MORNING REPORT

25/04/2016

Total Patient
Infection Centre
Lantai 1 =
Lantai 2 =
Lantai 3 =

Palem
Lontara
Lontara 1 =
Lontara 2 =
Lontara 3

ICU & CVCU

IRD
PCC
RS Unhas
Total Patient :

IDENTITY

Name : Dg DL
Date of birth : 10-7-1940
Medical Record : 755092
Gender : Male
Address : Jl.AR dg Ngunjung Lr 3
Hospital : Infection Centre 2nd Floor
Date of admission : April 23th 2016
Doctor on duty : dr. Ismunandar

History of current disease

Chief Complaint : Shortness of breath
Auto/Alloanamnesis :
Shortness of breath was felt since two weeks ago
before taken to the hospital, continue, and not
Influenced by activity and change of movement.
Cough occurred since 3 month ago with white
sputum, and blood (+). History of fever usually
occurred at night with much sweat, Headache (-),
Nausea (-), Vomiting (-), Dyspepsia (-), feces and
urine are in normal range. History of weight loss 2
kg in last few weeks. History of OAT 4 years ago,but
not succesfully.

Past Medical History

History
History
History
History

of
of
of
of

TB (+)
DM (-)
Hypertension (-)
cardiovascular disease (-)

Family History
Father : unknown
Mother
: unknown

Habitual Activity
History of smoking (+)
History of alcohol consumption (-)

History of Immunization
Complete immunization
History of allergy (-)

Physical Examination
General Status : Moderate illness/less
nourished/conscious
Vital Sign :

Blood Pressure : 100/70 mmHg

Pulse Rate : 80x/i
Respiratory rate : 24x/i
Temperature : 36,7o c (axilla)

Physical Examination
Head : Conjuctiva Anemic (-/-), Sclera
icteric (-/-)
Neck : JVP R+1 CMH2O
Chest Examination :
I : Symmetric between left and right chest
P : There are no pain or mass on the palpation,
vocal fremitus decreased in hemithorax sinistra
P : sonor in hemithorax dextra et sinistra
A : Respiratory sound : Vesicular
Additional sound ronchi +/+, wheezing -/-

Physical Examination
Cor :

I : Ictus Cordis not visible

P : Ictus Cordis not palpable
P : Heart in normal range
A : S1/2 regular, murmur (-), gallop (-)

Abdomen :

I : Flat and follows breath movement

P : Liver and spleen are not palpable
P : Timpany (+), ascites (-)
A : Peristaltic Sound (+)

Laboratory Finding

WBC : 13.500
HB
: 10,2
PLT
: 87.000
SGOT/SGPT : 87/68
Blood glucose : 110
Ureum: 80
Creatinin : 0,34

Chest X-Ray
Old-Activated Lung
Tuberculosis +
atelectasis sinistra

Problem findings
Suspect TB relaps
Diagnostic plan : Sputum BTA, Culture
and sensitivity Anti Tuberculosis
drug, gen X-pert
Therapeutic plan : Anti Tuberculosis
drug Categori II (2HRZES/HRZE/
(5HRE)3),

THERAPY

O2 3L/I via nasal canule

Ivfd RL 20 tpm
N-ace 1 amp/8 jam/iv
Check : Sputum of BTA, gram of
stain, fungi
Consul : Gen -expert

Prognosis
ad vitam
: dubia
Ad fungsionam : dubia
Ad sanationam : dubia