MORNING REPORT

26th April 2016

Patient Identity

Name : I Made Aryana

Gender : male
Age : 42 yo
Religion : Hindu
Address : Tukad Banyusari Denpasar
Occupation : Unemployed
ToA : 11.00 am
Anamnesis
Chief complain : Swelling on both of eye
Patient came with chief complain swelling in both of eye after bited
by insect 1 hour BATH. The sweling was abruptly and worsen. It
made the patient couldnt open his eye. Before it happened, his skin
in the stomach became redness and swelling with itching sensation.
After that, the swelling is spread to his eyes and aslo his face.

Patient had nausea and vommiting 1 times when arrived at hospital,

it was about glass aqua and the colour was white.
Anamnesis
Patient also complained headache, he felt like
will falling down, and then followed by
increasing heart beat and breathlessnes after 15
minutes he arrived at hospital.
History of fever, cough, and loss of concioussnes
after bited by insect was denied.
Past illness history
He had no history asthma, but has allergy to paracetamol

Family history
No one in the family has history of allergic disease

Social history
In the house there was a bee hive
Physical examination
Appearance : moderate ill
GCS : E4V5M6
Blood pressure : 90/60 mmHg
Temperatur axilla : 37.0 OC
Pulse rate : 120 x/min, regular
Respiratory rate : 24 X/min

GENERAL STATUS
Eyes : Ane -/-, ict -/-, pupil reflex +/+ isochoric,
palpebral oedema +/+
ENT : Tonsil T1/T1; pharing hiperemis (-)
Neck : JVP 0 cm H2O

Chest Examination
Heart
Inspection : Ictus cordis: not seen
Palpation : Ictus cordis :palpable at MCL S ICS V
Percussion : Upper border : ICS II
Right border : Right PSL
Left border : Left MCL
Auscultation : S1 S2 single regular, murmur (-)
Physical examination
Lung
Inspection : symetric , active and passive
Palpation : vocal fremitus : normal
Percussion : sonor / sonor
Auscultation : Ves +/+ , Rh -/- , wh -/-

Abdomen
Inspection : distention (-), redness, urticaria
Auscultation : normal bowel sounds
Palpation : liver : unpalpable
spleen : unpalpable
tenderness (+) epigastric region
Percussion : tymphani

Extremities
Cold + / +, Edema - / -
Laboratory examination (25/4/2016) Complete Blood Count
Parameter
Parameter Unit
UnitValue
Value Normal
NormalValue
Value Results
Results Remark
Remark

WBC 103
WBC 103/L
/L 4.10-11,00
4.10-11,00 8,83
22.10 Normal
High
LYM 103
LYM 103/L
/L 1,00-4,00
1,00-4,00 1,12
4.50 Normal
high
NE 103
NE 103/L
/L 2,5-7,5
2,5-7,5 1,3
16.30 Normal
High
RBC 106
RBC 106/L
/L 4,50-5,90
4,50-5,90 6,43
6.12 Normal
High
HGB
HGB g/dL
g/dL 13,5-17,5
13,5-17,5 13,89
18.10 Normal
High
HCT
HCT %
% 41,0-53,0
41,0-53,0 44,64
51.80 Normal
Normal
MCV
MCV fL
fL 80,0-100,0
80,0-100,0 90,55
84.60 Normal
Normal
MCH
MCH Pg
Pg 26,0-34,0
26,0-34,0 28,16
29.50 Normal
Normal
MCHC
MCHC g/dL
g/dL 31,0-36,0
31,0-36,0 31,11
31,11 Normal
Normal
RDW
RDW %
% 11,6-14,8
11,6-14,8 12
13.20 Normal
Normal
PLT 103
PLT 103L
L 150-440
150-440 180,10
269.00 Normal
Normal
MPV
MPV fL
fL 6,80-10,0
6,80-10,0 7,10
7,10 Normal
Normal
Laboratory examination (25/4/2016) Clinical Chem

Parameter Results Unit Value Remarks Normal Value

BUN 10 mg/dL Normal 8,00 23,00
Creatinine 0,82 mg/dL Normal 0,70 1,20
SGOT 18.30 U/L Normal 11,0 - 27,0
SGPT 10.70 U/L low 11,0 - 34,0
Albumin 4.48 g/dL Normal 3,4 4,8
Natrium 144 mmol/L Normal 136 145
Kalium 3,17 mmol/L Low 3,50 5,10
Assesment

Shock anafilactic ec susp

insect bite
Management

IVFD NaCl 0.9% 20 dpm

02 4 Ipm
Epinephrine 0.3 cc IM
Methyl prednisolone 125mg iv
Dyphenhidramine 50 mg iv
Planning diagnostic
Level IgE

Monitoring
Vital sign
Complaint
Thank You