MORNING REPORT

Wednesday, November 16th 2021

DM Dieny
DM Gio

dr. Amrul, Sp. B

 Patient 1
Name : Mr. Alimudin Kanna

Sex : Male

Age : 46 years old

Admission date : Thursday, November 18th 2021

No. MR : 542351

2
 History Taking
Major Complaint/Discomfort : pain in right thigh

Current Medical History :

The patient came with complaints of pain in the right thigh. Pain is felt in the area of ​the lump in the
right thigh. The pain feels like throbbing and continuous. The pain started 2 weeks ago, after a biopsy
at Wirasakti Hospital. Initially the lump that appears is small, but then it gets bigger, making it difficult
for the patient to walk. History of trauma (-), fever (-), nausea (+), vomiting (-).

History of past illness :

The patient had gone to an orthopedic and was told that the patient had osteoporosis. Then an X-ray
was performed and a tumor was found on the right thigh, so he was referred to an oncologist.
Hypertension (-), DM (-), Heart (-)

History of medicine :
History of taking antibiotics but the patient forgot the name of the drug

History of social/lifestyle :
Smoking (+) but has stopped for 6 months, alcohol (-)

3
 PHYSICAL EXAMINATION 4

General state: moderate illness

Karnofsky score: 70%
BP: 141/90 mmHg
RR : 22 x/m
HR : 122 x/m
Temperature : 36.7 C
SpO2: 98%
 5

Status Generalis
Head : Normocephal
Eye : anemic conjungtive -/-, icteric scleral -/-,pupil isokhor 2 mm/2 mm, light reflex (+)
Ear : Otorhea(-/-)
Nose : Rhinorea -/-, nostril breathing (-)
Mouth : lip mucous was wet, cyanosis (-)
Pulmo
– Inspection : Symmetrical chest expansion, retraction (-)
– Palpation : Crepitation (-) tenderness (-)
– Percussion : Sonor (+/+)
– Auscultation : Vesikuler (+/+) , Ronchi (-/-), Wheezing (-/-)
 6

Cor
Inspection : Iktus cordis not seen
Palpation : Iktus cordis not palpable
Auskultation : S1-S2 reguler, single, murmur (-), gallop (-)

Abdomen
Inspection : Flat, mass/lesion (-)
Ausculation : Bowel sound (+)
Palpation : Distention (-), tenderness (-)
Percussion : Tymphani

Ekstremitas : There is a lump in the right femur region covered with

gauze, blood (-), pus (-), tenderness (+), atrophy (+) a/r cruris dextra
 7
18/11/2021 Unit
Hb 11.4 g/dL (L)
RBC 3.89 x 10^6/ul (L)
HCT 32.5 % (L)
WBC 21.83 x 10^3 /uL (H)
Neutrophil 16.58 x 10^3/uL (H)
Lymphocyte 3.64 x 10^3/uL
Monocyte 0.90 x 10^3/uL (H)
Eosinophil 0.57 x 10^3/uL (H)
Basophil 0.15 x 10^3/uL (H)
Platelets 701.90 x 10^3 /uL (H)
Blood sugar 169.00 mg/dL
 8

Creatinin serum 0.47 mg/dL

Urea N 6.00 m.dL
Natrium 125 mmol/L (L)
Kalium 2.78 mmol/L (L)
Clorida 99 mmol/L
Calcium ion 1.04 mmol/L (L)
Total Calcium 2.68 mmol/L (H)

Pathology anatomy (11-11-2021) : metastasis adenocarcinoma

 Assessment

Metastasis adenocarcinoma inguinal (D)

9
 TREATMENT

- IVFD NaCl 0.9% 20 tpm

- Inj. Ranitidin 1 amp iv
- Inj. Ketorolac 1 amp iv

10
 Patient 2
Name : Mrs. Yesri Yulianti Foes

Sex : Female

Age : 24 years old

Admission date : Thursday, November 18th 2021

No. MR : 548902

11
 History Taking
Major Complaint/Discomfort : stomach pain

Current Medical History :

