MORNING REPORT

THURSDAY, February 16th 2017

COASS INCHARGE:
Gapar
Jenny Ismyati
Kevin Leonardo
PHYSICIAN INCHARGE:
dr. Harry
dr. Ivanna

CONSULENT : dr. Iqbal Lahmadi Sp.PD

 Total patients :
ER 7 (AU : 1 BPJS : 5 U:
1 )
Ward 74 (AU : 14 BPJS : 47
U: 13 )

Interna :
Melati ward 8 patients
Kenanga ward 14 patients
Total patients from 07 pm 04 am :
3 New-in patients
Male/49 yo/EH
Male/ yo /CKD + DM type 2
Female/25 yo/DF
Anamnesis (aloanamnesis)
Male / 46 yo
Chief Complaint: Diarrhea
Patient suffered from watery diarrhea since 2 days
before admission with frequency more than 5
times daily, consist of water, blood (-), mucus (-),
Patient also complained decreased of
consciousness since 1 day before admission.
Patient suffered from abdominal distension since 4
months ago and it getting worse since 3 day
before admission.
 Anamnesis (aloanamnesis)
Patient had history of chirrosis
hepatis since 3 months ago and
hospitalized once because of asites
Patient just consumed discharge
medication and never controlled to
the doctor
 Physical examination
BP = 120/70 mmHg HR = 64x, reguler RR = 22 tpm T ax 36,4 C

General appearance : looked severe ill GCS E3V5M6

Head anemic (+/+) icteric (-/-)

Neck JVP 3 cm H2O

Thorax
Cor Wnl

Pulmo Simetric, SF D = S SS v v Rh - - Wh - -
SS v v - - - -
DS v v - - - -

Abdomen Dystension, (+) shifting dulnes (+), bowel sounds (+), skin
turgor normal (+) epigastric pain (-)

Extremities Oedema +/+, palma eritem (-), CRT 2s

laboratory examination
Blood Lab Value
Leucocyte 9.000 3500;10000/L
Eritrocyte 2,89 3,50-5,50
Haemoglobi 8,2 11,5-16,5g/dl
ne
Hematocrite 26,2% 35.0-55.0%
Thrombocyt 116.00 150000-
e 0 400000/L
MCV 90,5 75-100
MPV 8,4 8,0-11
MCH 29,9 25-35
SGOT 25 40 u/l
SGPT 13 41 u/l
RBS 62 100-180 mg/dl
Ureum 31 15-45 mg/dl
Creatinin 1,56 0,9-1,3 mg/dl
Albumin
CXR 15/01/2017
 CXR 16/02/2017
Taken on 16th February 2017
Identity : Mr. T, 49 yo
PA position,
Symmetric
Soft tissue and bone normal
ICS D/S : normal
Trachea in the middle
Diaphragma: Dome shaped
Costophrenicocostalis Dextra & Sinistra normal
Costophrenicokardialis dextra & sinistra normal

Cor : site normal Size <50%, boot shaped heart,

Pulmo : normal

Concl: CXR normal

ECG 16/02/2017
 ECG 16/02/2017
Sinus Rhythm, regullar
HR : 60 bpm
Axis
frontal : normal
horizontal : clockwised
P-R interval : 0.2
QRS complex : 0,08
QT interval : 0,32
T inverted in lead v1-v2
Conclusion: normal sinus rhythm HR 60 bpm with
ischemic in anteroseptal (lowseptal)
CUE AND CLUE PROBLEM INITIAL PLANNING PLANNING PLANNING
LIST DIAGNOSE DIAGNOSE THERAPY MONITORIN
G

Male / 49 yo 1. Acute 1.1 Electrolite Loperamid VS

Ax: diarrhe Acute Stools loading 2 Complai
Watery a dysentric examinatio tab, next 1 n
diarrhea (+), diarrhea n tab each
bloody 1.1.1 Stool defecation
patches on Bacteria Culture and Mollagit 4x2
feces (-), 1.1.2. sensitivity tab
history of Protozoa test Azythromici
fever (-) on n 3x500 mg
the first day p.o for 3
of illness, 1.2 Acute days.
increased watery
thirsty (+) diarhea

PE:
Increased of
bowel
sounds
CUE AND PROBLEM INITIAL PLANNIN PLANNING PLANN
CLUE LIST DIAGNOSE G THERAPY ING
DIAGNOS MONIT
E ORING
Middle-aged 2. DOC 2.1 GDS 1. Inj. VS
male/ 49yo Hipoglikem Dekstrose 40
DOC ia % 2 ampul
PE: 2.1.1 drug 2. IVFD D 5 %
GDS: 62 induce 20 tpm
g/dl 2.1.2 low
intake
Lipid
2.2 profile 1.Dietary salt
cirrhosis Albumin restriction
hepar Globulin 2.High Protein
2.2.1 SGOT Diet
ensefalopa SGPT 3.Spironolact
ti Bilirubin one 1 x 100
hepatikum mg po
4.Furosemide
2x 40 mg iv
5.Propranolol
2x20 mg
CUE AND CLUE PROBLEM LIST INITIAL PLANNING PLANNING THERAPY PLANNING
DIAGNOSE DIAGNOSE MONITORING

Middle- 3. 2.1 Chronic - Blood Confirm Dx

aged Normochrom disease smear VS
male/ normocytic (Anemia of + - Blood complain
Anemia Inflamation) reticul transfussion
49yo 2.2 Accult ocyte CBC after
Blood loss count finish the
- Faece blood
PE: s transfussio
Conjunctiv analys n
a anemis is +
Hb : 8.2 Occult
blood
exami
nation
CUE AND PROBLE INITIAL PLANNIN PLANNING PLANNI
CLUE M LIST DIAGNOSE G THERAPY NG
DIAGNOS MONITO
E RING
Middle- 4. Asites 1.1Cirrhosi 1.Urinalisa 1.Dietary salt VS
aged Male/ s hepar restriction Complai
49 yo 1.1.1 2.Abdomi 2.Spironolactone n
Ax: hepatic nal 1 x 100 mg po
abdominal failure ultrason 3.Furosemide 2x
distention 1.1.2 portal ography 40 mg iv
hypertensi 4.Propranolol
PE: on 2x20 mg
Dystention
shifting
dullness
(+),
HGB 8.2
 Present Condition
BP : 120/70
HR : 82
RR : 20
T : 36,2
GCS 14
THANK YOU