21 September 2016

MORNING REPORT
WANDI
RSUD TANJUNG KLU
FK UNIZAR MATARAM

PATIENT 1

Name: Mr. R
Sex

: Male

Age

46

Admitted
Time

years old
:

21 September

: 13.30

Diagnose

2016

pm

: - Obs. Hemoptoe e.c TB Paru on

Treatment
- Susp. Pneumonia (CAP)
- Anemia Ringan HM ec Bleeding dd/ Susp. ADB

ANAMNESIS
Chief complaint

= Blood cough

Present illness
Patient come to emergency room of Tanjung
General Hospital with complaint blood cough since 6
hours before entering the hospital. Cough continuosly
pevceived to interfere with the activity, cough with fresh
blood and sputum.
Patient also complaint of fever (+) since 3 days
ago before entering the hospital, fever is felt up and
down, shiver (-), dizziness (+), limp (+) nausea (-),
vomiting (-), epigastric pain (+), decreased appetite (+),
patient also felt more days decreased body weight,
night sweats (-), urinary and defecation (+) normal.

Past medical history

Patient had a history of old cough since
4 months ago, HT (-), DM (-), Heart
disease (-)
Family History : (-)
Social History :
Smoking (+) as a teenager and quit after
suffering from tuberculosis
Alcohol (+)

Physical Examination
General state : moderate
GCS
: E4V5M6
BP
: 110/60 mmHg
Pulse
RR

: 88 x/minute

Temp

: 36,7 0C

: 22 x/minute

H/N : Ca -/-, SI -/-, palpebra edema -/-, JVP (-), nostril respiratory (-)

Thoraks
Cor
Inspection

: Ictus cordis invissible

Palpation

: Ictus cordis palpable at ICS V linea axila

anterior

Percussion : Upper side at ICS II linea sternalis dextra

Waist at ICS III linea parasternal sinistra
Right side at ICS V linea midclavicula dextra,
Left side at ICS V linea midclavicula sinistra
Auskultation: S1S2 reguler, Gallop (-), Murmur (-)

 Pulmo
Inspection : Simetris (+), retraction (-)
Palpation : vocal fremitus decrease,
tenderness (-)
Percussion : Sonor +/+
Auskultation : Vesicular +/+, rh+/+, wh-/ Abdomen
Inspection : distention (-)
Auskultation
Palpation

: bowel sound (+) normal

: epigastric pain (+)

Percussion : timpani all regio abdomen

 Extremities
Warm (+)
Sianosis (-)
Edema (-)
CRT < 2 sec

Pdx
DL
Rontgen Thorax PA
Sputum BTA 3x (SPS)
Kultur sputum

Result of Rontgen Thorax PA

Results of Laboratory Test

Nilai

WBC
Hb
HCT
MCV
MCH
MCHC
Trombosit
Glukosa

5,8
9,8
31,2
72,6
22,7
31,4
321
55

Assesment
-

Obs. Hemoptoe e.c TB Paru on Treatment

- Anemia Ringan HM ec Cronic Bleeding (ADB) dd/
ACDB

- Susp. Pneumonia

Therapy
IVFD RL 20 tpm
Inj. ondansentrone 1x25 mg
Inj. Ceftriaxone 2x1 g
Inj. Ranitidin 1x25mg
Inj. Asam Traneksamat 1x500 mg
Asam folat 3x1
Ambroxol tab 3x30 mg
OAT lini I

Thank you