MORNING REPORT

• Name : Mr. W
• Age : 50 Years old
• Hospitalized : 26 December
• Doctor : dr. Rinaldy Sp.P
• Member of Duty : dr. Yuris
dr. Fajar
dr. Wawan
dr. Saiful
dr. Vonna
dr. Wirio
dr. Juanda
dr. Putri
dr. Vina
dr. Afra
dr. Yenni
dr. Anna
 Disease history Mr. W, 50 years old

Chief Complaint : Shortness of breath since 3 days ago

Other Complaint : Cough of phlegm , chest pain

Patient came with complaints of shortness of breath since 3 days ago. Shortness
of breath is not affected by weather, dust, or c foods. Shortness of breath is not
affected by activity. Shortness of breath is worse if the patient coughs
continuously and slightly relieved if the patient is in a sitting position. Shortness
of breath is not accompanied by wheezing. History of shortness of breath was
denied. The patient also complained of cough with phlegm. Cough with phlegm
was felt since 3 days ago. Cough with greenish-yellow phlegm. History of
coughing up blood (-) history of long cough (-). The patient also complaints
chest pain when coughing. Chest pain has been felt since 3 days ago. Chest pain
does not radiate to the back and arms. The patient also complaint of fever. Fever
was felt since 5 days ago. Fever improves when the patient takes the medicine.
Fever was accompanied by chills at night. Night sweats (-). Appetite decreased
since a few days, nausea (+) vomiting (-) weight loss decreased 6 kilograms in
the last 2 months. Urination and defecation are within normal limits.
 Mr. W, 50 years old

• Disease History : Lung Tuberculosis (-), Asthma (-)

• Drug History : OAT (-), OAD (-), OAH (-)
• Allergic History : None
• Family History : None of the family members suffer from the
same disease
• Work History : Honorary employee
• IB : (240) Moderate
 Physical Examination (26-12-2023) Mr. W, 50 years old

Mouth
General status : Weakness
: Hygiene looks
Awareness good
: Compos mentis
Blood presure :
116/72 mmHg
Hearth rate Pursed Lips breathing (-)
: 101 bpm Neck
Respiratory rate : 26 x/i :
Temperature Hypertrophy of lymph (-),
: 38,0 oC

Swelling neck (-)

SpO2
Cor
: 91% room air
: Heart sound I-II regular,
murmur and gallop
negative
: 95% NK 3 Lpm Genitalia : normal limits
 Mr. W, 50 yo

Physical Examination of Lung

Inspection
Simetric, use of accessory muscles of breath (-), rib retraction (-),

Palpation
Upper Lung field SF Left = SF Right

Medial Lung field SF Left = SF Right

Lower Lung field SF Left = SF Right

Percussion Right Left

Upper Lung field sonor Sonor
Med Lung field sonor Sonor
Lower Lung field sonor Sonor
 Mr. W, 50 yo

Physical Examination of Lung

Auscultation Right Left

Upper lung field Ves (+) Ves (+)

Med lung field Ves (+) Ves (+)

Lower Lung Field Ves (+) Ves (+)

Rhonki
Upper Lung Field + +
Med lung Field - -
Lower Lung Field - -
Wheezing
Upper Lung Field - -
Med Lung Field - -
Lower Lung Field - -
 Mr. W, 50 yo
Laboratory
26/12/2023 Reference interval
Hb 13,7 14,0 – 17,0 g/dl
Ht 41 45 - 56%
Erit 5,2 4,2- 5.403/mm3
Leuko 12,68 4,5 – 10,5. 103/mm3
Trom 198 150 – 450x103/ mm3
Hit jenis 0/0/0/74/15/11 0-6/0-2/2-6/50-70/20-40/2-7 %
E/B/NB/NS/L/M
SGOT/SGPT 33/34 <35 / <45

Ur/Cr 26/0,81 13-43 / 0.67-1,17

Na/K/Cl 135/3,40/97 132-146/3,7-5,4/98-106

KGDS 98 11,50-15,50 / 26,00-37,00

Albumin 3,70 3,5-5,2
 Mr. W, 50 yo

ECG 26/12/2023

Conclusion : Tachycardiac sinus ryhtm,

101 bpm
 Mr. W, 50 yo

Chest X-Ray
26/12/ 2023

I 12/6/23
Conclusion
Pneumonia
USG THORAK (26/12/2023)

CONCLUSION : Pneumonia

DIAGNOSTIC & MANAGEMENT
Diagnostic
• Community Aquired Pnemonia
PSI 85 dd/ Lung Tuberculosis
• Mild Hypocalemia
• Dyspepsia Syndrome
Mr. W, 50 yo
Planning therapy
• Oxygen 3 liter/minutes
• High-protein Diet
• IVFD RL 15 gtt/I
• IV Cefoperazone 1gr/ 12 H
• IV PPI (Omeprazol) 40mg/12 H
• N-acetyl systein 3 x 200 mg
• Curcuma 3x 1 tab
• Vastral 1x1
• KSR 1x600 mg
 DIAGNOSTIC & Mr. W, 50 yo

MANAGEMENT
Diagnostic Plan and Evaluation Plan

Planing Diagnostic Evaluation Plans

• Laboratory of Blood • Chest X-Ray Evaluation after 5

• Electrocardiography days antibiotic

• Culture sputum microorganism and • Blood Evaluation after 3 days

resistancy antibiotic

• Sputum Gen Expert

• Chest X- Ray

• Culture of blood

• Culture Urine

• USG Thorax
 Mr. W, 50 yo

THANK YOU