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MORNING REPORT

Wednesday, April 16th, 2014


Mentor :
dr. Sp.P


Patient Identity
• Name : Mrs. S
• Age : 49 yo
• Adress : Durian Bungkuk Pelaihari
• Religion : Moslem
• Occupation : Housewife
Summary of Data Base
Chief Complain : General Weakness
Patient feel general weakness since 4 days ago.
Weakness feel in all of her body continuous and slowly. Skin of
yellow appear since 4 days ago. She complains her eyes look
yellow. There was no nausea or vomit, fever, but her urine look
like dark tea. There was no abdominal pain and respiratory
disorder. The complain didn’t disturb her activity.


History of prior illness: AIHA(+), transfusion(+)
History of family illness: -
BP = 100/60 mmHg Pulse rate = 60 bpm
Regular, weak
RR = 20 tpm

Tax : 36,5 C
General appearance looked Moderate ill GCS 456
Head Pale conjunctiva (+) Icteric (-)
Neck JVP= R + 2 cm H2O
Thorax: Heart: Inspection : Ictus cordis unseen
Palpation : Ictus Cordis palpable at ICS V LMC S
Percussion:
left border cor : ICS V LMC S
Right border cor: ICS II Linea Parasternalis Dextra
Heart waist (+)
Auscultation : S1, S2 single, murmur (-), gallop (-)
Lung: Symmetric, S S V V Rh - - Wh - -
S S V V - - - -
S S V V - - - -
Abdomen BU (+) normal
Abd. Pain - - -
- - -
- - -
Liver/Spleen enlargement (-)
Extremities Normal
Laboratory Result (15 April 2014)
Examination Result Normal value
hemoglobin 4.9 12.00-16.00 g/dl
Leucosit 8.7 4.0-10.5 Ribu/ul
eritrosit 2.19 3.90-5.50 juta/ul
hematocrit 17.3 37.00-47.00 Vol%
trombocit 241 150-450 Ribu/ul
RDW-CV 19.9 11.5-14.7 %
MCV 79.0 80.0-97.0 Fl
MCH 21.9 27.0-32.0 Pg
MCHC 27.7 32.0-38.0 %
Gran% 71.6 50.0-70.0 %
Limfosit% 20.3 25.0-40.0 %
Mid% 8.1 4.0-11.0 %
Gran# 6.20 2.50-7.00 Ribu/ul
Limfosit# 1.8 1.25-4.0 Ribu/ul
Mid# 0.7 Ribu/ul
BSS 148 <200 Mg/dl
Total Bilirubin 5.57 0.20-1.20 Mg/dl
Direct Bilirubin 2.01 1.00-0.40 Mg/dl
Indirect Bilirubin 3.56 0.20-0.60 Mg/dl
SGOT 30 0-46 u/l
SGPT 22 0-45 u/l
Ureum 26 10-50 Mg/dl
creatinin 0.6 0.6-1.2 Mg/dl
HbS Ag negative
Main
Complain
General Weakness
Anamnesis



Weakness (+)
Malaise (+)
Skin Icteric (+)
Dark tea urine (+)
History: AIHA
Physical
Examination
BP: 100/60 mmHg
PR: 60 bpm
RR: 20 tpm
T: 36,5
o
C
Anemic conjunctiva
Icteric sclera
Addition
Examination
Laboratory:
Hemoglobin: 4,9 g/dL
Hematocrit: 17,3 vol%
Total Bilirubin: 5,57 mg/dL
Direct Bilirubin: 2,01 mg/dL
Indirect Bilirubin: 3,56 mg/dL
Radiology:
Thorax imaging normal
Other:
ECG normal
Database Resume
Problem Data support
Auto Immune
Hemolytic Anemia



A:
Weakness
Malaise
Skin Icteric
Dark tea urine

PE :
Anemic conjunctiva
Icteric sclera

Lab Result:
Hemoglobin: 4,9 g/dL
Hematocrit: 17,3 vol%
Total Bilirubin: 5,57 mg/dL
Direct Bilirubin: 2,01 mg/dL
Indirect Bilirubin: 3,56 mg/dL
Problem List
Problem Planning
Diagnose
Planning Therapy Planning
Monitoring
Planning
Education
AIHA Coombs test Inj. Methyl prednisolone 2 x
125 mg
Transfusion washed PRC 1
kolf/day pre dexamethasone
VS
SC
Laboratory
Result



Initial Planning