Morning Report

June 10, 2017

Dept of internal
medicine
G26
OB interna
1. Tn. Suyitno/ HT esensial + colic abdomen / Marwah 1
2. Tn. Machfud/ Angina unstabil/ Arofah 5
3. Ny. Lantira/ OMI + abd. Pelvic pain / zam-zam 20
4. Julaeni/ CVA infark + cardiomegaly + OMI inferior/
Marwah 17
5. Tn. Sumidi/ Pneumoni + septicemia/ arofah 2
6. Tn. Ab. Tompo/ Post TB Paru + efusi pleura/ aofah 3
7. Ny. Ulinuha / sup. Hepatoma/ shofa 11
8. Ny. Ismaniah/ AF + dekom cordis / shofa 11
9. Ny. Taseh / DM+HT+hIpoglikemi/ shofa 16
10. Tn. Sahir/ DM tipe 2 + KAD / marwah
11. Tn. S/ DM +KAD/ marwah
Identity
Name : Mr. S
Age : 60 years old
Occupation : Farmer
Address : warukulon-laongan
Admission : June 9th, 2017 at 20.56
PM
 Shortness of breath

Patient came to emergency department with shorthness

of breath since this 2 weeks and become severe in this 2 dats.
Shortness of breath did not improve with the change of position.
Patient sleep with one pillow. Patient also complains coughing
since a 1week ago. The cough didnt containing mucus,
Patient also complain about having feversince this 1
weeks and also felt up and down temperature of fever.
Patient also having loss of appetite since about a month
ago and these past weeks he didnt ate any rice and only drank
 Past history of Illness

Similar complain (-)

Diabetes Mellitus (-)
Hypertension (-)

Family history

Family history : has similar complain since 21 month

 Social history

This patient work as a farmer

Vital Signs
BP
146/87mmHg
Pulse
127 x/min
Temp
38.2 C
RR
28 x/min
 A: clear, gargling (-), snoring (-), speak fluently
(+), potential obstruction (-)
B: spontan, RR 28x/min, ves / ves, rh + (Lobus
superior)/-, wh -/-, SaO2 92% with no oxygen
support nasal canul
C: acral warm, dry, red, CRT <2, pulse 127
bpm, BP 146/87mmHg
D: GCS 456, lateralization -, Pupil : round
3mm/ 3mm, Light perception +/+
E: temp 36,8C
GENERAL STATUS
 General condition : weak
Awareness : compos mentis
GCS : 456
H/N : a -/i-/c-/d+ (retraction of m. infra
clavicular
lymph node enlargement at neck (-)
normal JVP
Thorax
Inspection
Symmetrical, retraction +/+
Palpation
Thrill (-), fremitus WNL
Percussion
Lungs: sonor +/+(kobus superior
Cor: N
Auscultation
Lungs: ves /ves, rh +/+, wh +/-
Cor: S1S2 single, M -, gallop -
Abdomen
Inspection
flat
Auscultation
Met -, bowel sound WNL
Palpation
Pain (-)
Liver/Spleen is hard to evaluated
Percussion
Tymphany
Extremities
Inspection
Clubbing fingers (-), icteric (-), cyanosis (-), edema (-)
Palpation
Warm and dry, CRT <2
CLUE AND CUE
Male, 60 years old
Chronic coughing
Loss of appetite
Loss of weight
Abdominal pain
Fever
Leucosytosis
History of family : have the similar complain 1
years ago
Planning Diagnose
Ziehl
neelsen staining of sputum
Chest radiography
Complete blood count
Blood glucose level
Laboratory Findings
Eritrosit 4.27 GDA 118
Hb 13.3
Urea 63
LED 90
LED2 105 Creatinine serum 1.1
Limposit 2.9
Basofil 4.6 SGOT 26
Eosinopil 0,1 SGPT 26
Hematokrit 40
Leukosit 5.40
MCHC 33.30
MCH 31.10
MCV 93.70
Monosit 18.6
MPV 6
Neutropil 73.8
RDW 11
Trombosit 63
Ro Thorax
Assesment
Pulmonary tuberculosis
Septicemia
Dd: pneumonia
Planning Therapy
O2 NRM 10 lpm
Inf. Ringer acetate 1500 cc / 24 hours
Inj. Ceftriaxon 2x1 gr i.v.
Inj. Ranitidine 2x50 mg
Inj. Sodium metamizole 3x1 gr
INJ. Metilprednisolon 3x62,5 mg
If ziehl neelsen staining is (+) start
tuberculosis planning treatment.
Nebul pulmicort: bisolvon
PLANNING MONITORING
VitalSigns
Patients complaint
Adverse reaction of the drugs
PLANNING EDUCATION
Explain to the patien and his family about
The disease
Cause
Complication
Treatment and
Prognosis