Morning Report

April 16th, 2015

Doctor in charge:
DR.dr.Muh.Darwin P,Sp.PD K-HOM

Patients Identity
Name
: Mr. S
Sex
: Male
Age
: 65 yo
Occupation
: None
Address
:Teluk Tiram, Rt.15
Hospitalised since : Apr 15th 2015 (13.30)

 Mr. S/65 yo/Male (Autoanamnesys)

Chief Complain : Epigastric pain
Patient came pain epigastric with. Pain of epigastric has come since 1
month ago. Before hospitalized patient felt hard breath(+),
headache(+), pain of epigastric sometimes can also felt on the back
(+), nausea (+), acid in the mouth (+), fever(+), mucus secretion (+),
pain of right leg(+), bloating(+), burping (+), easy full (+). Coffee (+),
smoke (+).

 History of Last Illness : acute stroke 2 week ago, HT

History of Hospitalization History of Family illness
: Stroke (mother)

General
General appearance
appearance
Vital Signs

Looked
heavy ill,
ill,Conscious,
Conscious,
Looked moderately
GCS : 4 5 6GCS : 4 5 6

Vital Signs

Blood
150/80
mmHg
PulsePressure
Rate : 60 :tpm
regular,
strong

Blood Pressure : 110/80 mmHg

H: 158 cm
W: 55 kg

Pulse
Rate : rate
97 bpm
Respiration
: 18 Tpm,

GCS: E4V5M6

Respiration
0
Temp : 36,0rate
C : 20 tpm

GCS: E4V5M6

Head

Temp
: 36,8 0C (-/-),
SaO
2 : 97 %sclera (-/-), Edema palpebra (-/-), Diplopia (-),
Pale conjunctiva
Jaundice

Head

discharge (-/-), exophthalmus (-/-), lid retraction (-/-), lid lag (-/-), conjungtiva
petekie (-/-), digreas
epistaksisof
(-/-),
dirty
hedeache(+),
visus
(+)tongue (+)

Neck

Lympatic node swelling (-), struma (-), bruit thyroid (-)

Chest Heart
Neck

Chest Heart
Lung

Lung

- Inspection : ictus cordis invisible

Palpation : inpalpable in MCS ICS V

Right margin : Right : ICS II-III L.Ster (D).
Inspection
: ictus cordis visible
Auscultation : frequentcy 60 times/m, rhytm reguler

Palpation : palpable in MCS ICS V

Inspection : Simetric,
Auscultation
: normal barrel chest (-), pigeon chest (-)
Palpation : simetric
Percution :
Auscultation :
S | S
V |V
S | S : Simetric, barrel chest
V (-),
| V pigeon
Inspection
D
|
D
|
Palpation : fremitus vocal: simetricAuscultation:
(-)
Percution
: Wheezing (-), Ronchi
Auscultation
:

S | S
R |R
S | S
R |V
S | S
R |V
Auscultation: Wheezing (-), Ronchi (-)

chest (-)

Abdomen

BM: 10x (normal).

Percusion:
T | T | T
T | T | T
T | T | T

Tenderness:
+ |+ |+ |+ |- |+ |+

Skin

Rash (-), Skin Turgor Normal

Extremities

Superior D & S : Edema (-), Pain (-), Weakness (-), tremor (-/-)
Inferior D & S : Edema (-), Pain (+) D, Weakness (-), tremor (-)
Nail: normal

Oral Cavity

Normal

Problem list
Male, 65 yo
1. Epigastric
pain
DD:
1.1 Dispepsia

Data Support

Planning
Diagnosis

Planning
therapy

Monitor

Education

Pain of epigastric Endoschopy

(+)
Nausea (+)
bloating(+)
burping(+)
easy full (+)

1.2 Refluks
heart burn
gastroesofageal burping
vomite
disfagia
Choke

upper digest tract IVFD RL 20

Symptom
and biopsi
Inj. Ranitidin 2x1

examination Suportif:nutrition
infection
Helicobacter pylori
USG abdomen

Endoschopy
Ph observation

1.3

1-14

IVFD RL 20
Antasida
H2 blocker

Soft foods
but often
Avoid
triggers

Problem list
Male, 65 yo
2. High blood
pressure
( HT gr I)

Data Support
150/80 mmHg
smoke
Age > 55 yo (man)

