MORNING REPORT

05 May 2015

Consulen:
Dr Hj Nurul Aina, Sp,PD

DATA PASIEN
Name
Sex
Age
Race
Address

: Mr B
: Male
: 60 yo
: Banjar
: Jl. Kebun Bunga

AUTOANAMNESIS
Chief Komplain : Lost of appetite
Patient came after his monthly routine checkup from Policlinic of
geriatric because he lost his appetite. This caused pain on his
stomach and he felt nausea as well. Vommiting (-). The patient also
found lack of sleep. BAK (+). Dizziness (+). Weight loss (+)
History of illness : DM 9 years ago. Took medicines such as metformin,
novamid, Decolin, Aspilet, and glemipirid
History of family illness: (-)

Physical Examination
General
Looks
: Mild illness
Awareness
: Compos Mentis
GCS
: 4-5-6
BP
: 130/90mmHg left arm
N
: 110x/menit,
RR
: 20x/menit
T
: 35.4o C
SaO2
: 96%

Physical Examination
Skin

: Skin turgor normal , rash (-), ikterus(- ), hairfall(-)

Head : normosefali, pain(-)
Eye : konjungtiva anemis (+), edem palpebra(-/-),
sklera ikterik(-)
Ear
: deformitas(-), otoreea(-), tragus pain (-), mastoid
pain(-)
Nose : Deviation (-), rinorreha(-)
Mouth : Lip mukosa normal, sianosis(-), thypoid tongue(-),
hiperemis lip(-).
Throat: tonsilitis(-)
Neck : JVP (-), P> KGB (-), P> tiroid(-), pain (-)

Physical Examination
Thorax
gynecomastia(-), sekret(-), massa(-), spider naevi(-)
c0r
ictus visible,
palpation ICS V LMC S, cardiac waves(-)
Right margin LPSD ICS II-IV, Left margin LMCS ICS V
S1 S2 single, murmur (-), gallop (-)
p/ Ins : retraction (-)
Pa
: FV Simetris
Per : S S
S S
S S
Aus : V V rh - - Wh - V V
-- V V
-- -

Physical examination
Abdomen :

I : Cembung , venektasi (-), caput medusa(-), sikatrik(-)

Aus : Intestine sound normal.
Pa : Hepar normal, Lien normal, shifting dullness(-), undulasi (-)
Pain
-+-+- - Per : T T T
TTT
TTT
Ekstremitas : deformitas(-), palmar eritem(-)
edema - akral dingin - ---

Lab finding
There is no laboratory finding yet.
The only information was about the
patient fasting plasma glucose at 7
am: 237 mg/dL
-

Resume data dasar

Anamnesis: Anorexia(+), Epigastric pain(+), nausea(+)

Lack of sleep(+) History of DM (+) Weight loss (+)

Physic. : pale konjungtiva
Lab: GDS= 237mg/dL

CUE AND CLUE

PROBLEM LIST

INITIAL
DIAGNOSE

1. Mr.B/male/60
Y.O

1.Lost of
appetite
2.Epigastric
pain
3.Nausea
4.Lack of
sleep
5. History of
DM
6. Weight loss
7. Pale
Conjunctiva

1. Anorexia
Geriatri
e.c
dispepsia
2. DM type
II on
therapy
3. Anemia

Ax:
-Lost of appetite
-Epigastric pain
-Nausea
-Lack of sleep
-Weight loss
-history of
diabetes mellitus
-Pale Conjunctiva
GDS: 237mg/dL

PLANNING
DIAGNOSE

BNO
OMD
Endos
copy
GDP/2
JPP
DL

PLANNING THERAPY

P mon

Non Pharmacologic:
Bed rest
Dietary Program

VS, subject
complaints,
DL/day
GDP/2JPP
per day

Pharmacologic:
IVFD RL:Martos
20tpm
Inj. Ranitidin
2x1amp.
Inj. Ondancentron
3x4mg
Transfusion 1 colf if
Hb 10 mg/dL

THANK YOU