MORNING REPORT

Tuesday, 3rd September 2019

TEAM:
COASS PATIMAH COASS ROFI
COASS DEWI COASS NANI
ADVISER : DR. DIKARA WIDYANGGA SULFIAN MAULIDY, SP.PD

1
 Patient identity
Name : Mr. I
Age : 56 years old
Religion : Moslem
Ethnic : Banjarese
Occupation : Farmer
Address : Batola

Hospitalized since: September, 3rd 2019

2
Anamnesis
Chief Complaint: General weakness
Auto anamnesis
Patient came to Ulin Hospital with the complaints of weakness, he
experience weakness since 2 months ago and become worsened since
2 weeks. The patient felt weakness all over his body, came of
gradually and continously. Patient also experience pallor. He
experienced weight loss since 2 months from 47 to 42 eventhough his
appetite is normal. Two weeks ago the patient has been hospitalized
in Kapuas hospital for 10 days with the same complaint. This patient
got 6 bags of PRC, and admitted only once feel itchy, no fever
experienced. When the patient out he was suggested to go to Ulin
hospital to have another examination.
3
Nausea, vomit, black feces, jaundice disease, reddish urine,
abdominal pain, history of alcohol consumption, energy drink,
traditional drink (jamu), all of these is denied. The patient also have
the last result of examination of his blood from the previous
hospital.

4
 Anamnesis
History of past illness : the patient didn’t have spesific illness before this complaint.
Treatment History : the patient didin’t have any spesific treatments
Family History : no history of family with the same complaint
HT (-), DM (-), jaundice disease(-), malignancy (-)
History of allergy : he hasn’t have any allergy of food and medicine
Personal and social history : patient was smoking more than 20 years and stop at last years,
patient live with his child family

5
 BP =150/80 mmHg HR = 50x bpm RR= 20 x/minute weight= 42 kg
PHYSICAL Regular, lift strength T : 36,5 ◦C height= 154 cm
EXAMINATION Sa: 98% IBM = 17,7 kg/m2

General condition: looked mildly ill GCS E4V5M6 compos mentis

Eyes and skin -Sclera: icteric (-) Skin : turgor < 2 second, Rash(-), petekie (-)
-Conjungtiva: pale (+)

Head and Neck Nuchal rigidity(-), lymph nodes enlargement (-),

Thorax: Ictus cordis visible, palpable on ICS V LMC line
Cor LHM = 2nd ICS – 6th ICS LMC line
RHM : 2rd ICS – 6th ICS right sternal line
single s1=s2, gallop (-), Murmur (-)
Lung Inspection: Simetris
Palpation: fremitus vocal and symmetry
Percution S S Auscultation: Breath sound V V Rh - - Wh - -
S S V V - - - -
S S V V - - - -

6
Abdomen Inspection: flat, Striae (-), scar (-), caput medusae(-),
Auscultation bowel sound (+) normal
Palpation:
Abdominal pain : - - -

- - -

- - -
Percution : tympanic, liver span 7 cm, traube’s space
dullness, splenomegali schuffner II,
shifting dullness (-), undulation (-)

Extremities Edema - -
- -
Warm extremity + +
+ +

7
Laboratory findings
Pemeriksaan Hasil Nilai Rujukan Satuan Metoda

HEMATOLOGI
Haemoglobin 9.6 12,50-15,60 g/dl Colorimetric
Leukocyte 10.9 4,65-10,3 thousand/ul Impedance
Erythrocyte 3.30 4,10-6,00 milion/ul Impedance
Haematocrit 30.1 42,00-52,00 Vol% Analyzer Calculates
Platelet 61 150-356 ribu/ul Impedance

MCV, MCH, MCHC

MCV 91.2 75,0-96,0 Fl Analyzer Calculates

MCH 29.1 28,0-32,0 Pg Analyzer Calculates

MCHC 31,9 33,0-37,0 % Analyzer Calculates

HITUNG JENIS

Basophils 0.1 0.0-1.0 % Impedance

Eosinophils 0.7 1.0-3.0 % Impedance

Monocytes 7,6 2.0-8.0 % Impedance

Granulocytes 81.1 50.0-81.0 ribu/ul Impedance

Limphocytes 10.5 20.0-40.0 ribu/ul Impedance

8
 Pemeriksaan Hasil Nilai Rujukan

SGOT 48 5-34

SGPT 81 0-55

Ureum 41 0-50

Creatinine 0,55 0,57-1,11

Bilirubin Total 1.00 0.20-1.20

Bilirubin Direk 0.46 0.00-0.20

Bilirubin Indirek 0.54 0.20-0.80

Albumin 1.8 3.5-5.2

Globulin 6.9 2.2-2.6

HbsAg Reaktif Non Reaktif

9
Position : PA position, enough
inspiration
Soft tissue : Normal
Bone : Normal
Trachea : in the middle
Hemi diaphragm : dome shape (d/s)
Costophrenicus angle : dextra et sinistra
is sharp
Lung : increase bronchovaskular
pattern at paracardial dextra
Cor : CTR 50%

