Morning &

Duty
Report
MORNING & DUTY REPORT
 OVERVIEW

New Patients:

Emergency Patients
MMORNING AND DUREPORT

Non Emergency Patients

1

Yendrawati/Female/50 YO/FW 16
Chief Complaint:
• Red spot all over the body increased 3 days ago
Present Illness History
• Red spot all over the body increased 3 days ago, this complaint has
been felt since 2 weeks ago, Itchness in the red spots (+)
• History of vaccination for covid 19 3 weeks ago, 1 week after
vaccination start to appear the red spots
• Hystory of consume drugs like amoxicillin, ibufropen and
mefenamat acid 1 weeks ago, and after that this complaint more
increasing
• Reduced frequency of urination since 1 weeks ago
1

Yendrawati/Female/50 YO/FW 16
Present Illness History

• There is no breathlessne
• There is no fever
• There is no cough
• Defecation was normal
• Patient has been known with DM type II since 5 years
ago and routine consumed metformin 3 x 500 mg
• Patient has food allergic history with egg and fish
Past illness history

• History of DM (+) since 5 years ago and

routine got metformin 3 x 500 mg
• History of hypertension (-)

Family illness history

• History of family member with the same

disease (-)
Physical Examination
VII

• General Appearance : Moderete

• Consciousness level: CMC

• BP : 90/60 mmHg

• HR : 95x/minute

• RR : 20 x/minute

• T : 36.5 º C

• SaO2 : 98%
• Eye VII
– conjunctiva anemic (-)
– Icteric sclera(-)
• Neck
– JVP 5-2 cmH20
• Lung:
– Inspection: statically & dynamically symmetric
– Palpation: fremitus right=left
– Percussion: sonor
– Auscultation: vesicular, Rh -/- Wh -/-
• Cor: VII
– Inspection: ictus is not seen.
– Palpation: ictus is palpated at 1 finger medial LMCS ICS V
– Percussion:
 Left border: 1 finger medial LMCS ICS V
 Right border: linea sternalis dextra
 Upper border: ICS II
– Auscultation: regular, murmur (-), gallops (-)
• Abdomen: VII
– Inspection: enlargement (-)
– Palpation: hepar and lien not palpable
– Percussion: tympani
– Auscultation: bowel sound (+) N

• Extremities:
– Oedema pretibia -/-
– Physiologic Reflex +/+
– Pathologic Reflex -/-
• Localis state VII
– Iocated: face, thorak , abdomen, extremities
– Distributed : generalisated
– Size : plak
– Efflorecense : macula, skuama, krusta
Laboratory
Items Value VII
Hb 13.3 gr/dl
Ht 38 %
WBC 24.580 /mm3
Platelet 302.000/mm3
Diff. Count 0/9/55/31/5
Ur/Cr 56 / 1.6 mg/dl
SOGT/SGPT 18/27 U/L
Na/K/Cl 132/3.8/105 mmol/L
RBG 311 mg/dl
Albumin/Globulin 2.1/2.3 g/dL
BGA 7.35/14.2/122.9/7.9/-14.7/97.4%
PT/APTT/D-Dimer 12.1/31.4/3437
Chest X-Ray VII
ECG VII
Before After
IVC
Problems
• Drug eruption
• Hipercoagulable state
• Hypoalbuminemia
• Hyperglikemia
Working Diagnosis

• Allergy drug eruption

• Syok hypovolemic
• Diabetes melitus type II uncontrolled normoweight
• AKI stage I cb prerenal cb dehidration
• Hypoalbuminemia cb low intake
• Hypercoagulable state
Therapy

 Rest/ soft diet diabetes 1500 kkal

 Loading IVFD Nacl 0,9% 3 kolf then IVFD Nacl 0.9 % 6 hours/kolf
 Novorapid 3 x 8 IU sc (correction dose)
 Metilprednisolon 20 -16 – 8 mg
 Cetirizin 1 x 10 mg
 Lansoprazole 1 x 30 mg
 Transfussion albumin 20 % 100 cc
 Momethasone furoate cream 0.1% twice a day
Plan

• Check Ige Total