Planning
Diagnosis
Urinalisis
EKG
profil lipid
Blood sugar

1-14

Planning
therapy
Diuretic
lifestyle

Monitor
Rehidration
General
appearance
Observation

Education
Dietary
intake

Patients Identity

Name
:
Sex
:
Age
:
Occupation
:
Hospitalised since

Mr. B
Male
30 yo
Carrier
: April 16th, 2015

Summary of Data Base

Mr. S/ 30 yo /Male (Autoanamnesys)
Chief Complaint : abdominal pain and swollen eye.
Patient has felt burn and swollen of left eye since 3 days ago. Both of

his eyes are red and pain. Blur vision is not persistent. Sprue on the
lip has come a week ago. Lips became swollen and dry. His gums has
been bleeding since the sprue came. There was enlargement of
multiple lymph node on the pre and post auricular dextra and sinistra,
submental dextra and sinistra, cervical, right axilla, intercostal
sinistra and inguinal. The enlargement of lymph nodes was not pain in
palpation. The noduls are smaller than the first time it came.
History of last illness:
History of Family illness:

Physical Examination
General appearance

Looked moderately ill, Conscious, GCS : 4 5 6

Vital Sign

BP : 110/70 mmHg , PR : 118 bpm, RR : 22 tpm, T : 37,20C, SaO2 = 95%

Head,eyes, mouth

Pale conjunctiva (-/-), Jaundice sclera (-/-), decreased visual acuity (+/+),
Edema palpebra (-/+), Redness of eye (+/-),
Mouth : bleeding (+), stomatitis (+) pain (+)

Neck

JVP= R + 3 H2O , Lympatic node enlarged (+) pre auricular (+/+), Submental
(+/+), cervical (+), Intercostal 2- 3- 4- 5 sinistra lateral, axillaris dextra.

Chest Heart

Inspection : ictus invisible

Palpation : palpable in MCS ICS V
Right margin : Right : ICS II-III L.Ster (D).
Auscultation : S1 > S2 single, murmur (-) gallop (-)

Lung

Inspection : Simetric, barrel chest (-)

Palpation : FV assymetric
Percution :
Auscultation :
S | S
V |V
S | S
V |V
D | D
- |Wheezing (-), Ronchi (-)

Abdomen

Ascites per magna, BM: 12x.

Percusion:
Pain:
D| T |T
-|+|T | T |T
-|-|T | T |T
-|-|Hepatomegali (+) 7 cm below the arcus costae linea midclavicularis sinistra
Spleenomegali (-)
Shifting dullness (-)

Extremities

Superior D & S : Edema (-), Pain (-), Weakness (-)

Inferior D & S : Edema (-), Pain (-), Weakness (-)
Nail: pale

Laboratory Result 13/04/2015

Items

Result

Normal Value

Lymph#

176,8 x 103 /uL

0,8 4,0

Leukocyte

211,5 x

103 /uL

4.0 10.0

Mid#

16,3 x

103 /uL

0,1-0,9

Gran #

18.4 x

103 /uL

2,0 7,0

Lymph%

83,6%

20 - 40

Mid%

7,7 %

3,0 9,0

Gran%

8,7%

50,0 70,0

HB

11,7

13,0 16,0

RBC

4,0 x 106 /uL

4,0-5,5

HCT

34,8%

40,0 50,0

MCV

87,1 fl

82,0 95,0

MCH

29,2 pg

27,0 31,0

Items

Result

Normal Value

33,6 g/dL

32,0 36,0

RDW-CV

14,8%

11,5 14,5%

RDW-SD

45,9

35,0 56,0

PLT

27 X 103 /uL

150 450

MPV

9,8 fl

7,0 11,0

PDW

18,5

15,0 17,0

PCT

0,026%

0,108 0,282

MCHC

Problem List

Data
Support

Planning
Diagnosis

Enlarged
Lymph node
(+)
Eye
bleeding (+)
Stomatitis
(+)
Abnormal
hematology
lab (+)
enlarged
Lymph node
(+)

1, BMA
2, Peripheral
Blood
morphology

enlarged
Lymph node
(+)

Foto thorax
FNAB

Male/30 yo
1. Enlarged Lymph Node
DD :
2. Leukimia

2. Limfoma Hodgkin

3. Limfoma Non Hodgkin

Foto thorax
FNAB

Planning
therapy

Monitor

Education

CUE
Problem
AND List
CLUE

DataPL
Support

IDxPlanning PDxPlanning
Diagnosis
therapy

Male/30 yo
Anamnesis
2. Hepatomegali
2.1 Leukimia

2.1 Hepatitis

Hepatomegali
(+) 7 cm below
the arcus costae
linea
midclavicularis
sinistra
Hepatomegali
(+) 7 cm below
the arcus costae
linea
midclavicularis
sinistra

Liver FunctionTest

Monitor
PTx

Education
PMo

Thank you