Morning Report

th
Sunday, June 5 2016
CO A S S I S TA N C E I N C H A RG E

N E N E N G W U L A N DA R I
FA D I L L A S A F I R A

M O D E R ATO R :
d r. I Q BA L L A H M A D I S p . P D
Total Patients
Total patients :
Melati ward : 3 patients
Kenanga ward : 19 patients

Total Patients in ward:

Melati ward : 0 patients
Kenanga ward : 3 patients
Old male, 76 y.o., Dx : dyspepsia syndrome
Old male, 80 y.o., Dx: acute febrille illness + chronic lung disease dd lung TB, SOPT
Old male, 56 y.o., Dx: chonic febrille illness + mild anemia + chronic lung disease dd lung malignancy
Male, 47 y.o., Dx: acute waterry diarrhea
 Summary of Database
Old Male /40 y.o
Chief complaint : Chronic fever

Patient suffered from chronic febrill illness since 6 months before admission and getting worse since this
morning. Patient complained fever didnt relieve by the medicine and continues along the day.
Patient also complained chronic cough (+), no mucus and no blood in the sputum. The cough had been felt
since more than 3 months, so that he felt weakness on his body. Sometimes, the cough make he felt difficult
to breath.
Difficult to inhale when he is breating and getting hurt in the chest when he cough.
Patient complained decreased of apetitte since 3 months and loss of his body weight since 3 months ago.
Vomitting (-), nausea (+).
Past Medical History
Patient denied that he was an active smoker.
He admitted that he sometimes consume paracetamol to relieve his fever.
History of work in wood factory when he was young.
 Physical examination in Kenanga Ward
BP = 120/80mmHg PR : 88 tpm regular RR = 26 tpm T ax 39,2oC

General appearance looked moderately ill GCS 456

Head Anemic +/+ Icteric -/-
Neck JVP 5 cmH2O
Thorax Invisible Palpable at Ictus ICS VI MCL S,
Heart RHM SL D, LHM as ictus,
S1 S2 single, mur mur (-), gallop (-)

Lung Simetric, SF D = S SS decreased Rh - - Wh - -

SS decreased - - - -
DS v v - - - -
Percussion dull in the left lung, vesicular sound on the left lung
Abdomen Convex, Soefl, Hepar : Liver span 12 cm

Extremities Oedema in both lower extremity -/-

ECG in Kenanga Ward
Interpretation
Sinus Rhythm with HR 88 tpm
Axis :
Frontal axis : normal axis
Horizontal axis : normal axis
PR interval : 0,12ms
QRS complex : 0,08 ms
QT interval : 0,32ms

Conclusion : Sinus rhythm with HR 88 bpm

CXR
 Interpretation
PA position, relative symmetric
Soft tissue and bone normal
Right deviation of the trachea
ICS D/S normal
Sharp right costophrenicocostalis angle
Left costophrenicocostalis angle cant be
measured
Hemithorax D was normal
Hemithorax S there is radioopaque
appearance at ICS 2-ICS 5
Heart : site normal, Size difficult to measure
because of half of heart covered by radioopaque
appearence, shape difficult to measure.
Lung : Right lung is normal. Left lung, there is
radioopaque appearance at ICS 2-ICS 5 with the
firm border.
Increased level of left diafragma.
Conclussion: left pulmonary opacification of 1/3
upper lobe
 Lab Value Lab Value

Leukocyte 8.700 3500 - Ureum 57 10-50mg/dL

10000/L
Haemoglobin 9.5 11,0-16,5g/dl Creatinine 1.5 0,7-1,5mg/dL

MCV 82,0 80-97 SGOT 56 11-41U/L

MCH 28,3 26,5-35 SGPT 58 10-41U/L

Thrombocyte 130.000 150000-

390000/L
RBS 69 (<200)mg/dL
CUE AND CLUE PROBLEM INITIAL PLANNING PLANNING PLANNING
LIST DIAGNOSE DIAGNOSE THERAPY MONITORI
NG

Male/56 yo 1. Chronic 1.1. CT Scan Free dietary VS

Ax: Febrille Malignacy thorax and IVFD Nacl 20 dpm Complain
Got fever since 6 1.1.1 upper Symptomatic
months ago. Cough Illness
Pulmonary abdomen theraphy : PCT
with no sputum. with
Decreased of
Mass Bronchosco 3x500 mg p.o
paraneopl 1.1.2 py
appetitte. Decreased
of body weight since
astic Mediastinal Biopsy Confirm diagnose
3 months ago. syndrome Mass Fast Acid
Difficult to inhale Bacilli Test Consult to
when he is breating 1.2. Infection pulmonologist
and getting hurt in 1.2.2
the chest when he
cough.
Pulmonary
Tuberculosis
PE:
T: 39,2oC
CA +/+,
CXR : there is mass
in the 1/3 upper
lobe of left pulmo,
pleural effusion

ECG: Normal
Lab : Hb: 9.5 g/dl
CUE AND CLUE PROBLEM LIST INITIAL PLANNING PLANNING PLANNIN
DIAGNOSE DIAGNOSE THERAPY G
MONITOR
ING

Male/ 56 yo 2. Normochrom 2.1 due to - Blood complain

Ax: normocytic no. 1 smear + Confirm Dx CBC
Weakness, pale (+) Anemia 2.2 Chronic reticulocyte
disease count
PE:
Eye : anemic (+)
ikteric (-)

Lab :
Hb : 9,5 g/dl
MCV : 82
MCH : 28,3
CUE AND PROBLEM LIST INITIAL PLANNING PLANNING PLANNI
CLUE DIAGNOSE DIAGNOSE THERAPY NG
MONITO
RING

Male/ 56 yo 3. Azotemia 3.1due to no.1 - Urynalysis - Diet low Na Ur/Cr

Ax: renal 3.2 Acute - GFR intake
- Tubular examination - Lifestyle
PE: Necrosis modification
- 3. 3 Acute
Lab:
Ur: 57 mg/dl
Interstitial
Cr: 1.5 mg/dl Nephritis
Present conditions
Fever (), Fatigue (+), Anorexia (+)
GA : good GCS E4V5E6
BP : 120/80 mmHg
HR : 95 tpm
RR : 24 tpm
T : 38,6 oC
conjunctiva anemic +/+
Thank you