MORNING REPORT

Date :

Physician in charge
I :
II CVCU :
II HCU :
II UGD :
Chief on duty :
Consultant on duty :
Facilitator :
 Summary of Database
Mr/Mrs/Ms/yo/ward
Autoanamnesa/Heteroanamnesa
Chief Complaint:

History of Present Illness:

 Summary of Database
Past Medical History:

Family History:

Social History:

Review of System:
 Physical Examination
General appearance Sat O2 …. on … lpm
GCS VAS 0/10
BP mmHg PR bpm regular strong RR tpm Tax oC
Head Conjuctiva Anemic (-), Sclera Icteric (-), Nystagmus (-), Meningeal Sign (-), Pupil Isocor
Neck JVP R+ cmH20
Chest Symmetrical, retraction (-)
Lung Sonor | Sonor Vesicular | Vesicular Rhonkhi: -| - Wheezing : -| -
Sonor | Sonor Vesicular | Vesicular -|- -|-

Sonor | Sonor Vesicular | Vesicular -|- - |-

Cardio Ictus invisible, palpable at MCL (S) ICS V
LHM ~ ictus, RHM ~ SL (D) S1 S2 single, regular,
murmur (-) gallop (-)
Abdomen Flat, soefl, Bowel Sound (+) normal, shifting dullness (-)
Liver/ unpalpable, liver span 10 cm, epigastrium tenderness (-)
Lien/ Traube space tymphany
Extremities Edema (-), pale (-), MMT 5 | 5 , Pathologic Reflex (-); Lateralisation(-)
5|5
RT Tonus sphincter ani(+); colon mucous slippery; melena (-); hematoschezia(-)
 Laboratory Findings (dd/mm/yy)
LAB VALUE NORMAL LAB VALUE NORMAL

Leucocyte 4.700 – 11.300 /µL Ureum 20-40 mg/dL

Hemoglobine 11,4 - 15,1 g/dl Creatinine <1,2 mg/dL

PCV 38 - 42%

Thrombocyte 142.000 – 424.000 /µL Natrium 136-145 mmol/L

MCV 80-93 fl Kalium 3,5-5,0 mmol/L

MCH 27-31 pg Chlorida 98-106 mmol/L

Eo/Bas/Neu/ 0-4/0-1/51-67/ RBS < 200 mg/dl

Limf/Mon 25-33/2-5
PPT 9.3-11.4 detik
SGOT 0-40 U/L APTT 24.8-34.4

SGPT 0-41 U/L INR 0.8-1.30

Albumin 3.5-5.5 g/dL Calcium 7,6-11,0

Bilirubin total <1.0 mg/dl

Bilirubin direct <0.25 mg/dl Osm 275-295 mOsm/kg

Bilirubin indirect <0.75 mg/dl

 Urinalysis (dd/mm/yy)
LAB VALUE NORMAL LAB VALUE NORMAL
Turbidity 10 x
Color Epithelia ≤1

pH 4.5 – 8.0 Cylinder

SG 1.005 – 1.030 Hyaline
Glucose negative Granular
Protein negative Other
Keton negative

Bilirubin negative 40 x
Urobilinogen negative Erythrocyte ≤3
Nitrite negative Leukocyte ≤5
Leukocyte negative Crystal
Erythrocyte negative Bacteria ≤23 x 103/ml
Other
 Blood Gas Analysis (dd/mm/yy)

With Room Air/…. Normal

pH 7.35-7.45
pCO2 35 – 45 mmHg
pO2 80 – 100 mmHg
HCO3 21 – 28 m mol/L
O2 saturation > 95 %
BE (-3) - (+3) m mol/L
Temperature
Hb
Conclusion:
Electrocardiography (dd/mm/yy)
 Electrocardiography (dd/mm/yy)

• Sinus rhythm, HR ….. bpm

• Frontal Axis :
• Horizontal Axis :
• P wave :
• PR interval :
• QRS complex :
• ST segment :
• QT interval :
• T wave :

Conclusion :
Chest X-Ray (dd/mm/yy)
 Chest X-Ray (dd/mm/yy)

• AP position, symmetric, enough KV, enough inspiration

• Soft tissue was thin and bone was normal
• Trachea in the middle
• Hemidiaphragm D and S was dome-shaped
• Phrenico-costalis angle D and S was sharp
• Pulmo: bronchovesicular pattern was normal
• Cor: site N, size CTR 55%, shape N, elongation aorta (-), cardiac
waist (+)

Conclusion: normal chest x-ray

Lumbal X-Ray (dd/mm/yy)
 Lumbal X-Ray (dd/mm/yy)

 Alignment : Normal, no visible listhesis

 Trabeculation : Normal
 Curve : Normal
 Corpus : Normal, osteophyte (-)
 Intervertebral space : Narrowing (-)
 Proc. Tranversus/spinosus : Normal
 Pedicle : Intact
 Soft Tissue : Normal
Conclusion: normal lumbal x-ray
Abdominal USG (dd/mm/yy)
 Abdominal USG (dd/mm/yy)

 Hepar : size was normal; smooth surface; echoparenchym was homogen;

VH/VP was normal; no visible mass
 Gall bladder : size and shape were normal; no visible stone/mass/sludge; wall
thickening (-)

 Pancreas : size was normal; homogenous parenchym; calcification (-)

 Lien : size was normal; mass (-); cyst (-)
 Renal D/S : size was normal; echo cortex normal; margin of sinus cortex was
definite; ectasis at pelvicocalyceal (-); no visible stone/mass/cyst

 Vesica urinaria : enough content; smooth wall, mass (-), calcification (-)
 Prostat : size was normal, mass (-), calcification (-)
 No visible mass/lymph nodes nodules/intraabdominal free fluid
Conclusion: normal abdominal USG
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mr. Mrs. Ms./ yo/ w

Subjective

Objective

Laboratory
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mr. Mrs. Ms./ yo/ w

Subjective

Objective

Laboratory
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mr. Mrs. Ms./ yo/ w

Subjective

Objective

Laboratory
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mr. Mrs. Ms./ yo/ w

Subjective

Objective

Laboratory
Problem Analysis
 Risk Factors Analysis

Problem Theory Patient

Key Message Pathophysiology
Key Message Diagnosis
 Management Analysis

Problem Theory Patient

Key Message Management
Key Message Social
Condition This Morning
 Prognosis

• Ad vitam :
• Ad functionam :
• Ad sanationam :