Morning Report

Tuesday Night, January 29, 2019

CAR/LBN/CSO
No Name Gender Age Working Diagnosis

CHF NYHA III ec. susp. rheumatic heart disease

1. HS Boy 12 y.o
+ well-nourished + stunted

Hodgkin lymphoma + massive (R) pleural

2. CMS Girl 16 y.o
effusion + anemia

2
1
New Patient of Emergency Unit at 08.15 PM, HS, Boy, 12
years 6 months old, address: Sidikalang
BW: 27,2 kg BH : 134 cm
W/A: 60% (<P5) H/A : 85,8% (<P5) W/H :93,1 %
(well nourished, stunted)

Chief complain : Shortness of breath.

- Shortness of breath has been experienced since 3 months
ago, especially during activities, getting worse this week.
- Feeling of fast heart beat experienced since 3 months ago.
- Chest pain and bluish discoloration were not found.
- Fever was not found.
- Dry occasional cough was complained since 3 weeks ago.
- Vomitting and diarrhea were not found.
- Joint pain was not found.
- Urination and defecation were in normal limit.

History of Previous Illness:

- He has been hospitalized for 1 day in RS. Sidikalang and got
inj. Furosemide 20 mg/12 hr/IV, spironolakton 2x25 mg,
captopril 2x6,25 mg
- Patient had complaint of sore throat 1 month and 5 months ago,
sought medication to nearby midwife, given unrecalled
medication.
Physical Examination
General status :
Sensorium: Compos Mentis Temperature : 36,5oC
Anemis (-) Dyspnoe (+) Cyanosis (-) Edema (-) Icteric (-)

Localized status:
Head : Eyes : Light reflexes (+/+), isochoric pupil Ø2mm/2mm, pale inferior
palpebral conjunctiva (-/-), icteric sclera (-/-)
Ear/Nose : within normal limit
Mouth : cyanosis (+)
Neck : lymph node enlargement (-)
Thorax : Symmetric Fusiform, no retraction
Heart rate : 120 bpm (N: 60 – 120 bpm), regular, murmur sistolic
Respiratory rate : 45 bpm (N: 16-20 bpm), regular,rales(-), wheezing (-)
Abdomen: Soepel, Peristaltic sound (+), liver and spleen was not palpable
Extremities : Pulse 120 bpm, regular, warm extremities, CRT< 2”, BP: 110/80 mmHg
Clubbing finger (-), Bluish discoloration (-), SpO2 99 %
 Laboratorium result from Salak Region Hospital
January 28th 2019
Hb : 11,4 g/dL Urinalysyis :
Eritrocyte : 4,61 x 10*6 Color : Yellow
Hematocryte : 32,3 % pH : 6,0
Leucocyte : 8.900 g/uL Nitrit : negatif
Trombocyte : 564.000 /uL Glucose : negatif
MCV : 70 fl Protein : negatif
MCH : 24,8 Pq Ketones : negatif
MCHC : 35,4 g/dl Bilirubin : negatif
Urobilinogen : negatif
E/B/N/L/M : 1/1/51/39/8 Eritrocyte : negatif
Leucosyte : negatif
Blood Smear Morphologi :
Hipokrom mikrositer, pencil cell Blood Glucose ad Random : 117
(+), normal shape, big
trombosit (+), clumping (+) HbsAg : negatif
Chest X-Ray

CTR : 69%
USG Hepar
ECG
ECG
Differential diagnosis
1. CHF NYHA III ec. Susp. Rheumatic Heart Disease + Well Nourished
(Underweight + Stunted)

Working diagnosis
CHF NYHA III ec. Susp. Rheumatic Heart Disease + Well Nourished
(Underweight + Stunted)
Theraphy
• Head up 30o midline position
• O2 nasal canul ½ - 1 litre/minute
• IVFD D5% NaCl 0,45% 4cc/hr
• Inj. Dobutamine 408 mg in 50 cc NaCl 0,9%
• Inj. Furosemide 20 mg/12 jam/IV
• Spironolactone 2x25 mg
• Captopril 2x6,25 mg
Planning
• Check CBC, LED, RFT, AGDA, Electrolyte
• Echocardiography
• Consult to Cardiology division
Time Sens BP HR RR Temp Additional
(bpm) (tpm)

20.15 CM 110/80 140 42 36,5o Blood sampling

21.15 CM 100/80 138 40 36,5o

22.15 CM 100/80 135 40 36,5o Move to ward

Patient’s photo
2
New Patient of Emergency Unit at 22.45, CMS, Girl, 16 years
11 months old, address: Kabanjahe
BW: 57 kg BH : 168 cm UAC: 25 cm
W/A: 105,5% H/A : 103% W/H :105,5 %

Chief complain : Shortness of breath.

