MORNING

REPORT
Juli, 2023
IDENTITY

● Name : Mrs. R
● Age : 64 years old
● Gender : Female
● Address : Batu
● Arrival Date : 07 Juni 2023
● Patient Type : Non-Trauma
 ANAMNESIS

Main Complaint: Pain on the left shoulder and thigh

The patient came to the RSKH ER with complaints of pain in the shoulder and left thigh with a VAS score of 7-8 which was
exacerbated by movement and improved when the patient's arms and legs were rested. The patient fell from a motorbike 3 months
ago with her husband and the left side of the patient's body was crushed by the husband's body. After the incident, the patient went
to Punten Hospital and was given pharmacological therapy so that the pain was reduced but still came and went. During these 3
months the patient can still walk and can still lift things. However, since 3 days before the MRS, the patient complained of severe
pain so that the legs felt heavy and could not walk and pain in the left shoulder so that the left hand hurt when moved. Dizziness (-),
nausea (-), vomiting (-), edema (+), weakness (+) in the right arm.

Past Medical History: The patient has a tumor mammae since 26 years ago
Family History: -
Medicine History: -
 GENERALIST
STATUS
Consciousness
: CM
GCS : 456

BP : 131/55mmHg

HR : 95/minute
RR : 24/minute
SpO2 : 98% on RA
Tax : 36.7 c
 PHYSICAL
EXAMINATION
THORAX :
HEAD/NECK: Cor:
Head Inspection: ictus cordis invisible
Eyes: Anemic conjunctiva (-/-), icteric Palpation: ictus cordis palpable at ICS 5 MCL S
Percussion: Right heart border at ICS 4 PSL D, Left
sclera (-), Isochor pupil diameter heart border at ICS 5 MCL S
3mm/3mm, Light reflex direct and Auscultation: S1 S2 single, regular, murmur (-),
indirect +/+ gallop (-)

Ears : bloody Otorea (-/-) Pulmo:

Nose : epistaksis (-/-) Inspection: normal chest wall shape, retraction (-)
Palpation: symmetrical D/S chest wall movement
Percussion: sonor
Neck : Auscultation:
Inspection: tracheal deviation (-)
Ves + + Wh - - Rh - -
Palpation: enlarged lymph nodes (-) + + - - - -
Auscultation : Bruits (-) + + - - - -

Abdomen
Inspection: Flat, inflammation (-)
scar (-) eritem (-)
Auscultation : Bowel Sounds (+)
8x/minute
Abdominal Percussion: Timpany
Abdominal Palpation: Defans (-)
Superficial and profundus pain (-)
Extremity:
Dry red warm akral +/+/+/+,
CRT< 2, Pitting oedem (-)
PHYSICAL
EXAMINATION
Localist stat
Reg Mammae S:
- Look: a red-brown brownish mass measuring +- 5 cm x 4 cm
is visible above the breast nipple
- Feel: palpable mass, unclear boundaries, fixed, hard lumpy
masses around the papilla mammae, retraction (+),
tenderness (-)
Reg Humerus S
- Look : edema (+), erythema (-), scar (-)
- Feel: palpable edema 4-5cm in diameter, clear boundaries,
tenderness (+), deformity (+)
- Movement : ROM (+) abduction 30 degrees max. adduction
0
CLINICAL PICTURE
 PROBLEM LIST & PLANNING
Problem list Devinitive Diagnosis Planning Planning Therapy
Diagnosis

Main Complaint: - General Weakness • Blood count - Inf NS 0,9% 20 tpm

• Pain on the left shoulder and thigh since 3 months ago - Susp Ca Mamme S • X-Ray Thorax - Inj Ketorolac 2x30mg
after fell of from the motorcycle - Susp Pathologic Fractur APX-Ray - Inj Ranitidin 2x5mg
• Since 3 days before the MRS, the patient complained of severe Humerus S Humerus S - Drip KCL 25 mcg dalam
pain so that the legs felt heavy and could not walk and pain in the - Low back pain A/PX-Ray 500cc
left shoulder so that the left hand hurt when moved
Femur S A/P - NS 20 tpm
• History : Tu mammae since 26 years ago T4N1M1
• Biopsy - D40 2 fl, D10 12 tpm
- Cek GDA
- tramadol drip 100 mg/8
jam
THANK YOU