MORNING REPORT

Wednesday, 14th August 2019

TEAM:
COASS ATANTA COASS RAUDHAH
COASS AGNES COASS SEKAR
ADVISER : DR. DIKARA WS MAULIDY, SP.PD

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 Patient identity
Name : Mrs. P
age : 53th
Religion : Moslem
Ethnic : Dayak
Occupation : Farmer
Address : palangkaraya

Hospitalized since: August, 14th 2019

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 Anamnesis
Chief Complaint: Weakness
Auto anamnesis
Patient came to Ulin Hospital with the complaints of weakness, she experience
weakness since 3 weeks ago. the patient felt weakness all over her body, came of
sudden and continously. She experienced nasuea without vomit, and also pain
and burning sensations on her back. She was brought to Doris Hospital in
Palangkaraya first because of the complaints of weakness. Before went to Doris
Hospital, the patient also complain of nausea and vomit since before she came to
the hospital, she didn’t feel like eating because of the nausea. The patient
vomitted three times, without blood, with the characteristic of the vomit is,
yellow color and the content of the vomit could be food, or saliva.

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Anamnesis
She also complaint having black feces two times, and denied having any fever.
She denied having any trouble in urination. In Doris Hospital, the patient
vomitted two times. The patient said, when she tried to eat she felt nausea and
then she vomitted. Patient developed fever on her second day in Doris Hospital.
The fever came so sudden, and then she experienced pain and burning
sensations on her back. the patient complain about having fluid-fills bumps on
her back.

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Anamnesis
the patient said, she had been consuming pain reliever drug every night before
going to sleep since months ago, because she like to feel pain all of her body,
because of her job. The patient denied having any hypertension nor diabetes
mellitus in the past.

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Anamnesis
History of past illness : the patient have history of tuberculosis in 2000 with 6 months treatment,
she had varicella zoster when she’s at elementary school
Treatment History : tuberculosis 6 months treatment, and using pain reliever drug every night
before going to sleep since months ago
Family History : HT (-), DM (-)
Social history: the patient live with her child an her child’s family
History of allergy: She hasn’t

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 BP =130/80 mmHg HR = 102x bpm RR= 20 x/minute weight= 50 kg
PHYSICAL Regular, lift strength T : 36,8 ◦C height= 160 cm
EXAMINATION Sa: 98% IMT = 19,5

General condition: looked mildly ill (VAS 4) GCS E4V5M6 compos mentis
Eyes and skin -Sclera: icteric (-/-) Skin : turgor < 2 second
-Conjungtiva: pale (+/+) Rash(-), petekie (-), clustered vesicle (+) as high of
T4

Head and Neck Nuchal rigidity(-), JVP R+2 cmH2O with bed 30o
Thorax: Ictus cordis invisible, 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 symmetry
Percution S S Auscultation: Breath sound V V Rh - - Wh - -
S S V V - - - -
S S V V - - - -

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Abdomen Inspection: rounded, Striae (-), scar (-), caput
medusae (-), venectasi (-)
Auskultation bowel sound (+)
Palpation:
Abdominal pain : - + -

- - -

- - -

Percution : liver span 8 cm, troube space tympani,

shifting dullness (-)

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

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Laboratory findings
Lab Result Value Lab Result Value

Haematology Ureum 16 0 – 50
Haemoglobin 6.5 14.0 – 18.0 Creatinine 0.74 0.57 – 1.11