The patient was referred from Rote with complaints of abdominal pain after giving birth 14 days ago.
Pain is felt throughout the abdomen. The pain feels like a stabbing and lasts continuously. Complaints
are also accompanied by pain when urinating. Fever (+) vomiting (+) every time you eat, can't fart,
defecate (+) watery > 1 time a day, blackish color mixed with mucus, dregs (-) blood (-), still felt today

History of past illness : -

History of medicine (RSUD Ba’a):

IVFD RL 20 dpm Ceftriaxone 2x1 g iv
ARV according to internal medicine doctor Metronidazole 3x500 mg iv
Paracetamol 3x500 mg Cotrimoxazole 2x960 mg iv
Metoklopramid DC& NGT decompretion
Omeprazole 2x1 amp iv Neostigmin according to surgeon
Vit. B6

History of social/lifestyle : -
12
 PHYSICAL EXAMINATION 13

General state: moderate illness

BP: 127/86 mmHg
RR : 20 x/m
HR : 103 x/m
Temperature : 38.4 C
SpO2: 99% with 02simple mask 6 lpm
 14

Status Generalis
Skin : Pale
Head : Normocephal
Eye : anemic conjungtive +/+-, icteric scleral -/-,pupil isokhor 2 mm/2 mm, light reflex (+)
Ear : Otorhea(-/-)
Nose : NGT installed, gastric fluid is greenish
Mouth : lip mucous was wet, cyanosis (-)
Pulmo
– Inspection : Symmetrical chest expansion, retraction (-)
– Palpation : Crepitation (-) tenderness (-)
– Percussion : Sonor (+/+)
– Auscultation : Vesikuler (+/+) , Ronchi (-/-), Wheezing (-/-)
 15

Cor
Inspection : Iktus cordis not seen
Palpation : Iktus cordis not palpable
Auskultation : S1-S2 reguler, single, murmur (-), gallop (-)

Abdomen
Inspection : convex, distended (+)
Ausculation : Bowel sound (-)
Palpation : Tenderness in the right and left lower quadrants, the height
of the uterine fundus is palpable 2 fingers above the pubic symphysis
Percussion : Tymphani

Ekstremitas : warm acral, CRT <2 sec, non-pitting edema in the right
hand, right foot, left foot
Genitalia : installed DC, urine output 600 cc, yellow
 16
18/11/2021 Unit
Hb 9.6 g/dL (L)
RBC 4.22 x 10^6/ul
HCT 30 % (L)
WBC 15.32 x 10^3 /uL (H)
Neutrophil 11.83 x 10^3/uL (H)
Lymphocyte 1.89 x 10^3/uL
Monocyte 1.35 x 10^3/uL (H)
Eosinophil 0.12 x 10^3/uL
Basophil 0.12 x 10^3/uL (H)
Platelets 336.50 x 10^3 /uL
Blood sugar 89 mg/dL
 17

Creatinin serum 0.45 mg/dL

Urea N 15.00 m.dL
Natrium 138 mmol/L
Kalium 3.98 mmol/L
Clorida 113 mmol/L (H)
Calcium ion 1.11 mmol/L (L)
Total Calcium 2.20 mmol/L (H)
PT 11.50 sec
INR 1.12
APTT 22.70 sec (L)
BNO 18
19
 20

Expertise of BNO

- Ground glass image in the abdominal cavity

- Decreased intestinal gas distribution
- Currently, no pneumoperitoneum is seen
 Assessment

Susp. Ileus Obstruktif (e.c post partus uterus) +

HIV infection clinical stage II on ARV

21
 TREATMENT

- IVFD NaCl 0,9% 1000 cc/24 hours, D5 500 cc/24 hours, asering
500 cc/24 hours
- blood culture
- Ciprofloxacine 2x200 mg iv
- Metronidazole 3x500 mg infus
- Omeprazole 2x40 mg iv
- Metoklopramid 3x1 amp iv
- NGT flowed
- milk diet 6x100 cc p.o

22
Thank you

23