCS : 456
BP : 106/50 mmHg
PULSE RATE : 99 x / minutes
TEMP : 37 oC
RR : 21 x/minutes
 Head and Neck :
Anemic (-/-), Icteric (-/-), Cyanosis (-/-),
Dyspneu (-)
dirty tongue
Thorax : simetric bilaterally, retraction (-/-),
Pulmo : ves/ves, rh (-/-), wh (-/-)
Cor : S1-S2 single reguler, murmur(-), gallop(-)
 Abdomen :
Abdomen : soepel, meteorismus
(-),BU(+N), hepar and lien not palpable
Extremity : warm, dry, red, pitting
edema in the both of leg
 Clue and Cue
Male, 45 years old
Chronic cough
Sweat in the night
Weight loss
Shortness of breath
Fever
Complete treatment of pulmonary tuberculosis for
6 months
History of DM
Leg swelling
 Problem List
Chronic cough
DM
 Early Assessment
Pulmonary TB
DM type 2
 Planning Diagnose
CBC
Thorax photo
LFT
RFT
Random blood sugar
FOTO THORAX
 LABORATORIUM
Diffcount 2/2/89/4/3
Hematokrit 29,2
Hemoglobin 9,8
LED 114/119
Leukosit 11.000
Trombosit 408.000
Bilirubin direct 0,28
Bilirubin total 0,78
SGOT 16
SGPT 15
Albumin 2,9
Globulin 2,7
Urea 15
Serum creatinin 0,5
Uric acid 2,0
GDA 279
 Secondary Diagnosis
Pulmonary TB
DM type 2
 Planning Therapy
O2 nasal 2 lpm
Ivfd Asering 1500 cc/24 jam
Inj Ranitidin 2x50 mg IV
Inj Metamizole 3x1 gram IV
Inj Ceftriaxon 2x1 gram IV
Inj RCI 3x4 IU ac
 Monitoring
Vital signs
Complaint
 Prognosis
Dubia ad bonam
 Education
Explaine to the family about the
disease of the family, about its
theraphy and intervention will be
done, and also about complication
and prognosis.