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Morning Report
Morning Report
Name : SUP
Age : 63 years old
Sex : Female
Nationality : Indonesian
Religion : Islam
Occupation : Housewife
Address : Jl. Gunung Talang 1, Denpasar
Date : 26th March 2017 (21.26 WITA)
Anamnesis
Past History
No history of having the same complaint before.
Family History
There is no family with the same condition. No systemic
Social History
Patient was is a housewife. Patient has no history of
Vital Signs
BP : 110/70 mmHg
PR : 88 x/min
RR : 20 x/min
Temp. Ax : 39 0C
PHYSICAL EXAMINATION
EYES
Anemic -/-
Icterus -/-
PR +/+ isochoric
ENT
Tonsils T1/T1
NECK
Gland enlargement (-), JVP + 0 cm H20
PHYSICAL EXAMINATION
THORAX
Cor :
Inspeksi : ictuss cordis unseen
Palpation : Ictuss cordis unpalpable
Percussion : UB : ICS II
LB : MCL ICS 5
RB : PSL D
Auscultation : S1S2 Single Regular, Murmur(-)
PHYSICAL EXAMINATION
THORAX
Pulmo:
Inspeksi : Simetris statis & dinamis
ABDOMEN
Inspection : distention (-)
EXTREMITIES
Warm +/+ edema - / -
+/+ -/ -
LABORATORY EXAMINATION
Parameter Result Unit Reference range
3/L
WBC 17,96COMPLETE
(H) BLOOD10
COUNT (7/3/16) 4,10 11,00
-Neu 91,44% 16,43 (H) 103/L 2,50 7,50
-Lym 4,56% 0,82 (L) 103/L 1,00 4,00
-Mono 3,75% 0,67 103/L 0,10 1,20
-Eo 0,01 % 0,00 103/L 0,00 0,50
-Ba 0,24% 0,04 103/L 0,00 0,10
RBC 3,6 (L) 106/L 4,50 5,90
HGB 9,63 (L) g/dL 13,50 17,50
HCT 31,9 (L) % 41,00 53,00
MCV 88,59 fL 80,00 100,00
MCH 31,9 pg 26,0 34,0
MCHC 30,18 (L) g/dL 31,00 36,00
RDW 11,49 (L) % 11,60 14,80
PLT 304,2 103/L 150,00 440,00
LABORATORY EXAMINATION
Parameter Result Unit Reference range
KIMIA KLINIK
AST/SGOT 12,7 U/l 11-27
ALT/SGPT 7,9 (L) U/l 11-34
BUN 26,0 (H) Mg/dl 8-23
Creatinin 1,38 (H) Mg/dl 0.70-1.20
Natrium 134 Mmol/L 136-145
Kalium 4,2 Mmol/L 3.50-5.10
BSA 356 <200
IMAGING
Thorax Photo AP
Cor: Normal in size & shape
Pulmo: Bronchovascular pattern
normal, infiltrate (-), nodul (-)
Costophrenic angles: both sharp
Diaphragm: both normal
Bones & soft tissues: normal
Conclusion:
Heart and Lung within normal limit
ASSESSMENT
DIAGNOSTIC
HbA1c
FL, UL
MONITORING
Complaints