- This has been experienced since 4 months ago, it’s getting
worst in a week this week.
- Cough was found in 4 months, slime was found, blood was
found 3 times since 2 days ago.
- Vomiting was found, contents blood, frequency 3 times,
volume ½ aqua cup, fresh blood
- Dark stool was found since 4 months ago, diarrhea was not
found, last defecation was 3 days ago
- Pale was found and noticed since 4 months ago
- Tumor on the right neck was found, begin with a small tumor
since 2 years ago, it’s getting bigger everyday and now it also
occurred in armpit. Biopsy has done before
- History of menstruation 5 months ago

History of Previous Illness:

- 2 years ago, patient came to doctor and done the biopsy for
tumor in neck with result lymphoma TB and got TB drugs for 11
month, and they go to penang and diagnosed with lymphoma,
and they go to Pulmonology Consultant and did the biopsy
again with the result hodgkin lymphoma. Since 4 months ago
they did the herbal theraphy and got the herbal drink, since that,
the patient start to have dark stool and bloody vomit
Physical Examination
General status :
Sensorium: Compos Mentis Temperature : 36,3oC
Anemis (+) Dyspnoe (-) Cyanosis (-) Edema (+) Icteric (-)

Localized status:
Head : Eyes : Light reflexes (+/+), isochoric pupil Ø2mm/2mm, pale inferior
palpebral conjunctiva (+/+), icteric sclera (-/-)
Mouth : pale lips (+)
Neck : lymph node enlargement (+), ± 2cm x 4cm, batas tegas, mild, no hiperemis
Axillaris : (R) lymph node enlargement (+), batas tidak tegas, 4cmx4cm
Thorax : Symmetric Fusiform, no retraction
Heart rate : 100 bpm, regular, murmur (-)
Respiratory rate : 28 bpm, regular,rales (-), wheezing (-)
Abdomen: Soepel, Peristaltic sound (+), liver 3 cm palpable BAC, spleen was not
palpable
Extremities : Pulse 100 bpm, regular, warm extremities, CRT< 2”, BP: 140/70 mmHg
pale palmar & plantar (+)
 Laboratorium result from Efarina Etaham Hospital
January 29th 2019

Hb : 4 g/dL E/B/N/L/M : 1/0/79/6/12

Eritrocyte : 1,3 x 10*6
Hematocryte : 12 % Albumin : 2,6

Leucocyte : 22,7 g/uL

Trombocyte : 63.000 /uL
MCV : 66 fl
MCH : 21 Pq
MCHC : 32 g/dl
 Laboratorium result from Efarina Etaham Hospital
January 27th 2019

Hb : 3,3 g/dL E/B/N/L/M : 1/0/78/6/6

Eritrocyte : 1,5 x 10*6
Hematocryte : 11 % Blood glucose : 118

Leucocyte : 40,1 g/uL

Electrolyte
Trombocyte : 243.000 /uL Natrium : 139 mmol/L
MCV : 52 fl Kalium : 4,0 mmol/L
MCH : 15 Pq Clorida : 97
MCHC : 29 g/dl
Chest X-Ray
Differential diagnosis
1. Non-Hodgkin Lymphoma + Massive (R) Pleural Effusion

Working diagnosis
Non-Hodgkin Lymphoma + Massive (R) Pleural Effusion
Theraphy
• O2 nasal canul 1-2 litre/minute
• IVFD D5% NaCl 0,45% 4cc/hr
• Inj. Ceftriaxone 1 gr/12 jam/IV
Planning
• Check CBC, HST, Blood Glucose + electrolyte + AGDA + RFT +
Procalcitonin, Albumin
• Check blood culture
• Consult to Hematooncology Division
• Consult to Respirology Division
• Consult to Thoracic and Cardiovascular Division
Time Sens BP HR RR Temp Additional
(bpm) (tpm)

23.00 CM 140/70 100 28 36,5o Blood sampling

00.00 CM 140/70 100 30 36,5o

01.00 CM 140/70 100 30 36,5o Move to ward

Patient’s photo
Thank You