MORNING REPORT

Wednesday, 24th April 2019

Mentor:
….
 Patient Identity
Sex : Male
Name : Mr. D
Age : 74 y.o
Occupation : Coal miners
Hospitalized since : April, 23th 2019
 Resume of Medical Record

• Chief of complaint: Cough

Patient came to the hospital with chief of complain cough.
Cough occurred since 6 month ago. He said the cough with
brown sputum 2 days ago. Patient was treated a month ago
but it was stop . Sweating at night (+) , fever (+) , nause &
vomit (-/-), loss appetite (+), general weakness (+)
• History of past illness: TB was treated
• Medical History : Treatment of TB 1 years ago
• Family History : -
• Social history: smoking (+) but was stop 30 years ago
• History of allergy: -
 PHYSICAL EXAMINATION

BP= 110/70 mmHg HR: 100x/minute RR = 24 x/minute T : 36,5 ◦C

General Condition : looked moderately ill GCS 456

Head Anemic Conjunctiva (-) Skin : turgor < 2 second

Neck JVP= R +2 cm H2O

Thorax: Cor: Ictus cordis invisible, palpable on ICS V MCL sinistra
LHM = ictus cordis RHM : SL D
Murmur (-)

Lung: Simetris , S S V V Rh - - Wh - -
S S V V + - - -
S S V V - - - -

Abdomen Rounded, bowel sound N, liver span 10 cm, troube space tympani, shifting
dullness (-), caput medusae (-), venectasi (-), aortic pulse non-palpable

Ekstremitas Weakness on foot

 Laboratory Finding
Lab Value Lab Value
Hb 13,4 12,5-16,7 g/dl Gran% 85,5 50,0-70,0 %
Leukosit 15,5 4,65-10,5 ribu/ul Lym% 6,4 25,0-40,0 %
Eritrosit 4,61 4,10-6,00 juta Mono% 7,9 2,5-7,0 ribu/ul
Hematokrit 38,2 42,0-52,0 vol% Gran# 13,23 2,50-7,00 mg/dl
Trombosit 391 150-356 ribu/ul Limfosit# 0,99 1,25-4.0 mg/dl
RDW-CV 12,5 12,1-14,0%
MCV 82,9 75,0–96,0 fl Mono# 0,3
MCH 29,1 28,0-32,0 pg SGOT 20 0-46 u/l
MCHC 35,1 33,0-37,0 % SGPT 9 0-45u/l
Ureum 21 10-50 mg/dl Natrium 131 135-146 mmol/l
Creatinin 0,94 0,7-1,4 mg/dl Kalium 3,6 3,4-5,4 mmol/l
 POMR
CUE AND CLUE Problem Idx PDx PTx PMo
List
D/74 yo 1. Cough + RO thorax Mo.
Cough since 6 month ago general Complain,
Brown sputum weakness
History past illnes TB

Complete feces,
Colonoscopy,

Mo.
Complain,
Vital Sign,
Complete
Blood Test

Mo.
Complain,
Conjungtiva
Examination,
Vital Sign,
Complete
Blood Test
 CUE AND CLUE Problem Idx PDx PTx PMo
List
M/54 yo 4. 4.1 Hepatorenal USG renal Rehidrasi Fluid
Bloody vomit Hiperurisemia syndrome balance
Black tarry stool Mo Ur/Cr
History past illnes same
complain (+) asites (+)
hepatitis B (+)
5. 5.1 Hepatorenal Kalitake3 x 1 Fluid
Anemic conj (+/+) Hiperkalemia syndrome sach balance
Icteric sclera (+/+) Mo serum
electrolit
lab
Hb 7.6 g/dl
MCV 88,7
MCH 24,5
HBsAg (+) reaktif
Ur/cr 103/1,1
K 6,2
Thank you