Conclusion : suspect bronchitis

kronis

10
Sinus bradicardia
Heart rate 46 x/m, Regular
Frontal axis normal
Horizontal axis normal
PR interval 0,12 sec (normal 0,12-
0,20 sec)
Complex QRS : 0.06 sec (normal
<0,12)
QT interval : 0,52 sec (normal
0,32-0,42
S-T segment : ST elevation (-), ST
depression (-)
T Wave normal, T inverted (-)

Conclusion : Sinus bradicardia,

HR:46x/m, normo axis, Prolonged
QT interval

11
 POMR
CUE AND CLUE Problem List Idx PDx PTx Pmo Ped
Mr. I / 56 yo 1. Bicytopenia 1.1 - Blood smear Diet: c/ Vital signs - Give
hematological - Bone marrow BBI = 90% (154-100)= 48.6 c/ blood routine information
Subjective : disorder aspiration KKB= 30 x 48.6 = 1458 every 3 days about the
- General weakness all 1.1.1 MDS - Reticulocyte K= (70% x 1458 ) : 4 = Observation disease,
since 2 month ago and 1.1.2 Hemolytic test 255.15gr/day bleeding prognosis,
become worsened since 1.1.3 Leukemia - Peripheral P= ( 20% x 1458 ) :4 = 72,9 gr/ manifestation complicatio
2 weeks. 1.2 related to blood day n and
liver disease morfology L= (10% x 1458) :9 = 16.2 management
Physical examination: - USG gr/day to patient’s
Conjunctiva pale (+) abdomen family
Sklera ikcteric (-), -IVFD NS : D5 (1:1) - Bed rest
Splenomegali Schufner II Infusion:
10x100 = 1000
Laboratory findings: 10x50 = 500
Hb: 9.6; 22x 20 = 440
MCH : 29.1; erythrocyte:
3.30 1940
MCV : 91.2 MCHC : 31.9 1940x20
Trombosit 61.000 24x60 = 20 tpm
HBsAg reactif
Total bilirubin 1.00 Not needed transfutiom for now,
Bilirubin direct 0.46 Hb target > 8 mg/dl
Bilirubin indirect 0.54
SGOT 48 Po. Asam folat 1x3 mg
SGPT 81
Confirm diagnozed
12
 POMR
CUE AND CLUE Problem Idx PDx PTx Pmo Ped
List
Mr. I / 56 yo 2. Hepatitis B - Confirmed diagnosed Planning Planning
Subjective : infection - Bedrest Monitoring: Education:
- General weakness all since 2 - Liver diet 1700 kkal/day, S, HbeAg, HBV- - Give
month ago and become protein 100 gram/day DNA information
worsened since 2 weeks. - IVFD NS : D5% = 1 : 1 = SGOT/SGPT/ 3 about the
20 tpm months disease,
Physical examination: USG, AFP/6 prognosis,
HBsAg reaktif Po. Hepamax 3x1 caps months complication
Total bilirubin 1.00 Lactulosa syrup 3 x 1C Electrolyte and
Bilirubin direct 0.46 Curcuma 3x 1 tab PT-aPTT management
Bilirubin indirect 0.54 to patient’s
SGOT 48 mg/dl family
SGPT 81 mg/dl - Suggest to his
wife to
perform
laboratory
testing for
Hepatitis B

13
 POMR
CUE AND CLUE Problem List Idx PDx PTx Pmo Ped

Mr. I / 56 yo 3. Malnutrition Diet: Planning Planning

Subjective : BBI = 90% (154-100)= 48.6 Monitoring: Education:
- She experienced weight loss KKB= 30 x 48.6 = 1458 S, VS - Give
since 2 months from 47 to 42 K= (70% x 1458 ) : 4 = BMI information
eventhough his appetite is 255.15gr/day Diet recall about his
normal. P= ( 20% x 1458 ) :4 = 72,9 gr/ nutritional
day state and
- IMT 17.7 L= (10% x 1458) :9 = 16.2 management
gr/day to improved it
- Consumption
- Consult to Clinical Nutrition full portion of
Specialist meal

14
 POMR
CUE AND CLUE Problem List Idx PDx PTx Pmo Ped

Mr. I / 56 yo 4. Hipoalbuminemia 4.1 Decrease urinalisis Diet Protein Planning Planning

Subjective : production of liver P= ( 20% x 1458 ) :4 = 72,9 gr/ Monitoring: Education:
- General weakness 4.2 low intake day Urinalisis, - Give
4.3 renal loss cek Ur/cr, information
Laboratory Albumin correction cek about the
- Albumin : 1.8 0.8 x 42 x (2.5 -1.8) = 23.52 gr proteinuri, disease,progno
albumin after sis and
Infus albumin 25% : 100 ml correction management
to patient’s
family
- Increase
consumption
of haruan fish
and egg

15
Thank You

16