MORNING REPORT

November, 21th 2016

Doctor in Charge :
Dr. dr. Agus Yuwono, Sp.PD-KEMD

Patient Identity
Name
: Mr. A
Sex
: Male
Age
: 19 y.o
Occupation
: Student
Hospitalised since : June 20th, 2016

Summary of Data Base

Chief Complaint: Demam
Keluhan demam muncul 3 hari SMRS, mendadak tinggi namun tidak
diukur. Demam naik turun, naik saat siang hari, turun saat sore dan
malam hari. Demam sedikit turun ketika diberi obat paracetamol
namun kembali naik. Saat demam, pasien menggigil, tidak ada
berkeringat pada malam hari.
Pasien mengeluh mual dan muntah. Muntah bisa sampai 10 kali,
muntah berisi cairan putih, banyaknya sekali muntah gelas aqua.
Pasien juga mengeluh nyeri perut (VAS score: 5) dan sakit kepala di
kedua sisi seperti terikat. Nafsu makan pasien juga menurun karena
muntah. Keluhan nyeri belakang mata (-) nyeri sendi (-) nyeri menelan
(-) batuk (-) sesak (-) ruam (-) gusi berdarah (-) mimisan (-) BAB
kehitaman (-) BAK berwarna gelap (-)
RPD: (-)
RPK: (-)

Physical Examination
General
Appearance

Sakit sedang

Consciousness

Compos mentis GCS 4-5-6

Blood Pressure

125/80 mmHg

Pulse Rate

96 bpm regular, strong

Respiration
Rate

22x/m

Temperature

38,0o C

Skin

Petekie (+) turgor baik, tumor (-), infection (-), rash (-),
ekskoriasi (-) nodul (-), sklerosis (-) ikterik (-)

Physical Examination
General
Appearance
Head

Thoracic

Heart

Normocephali, Pembesaran KGB (-) Epistaksis (-)

Pupil isokor (3 mm/3 mm) Konjungtiva anemis (-/-)
Faring hiperemis (-)
Inspection : Simetric
Palpation : Symmetrical movements
Percussion: Sonor
Auscultation :
V |V
V |V
V |V
Wheezing (-), Rhonki (-)
Inspection : ictus invisible
Palpation : palpable in MCS ICS V
Right margin: ICS II-IV L.Paraternal Dextra.
Left margin: ICS II L.Parasternal Sin-ICS V MCS Sin
Cardiac waist : (+)
Auscultation : S1 > S2 single, murmur (-) gallop (-)

Physical Examination
General
Appearance

Abdomen

BU (+) Normal
Palpation: Pain
- | + |- | - |- | - |Hepatomegali (-) Splenomegali (-) Asites (-)

Extremity

Superior D & S : Edema (-), Pain (-), Weakness (-)

Inferior D & S : Edema (-), Pain (-), Weakness (-)
Ulcers (-)

Rectal

Haemorrhoids (-), fisurra (-)

Problem List
No

1.

Problems

Sakit Pinggang
1.1. Nefrolitiasis dextra
1.2. Cholelitiasis
1.3. Abses hepar

Problem Oriented Medical Record

No

Problem

P.Dx

P.Tx

P.Mo

P.E

1.

Sakit Pinggang
1.1. Nefrolitiasis
dextra
1.2. Cholelitiasis
1.3.
Abses
hepar

Urinalisis,
Darah Rutin
Serum Ur/Cr
level,
SE,
USG abdomen,
IVP
Bilirubin TDI
SGOT/SGPT

Bed rest
IVFD NS 20 tpm
IVFD Ciprofloxacin
2x400 mg
Inj Metoclopramide
3x10 mg
Inj Omeprazole
1x40 mg
Inj Scopamin 3x1
amp (k/p)
P.O Codein 1x15mg
P.O PCT 3x500 mg

Urine
output,
Subjective,
Vital Sign

Diet Ginjal

THANK YOU