MORNING

REPORT

pembimbing:
Dr. Ira Nurasyidah, Sp.P
 Patient’s Identity

• Name : Tn. M
• Age : 38 years old
• Religion : Islam
• Race : Banjar
• Status : Married
• Ocuppation : Farmer
• Address : Tinggiran, Kandangan
Hospitalized on: 23/10/2018
 Anamnesis
Main complaint: cough

Patient came to the ER on 23 october 2018 with the chief complaint cough. Patient is reffered
from Ceria Hospital. Patient have already suffering cough since 5 months before admitted to the
hospital and is getting worse 3 months before he admitted to the hospital. Cough with greenish
sputum and without blood, but since 2 weeks ago until now cough without sputum. Complaints
of shortness of breath are denied.

Patient also complain chest pain located in the right side and spread to the back. Chest pain only
arise when he cough and dissappear when he in resting state. The pain is sharp and warm which
felt like being stabbed. According to the patient, the pain scale is 5 to 8. Based on patient’s
explanation that chest pain very disturbed her activity.
Patient also complain fever since 2 weeks before admitted to the hospital. The fever
fluctuates without night sweats and the temprature is decreased when he took medicine.
Patient felt nausea and vomitting 1 times before admitted to the hospital. Decreased
appetite is denied, but patient confesses that he loss of weight.
• History of past illness:
• Patient said that this is the second time he get admitted to the hospital
with the same complaint for 4 days. Patient suffering from DM since 4
years ago. History of HT, Asma, Heart disease, Hepatitis is denied.
• History of family’s illness: TB lung, HT, DM, heart disease are denied
• Smoking history: (+) 2 packs a day since 3 years ago. Now he quit
smoking.
• NAPZA: (-), Alcohol consumption(-)
• Allergy: (-)
• Diet habit: 3 times per day with variety food normal adult portion
 PHYSICAL EXAMINATION
BP: 110/80 mmHg HR= 110 x/menit RR: 18 x/menit Tax= 37,0 ◦C
Sp O2: 98 %
General circumstance: Moderate sickness GCS E4V5M6
Head and skin Pale conjungtivity (-) Rash (-)

Neck meningeal sign(-)

Thorax: Ictus cordis unseen and palpable on ICS V linea midclavicula sinistra, thrill (-)
Cor: S1, S2 single, Murmur (-) gallop (-)
Chest: Simetris (-/+) Palpation: Crepitation (-/-)

Percussion : R S
- - - -
R S ; Aus: rh - - Wh
- -
R S
- - - -

Fremitus fokal dextra/sinistra (-/+)

Abdomen Inspection
Striae (-), scar (-), sikatric (-), venectasi (-),
caput medusa (-)
auscultation: bowel sound : 5x/min

Percussion: tymphany on all abdominal regio

Palpation: hepatomegaly (-) splenomegaly (-)
pain (-)

Ekstremitas Pitting edem on lower extremity (-/-), deformity

(-)
 HASIL PEMERIKSAAN (23/10/2018)
Pemeriksaan Hasil Nilai rujukan satuan

Hemoglobin 11,2 14,0-18,0 g/dl

Lekosit 9,5 4,0-10,5 ribu/ul
Eritrosit 4,32 4,10-6,00 juta/ul
Hematokrit 35,4 42,0-52,0 %
Trombosit 532 150-450 ribu/ul
RDW-CV 13,3 12,1-14,0 %
MCV 81,9 75,0-96,0 Fl
MCH 25,9 28,0-32,0 Pg
MCHC 31,6 33,0-37,0 %
Basofil % 0,2 0,0-1,0 %
Eosinofil% 0,5 1,0-3,0 %
Gran% 83,6 50,0-81,0 %
Limfosit% 9,3 20,0-40,0 %
Monosit% 6,2 2,0-8,0 %
Basofil# 0,02 <1,00 ribu/ul
Eosinofil# 0,05 <3,00 ribu/ul
Gran# 7,96 2,50-7,00 ribu/ul
Limfosit# 0,88 1,25-4,00 ribu/ul
Monosit# 0,59 0,30-1,00 ribu/ul
HEMOSTASIS
Hasil PT 11,5 9,9-13,5 Detik
INR 1,06 -
Control normal PT 10,8 -
Hasil APTT 26,6 22,2-37,0 Detik
Control normal APTT 24,8 -
KIMIA
DIABETES
Gula Darah Sewaktu 105 <200,00 mg/dl
HATI DAN PANKREAS
SGOT 23 5-34 U/L
SGPT 92 0-55 U/L
GINJAL
Ureum 35 0-50 mg/dl
Kreatinin 0,86 0,72-1,25 mg/dl
ELEKTROLIT
Natrium, 133 136-145 Meq/L
Kalium 4,1 3,5-5,1 Meq/L
Chlorida 103 98-107 Meq/L
CXR (23/10/2018)
 CUE AND CLUE Problem List
POMR PDx PTx Pmo

Ax: 1. Fluido pleural fluid analysis intercostal drainage (ICD)

-Chest pain located in right side pneumothorax arterial blood gases. tube insertion
-sharp and warm which felt
like being stabbed
PE:
Movement of chest: asimetrical
Percussion: dullnes (+/-)

CXR:

Lab 23/10/2018
 CUE AND CLUE Problem List
POMR
PDx PTx Pmo

Ax: 1. Lung TB new case

Cough for 5 month
lose of weight
Night sweats

PE:

CXR:

Lab 23/10/2018
Thank You