MORNING REPORT

FRIDAY, SEPTEMBER 28TH 2018

 PATIENT IDENTITY

 Initial : RCO
 Sex : Male
 Age : 24 years old
 Religion : Moslem
 Ethnic : Javanese
 Marital Status : Unmarried
 Address : Jl. Mahendradata - Denpasar
 Time of arrival : September 27th 2018 at 19.30
 No. Med. Record : 18039816
ANAMNESIS

Chief complaint: Cough

Present history:
Patient came to emergency department of Sanglah Hospital
complaining about coughing that he has since 2 months before
admitted to the hospital.
 Cough emerged suddenly and persistent
 Cough came along with white colored sputum
 The complain was felt worsening since 2 days BATH until patient
felt his throat sore and affecting his appetite because he couldn’t
properly swallow the food
The patient also complained fever since more than 1 month ago
 The fever was fluctuating but 1 day BATH he felt the fever was
raising
 He has took some medications to decrease the fever but it
didn’t get better

Loss of appetite is confirmed

Patient was also complaining about losing weight in the past 2
months as he already lost 9 kg (from 62 kg to 53 kg)
The patient also complained cold sweating at night for the past 2
months
Urination and defecation were normal.
Past Illness History

 Patient never had these kind of complains before. History of

systemic disease such as hypertension, kidney disease, DM,
etc were denied. History of respiratory tract disease was
also denied.
 Patient had been operated due to his appendicitis in 2016.
Family History
 No family member of the patient has the same complain
with the patient.

Social history:
 Multipartner sexual history is confirmed.
 Habit of drinking alcohol and smoking was denied.
 Patient is a college student.
 PHYSICAL EXAMINATION

Present State
General appearance : Moderate ill
Level of consciousness : Compos mentis, GCS E4V5M6
BP : 100/70 mmHg
PR : 94 x/min, regular, strong pulse
RR : 24 x/min, regular
Tax : 38.8ºC
VAS : 2/10
SpO2 : 93% room air
General State
 Eyes : conjunctiva anemic (-/-); sclera icterus (-/-), reflex
pupil (+/+), isokor, palpebral edema (-/-)
 ENT : Tonsils T1/T1; pharyngeal hyperemia (-); oral
plaque (+)
 Neck : JVP PR +0 cmH2O; enlargement of regional
lymph nodes (-)
Oral Candidiasis
Thorax : symmetrical
Cor
Inspection : Ictus cordis unseen
Palpation : Ictus cordis palpable at ICS V MCL sinistra
Percussion :
UB : ICS II Sinistra
LB : MCL ICS V Sinistra
RB : PSL Dextra
Auscultation : S1 S2 normal regular, murmur (-)
Pulmo
Inspection : Symetric
Palpation : symetric, Vokal fremitus normal
Percussion : sonor in all the lung lobes
Auscultation : vesicular + + , Rh - - , Wh - -
+ + - - - -
+ + - - - -
Abdomen :
 Inspection : Distention (-), scar (+) midline below umbilicus
 Auscultation : Bowel sounds (+) normal
 Palpation : tenderness (-) ; liver and spleen not palpable
 Percussion : timpani (+)

Extremities : Warm +/+, oedema -/-

Dermatology State :
TINEA CORPORIS

 Regio : ante brachial

posterior
 Efflorescence :
erythematous macula,
soliter, geographical shape,
clear margin, 5x6 cm,
there’s white thin scuama
above the lesion, active
margin
Veruca Vulgaris

 Regio : Fascial
 Efflorescence :
erythematous papula,
soliter, circle shape, clear
margin, 1 cm diameter,
lesion surface is rough.
COMPLETE BLOOD COUNT
Parameter Result Unit Remarks Reference Range

WBC 8.44 103/μL 4.1 – 11,00

-Ne 71.46 % 47,00 – 80,00

-Ly 22.25 % 13,0 – 40,0

-Mo 5.00 % 2,00 – 11,00

-Eo 0.32 % 0,00 – 5,00

-Ba 0.97 % 0,0 0 – 2,00

RBC 4.83 106/μL Low 4,00 – 5,20

HGB 12.54 g/dL Low 13,50 – 17,50

HCT 39.44 % 36,00 – 46,00

MCV 81.70 fL 80,00 – 100,00

MCH 25.98 pg Low 26,00 – 34,00

MCHC 31.80 g/dL 31,00 – 36,00

RDW 11.83 % 11.6-14.8

PLT 197.40 103/μL 150,0 – 440,0

Parameter Result Unit Remarks Reference Range

Random blood 101 mg/dL 70-140

sugar level
 Blood Chemistry

Parameter Result Unit Remarks Reference range

SGOT/AST 44.2 U/L High 11.00 - 33.00
SGPT/ALT 41.60 U/L 11.00 - 50.00
Albumin 3.30 g/dL Low 3.40-4.80
BUN/ureum 15.00 mg/dL 8.00 - 23.00
LDH 1581 U/L High 240-480
Creatinine 0.78 mg/dL 0,70-1,20
Kalium (K) 3.89 mg/dL 3.50 - 5.10
Natrium (Na) 137 mmol/L 136 – 145
Blood Gas Analysis &
Electrolite
Parameter Result Unit Remarks Reference
range
pH 7.48 high 7.35-7.45

pCO2 33.2 mmHg Low 35.00-45.00

pO2 169.60 mmHg High 80.00-100.00

HCO3- 24.30 mmol/L 22.00-26.00

Natrium 137 mmol/L 136-145

(Na)
Kalium (K) 3.89 mmol/L 3.50-5.10

Chloride 82 mmol/L Low 96-108

(Cl)
IMAGING RESULT
thorax AP
 Cor and pulmo : normal size and
shape
 Infiltrat/nodul was not seen
 Pulmo: broncovascular pattern
no sign of specific proses in both
lung
 Right and left pleural sinuses are
sharp
 Right and left diaphragm is
normal
 Bones: no abnormalities
Impression:
 Cor : Normal
 Pulmo : no sign of specific proses
in both lung
ASSESSMENT

 Susp. HIV infection stage IV (WHO)

 Wasting syndrome
 Oral candidiasis
 Susp. Lung TB
PLANNING

■ IVFD NaCl 0.9% 20 dpm

■ O2 4 lpm nasal canule
■ Nistatin 10 drops every 8 hours
■ Paracetamol 500 mg every 8 hours
■ N. Acetyl Systein 200 mg every 8 hours
■ PDx:
■ BTA sputum 2x
■ Gene expert
■ HbsAg & anti HCV
■ Anti HIV
■ KOH Swab
MONITOR
■Vital Sign
■Complain
Thank you