Morning Report

Sunday, May 29th 2016

CO ASSISTANCE INCHARGE

FADILA SAFIRA
AFIFAH MUKARROMAH

MODERATOR :
dr. IQBAL LAHMADI Sp.PD
 Total Patients

Total patients :
Melati ward : 9 patients
Kenanga ward : patients

Total Patients in ward:

Melati ward : 2 patients
Female, 65 y.o, Dx : Acute wattery dhiarrea + HT grade II
Female,
Kenanga ward : 4 patients
Male, 29 y.o, Dx : Syndrom dispepsia
Male, 23 y.o, Dx acute leukimia
Male, Tn S, 60 y.o, Dx : AKI + IMA
 Summary of Database

Mr. A/Male /23 y.o

Chief complaint :Fever

Patient suffered from fever and sweat at night since 2
months before addmision and getting worse this
morning. The intermittent fever and high perceived
at night. Patient also complaint body weakness and
dizziness. He also said the weight loss of 3 kg during
the last 1 month.
 the patient had never went to the doctor and in the
diagnosis of typhoid and intestinal inflammation
 Physical examination in Kenanga Ward
BP = 110/70mmHg PR : 84 tpm, regular RR = 22 tpm T ax 3,9oC

General appearance looked mildly ill GCS 456

Head Anemic +/+ Icteric -

Neck JVP 5 cmH2O ,

Thorax Invisible Palpable at Ictus ICS VI MCL S,

Heart RHM SL D, LHM as ictus,
S1 S2 single, mur mur (-), gallop (-)

lung Simetric, SF D = S SS v v Rh - - Wh - -
SS bv bv - - - -
DS bv bv - - - -

Abdomen Convex, Soefl, Hepar : Liver span 12 cm, tenderness in epigastric region

Extremities Oedema in both lower extremity -/-

 Lab Value Lab Value

Leukocyte 178.000 3500 - Ureum 26 10-50mg/dL

10000/L
Haemoglobin 7,4 11,0-16,5g/dl Creatinine 0,9 0,7-1,5mg/dL

MCV 101,7 80-97 SGOT 51 11-41U/L

MCH 32,36 26,5-35 SGPT 58 10-41U/L

Thrombocyte 210.000 150000-

390000/L
RBS 183 (<200)mg/dL
CUE AND CLUE PROBLEM INITIAL PLANNING PLANNING PLANNING
LIST DIAGNOSE DIAGNOSE THERAPY MONITORI
NG

male/23 yo 1.Fever with 1.1. Blood smear Free diet

Ax: leukositosis Malignancy Bone VS
Fever (+), sweat at 1.1.1 Marrow IVFD Nacl 20 dpm Complain
night (+) diziness Chronic analysis DR
(+) General
weakness (+)
leukemia Uric acid Confirm diagnose
PE: 1.1.2 Acute
T: 39oC leukemia
CA +/+, tenderness
in epigastric region,

Lab :
WBC : 178.000 /
mm3
Hgb: 7,4 gr/dl
CUE AND CLUE PROBLEM LIST INITIAL PLANNING PLANNING PLANNING
DIAGNOSE DIAGNOSE THERAPY MONITORIN
G

male/ 23yo 2. 2.1 due to - Blood smear Confirm

Ax: Normochrom no. 1 and Diagnose DR post
Weakness (+), normocytic reticulocyte transfusi
Diziness (+) count Transfussion
Anemia
- Faeces analysis 500 cc daily
PE: and Occult
Eye : anemic (+) blood
ikteric (-) examination

Lab :
Hb : 7,4 g/dl
MCV : 101
MCH : 32

Male /23 y.o Confirm Cek SGOT,

3. Transaminitis 3.1 due to Monitoring diagnose SGPT
lab :
SGOT : 51 no 1 SGOT and
SGPT : 58 SGPT
Thank you