Leukocyte 13.7 4.0 – 10.5

Erythrocyte 1.53 4.10 – 6.0 Natrium 145 136 – 145

Haematocrit 21.0 42.0 – 52.0

Platelet 325.000 150 – 450 Kalium 3.2 3.5 – 5.1

MCV 137.3 75.0 – 96.0 Chloride 107 98 – 107

MCH 42.5 28-32

MCHC 31.0 33-37
Basophils 0.2 0.0 –1.0

Eosinophils 0.2 1.0 – 3.0

Granulocytes 59.1 50.0 – 81.0

Lymphocytes 33.2 20.0 – 40.0

Monocytes 7.3 2.0 – 8.0

SGOT 34 5 – 34

SGPT 38 0 – 55

Plasma glucose 92 <126

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 POMR
CUE AND CLUE Problem Idx PDx PTx Pmo Ped
List
Mrs. P / 53 yo 1. Anemia 1.1 AIHA - Reticulocyte Diet: c/ Vital signs Disease
Macrocytic test BBI = 90% (160-100)= 45 c/ blood routine education,
Subjective : 1.2 Folic Acid - Coomb’s test KKB= 30 x 45 = 1350 bed rest
- The patient complain Deficiency K= (70% x 1350 ) : 4 = 236
weakness all over her body gr/day
since 3 weeks ago 1.3 B12 deficiency P= ( 20% x 1350 ) :4 = 67 gr/
- Patient also having black feces day
2 times before she came to L= (10% x 1350) :9 = 15 gr/day
Doris Hospital -IVFD RL
Infusion:
Physical examination: 10x100 = 1000
Conjunctiva pale (+/+) 10x50 = 500
30x 20 = 600
Laboratory findings:
Hb: 6.5; leukocyte: 13.7 2100
MCH : 137.3; erytrocyte: 1.53 2100x20
MCV : 42.5 24x60 = 29 tpm
MCHC : 31.0 Blood Transfusion (PRC):
= ΔHb x 3 x BW
= (10-6.5) x 3 x 50
= 3.5 x 3 x 50
= 525 cc
PO:
-Folic acid 1x3 tab (1 gr)

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 POMR
CUE AND CLUE Problem Idx PDx PTx Pmo Ped
List
Mrs. P / 53 yo 2. 2.1 Upper GIT - Endoscopy -Stop NSAID drug c/ Vital signs Disease
Gastrointestinal bleeding ec. -IVFD RL education,
Subjective : bleeding NSAID Infusion: bed rest, stop
- The patient complain consumption 10x100 = 1000 any pain
weakness all over her body 10x50 = 500 reliever drug
since 3 weeks ago 30x 20 = 600
- Patient also having black feces
2 times before she came to 2100
Doris Hospital 2100x20
- She consumed pain reliever 24x60 = 29 tpm
drug every night before going
to sleep to relieve pain - Omeprazole injection 1x40mg
- sulcralfat 3x10 cc
Physical examination: - Gastric lavage with cold NaCl
Conjunctiva pale (+/+)

Laboratory findings:
Hb: 6.5
erytrocyte: 1.53

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 POMR
CUE AND CLUE Problem List Idx PDx PTx Pmo Ped

Mrs. P / 53 yo 3. Herpes Zoster PO: c/ Vital signs Disease

Subjective : - Acyclovir tab 4x800 mg education,
- Patient said having fever on - Ibuprofen tab 3x200 mg bed rest.
her second day in Doris
Hospital
- She also complaint having
pain and burning sensations
on her back
- She had varicella zoster when
she’s at elementary school

Physical examination:
Clustered vesicle on her back (+)
as high of T4

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 POMR
CUE AND CLUE Problem List Idx PDx PTx Pmo Ped

Mrs. P / 53 yo 4. Dispepsia 4.1 Gastritis - Endoscopy -IVFD RL c/ Vital signs Disease

Subjective : syndrome 4.2 Peptic ulcer Infusion: education,
- Patient said having nausea 10x100 = 1000 bed rest,
and vomitted before going to 10x50 = 500 prevent for
Doris Hospital 30x 20 = 600 eating sour
- Patient vomitted 3 times at and spicy
home, then vomitted again 2 2100 food, eat with
times when she was in Doris 2100x20 a little
Hospital 24x60 = 29 tpm portion but
- Patient still complaint nausea more often
and can’t eat properly -Metoclopramid 3x10mg (prn
because of the nausea vomit)

Physical examination
- Epigastric pain (+)

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Thank You

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