You are on page 1of 18

MORNING REPORT

16 APRIL 2013

Patients Identity

Name : IMKS Sex : Male Age : 39 yrs old Nationality : Indonesia Job : Private Sector Religion : Hindu Marital status : Married Address : Br Pegambangan, Batubulan, Gianyar Date of admission: 15/04/2013 Time of admission: 13.00

Chief Complaint : Itchiness Present History : Patient came to the emergency department complaining itchiness since 1 day BATH. Itchiness claimed to be present whole over the body and its told to be very disturbing until patient could not conduct his daily activities.

ANAMNESIS

This complain started at 17.00 oclock one day BATH. His skin became reddish with patches soon after he felt the itching Complain of itchiness arise after taking medication such as Paracetamol and Ibuprofen. This medication was taken 2 days before BATH.

Present History :

Complains such as having watery and red eyes. palpitation, breathlessness, nausea, vomiting, abdominal discomfort or collapse was denied by the patient.

ANAMNESIS
Past Medical History : Patient have not experience the same complain before. History of drug or food allergy was denied by the patient History of asthma, dermatitis atopic or rhinitis allergic was denied by the patient. History of heart disease, hypertension, diabetes were denied by the patient. Medication History : Paracetamol and Ibuprofen was given for the past 2 days BATH

ANAMNESIS
Family History : None of the patients family members have the similar complain Patients mother suffers from asthma since she was a teenager History of diabetes , cardiovascular disease, hypertension were denied. Social History : Smoking (+). 10 butts of cigarette per day Alcohol consumption were denied

Physical examination
Appearance Level of conciousness Blood pressure Temperatur axilla Pulse rate Respiratory rate Eyes : : : : : : Mildi ill E4V5M6 130/90 mmHg 36,7 OC 84 x/min, reguler 20 X/min thoracoabdominal type

ENT Neck
Chest examination Heart inspection palpation percussion auscultation

: Anemia +/+, ict -/-, RP +/+ isocoric , oedem palpebra - -/- - watery eyes -/: Tonsil, Pharynx, tongue WNL : JVP PR 0 cm H2O, enlargement (-)

: Ictus cordis: not seen : Ictus cordis : not palpable : Upper border : ICS II Right border : Right PSL Left border : ICS 5 MCL Sinistra : S1 S2 single regular, murmur (-)

Physical examination
Lung examination inspection : symetric palpation : vocal fremitus is normal percussion : sonor / sonor auscultation : Ves +/+ , Rh -/- , wh -/Abdomen inspection : distention (-) auscultation : normal bowel sounds palpation : liver : unpalpable spleen : unpalpable tenderness: ballotement: percussion : tymphani

Extremity : Pitting edema - -/ - - warm + + /+ + Others : Macula Erytematous all over his body with various size ( + )

COMPLETE BLOOD COUNT


Parameter WBC -Ne -Ly -Mo -Eo -Ba RBC HGB HCT Result 6.223 4.337% 1,185% 0,40% 0.27 % 0.01 % 4.709 12.6 40,24 Unit 103/L 103/L 103/L 103/L 103/L 103/L 106/L g/dL % Remarks Reference range 4,1 10,9 2,5 7,5 1,0 4,0 0,1 1,2 0,0 0,5 0,0 0,1 4,00 5,20 12,00 16,00 36,0 46,0

MCV
MCH MCHC RDW PLT MPV

94.3
32.6 34.6 11,19 327,0 6.8

fL
pg g/dL % 103/L fL

80,0 100,0
26,0 34,0 31,0 36,0 11,0 14,8 150 440 0,0 100,0

BLOOD CHEMISTRY PANEL

Parameter
SGOT SGPT BUN Creatinin BS

Result
28, 32 32, 54 14, 82 0, 78 104,00

Remarks

Reference range
11-33 11-50 10-23 0.5-1.2 70,00-140,00

ECG

Sinus rhythm HR :75x/mnt, reguler Axis : Normal P wave : Normal PR interval : Normal ORS complex : Normal ST-T segment changes: (-) Result: Normal ECG

Assesment

Hypersensitivity Reaction e.c susp drugs (Ibuprofen, Paracetamol)

Treatment
Hospitalized
IVFD

NaCl 0,90 20 dpm Methylprednisolone 2 x 62.5 mg Dipenhydramine 3 x 10mg Stop suspecting substances

Planning
Diagnostic Planning : IgE total Monitoring: Vital Sign and Complaints