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Morning Report

03/02/2019
DM Yemima
Konsulen : Dr. Nikson E. Faot, Sp.P
Name : Mr. GN S O A P
Date of Birth :
October, 1st, 1988
Age : 30 y.o
Sex : Male S : patient treated day 5. General condition : looks TB Lung relaps 1. OAT Kategori 2
moderate
Address : Soe Hemoptoe perbaikan (2HRZES/HRZE/SHR3E
Patient referral from Soe , Awarness : Compos Mentis
Job : private with abdominal pain, GCS : E4V5M6 3)
Status : Married nausea and vomiting.
Last Education : Vital sign : 2. IVFD NaCl 0.9 % 20
Coughing and abdominal BP :
bachelor degree pain are felt approximately T: tpm
Tribe : Soe 4 months ago. Cough with RR :
Payment : BPJS white phlegm. Coughing is p:
especially felt at night. SpO2 :
Room : Tulips
Approximately 1 month VAS :
MR number: 507162 ago, coughing was BB : 43 kg
IGD Entry date : accompanied by blood TB : 165 cm
January, 31st , 2019 BMI : 15,79 kg/m2
The history of OAT drug
Date of entry : consumption in 2016 and
January 31st, 2019 2018 was declared
complete, did not break up
the drug. TB in the family
was denied
Head and Neck

 Skin: brown, normal skin turgor, Jaundice (-), cyanosis (-), pale (-)
 Hair: black and not easily removed
 Eyes
 Conjunctiva: Pale + / +
 Sklera: jaundice - / -
 Pupil: round isocor + / +, Direct Light Reflex + / +
 Nose: epistaxis (-), deformity (-), nasal lobe breathing (- / -)
Mouth:
 The tongue is not dirty
 The mucosa of the mouth and lips is moist
 T1-T1 tonsils are not hyperemic
Ears:
 signs of inflammation: - / -
 Mastoid tenderness - / -
 Signs of injury in the mastoid area - / -
Neck:
 KGB enlargement (- / -)
 Use of respiratory aids (- / -)
Pulmo
 Inspection: symmetrical when static (+ / +) and dynamic (+ / +), widening ribs
(- / -), breathing aid muscles (- / -),
 Palpation: Pain Relief (-)
 Percussion: sonor in both lung fields
+ +
 Auscultation: vesicular breath sounds + +
ronkhy + +

Wheezing
Cor Abdomen

Inspection: Ictus Cordis is not


visible
Palpation: Ictus Cordis is not
palpable Inspection: the abdomen looks
Percussion convex
Upper cardiac limit: Cystic Auscultation: 10x / minute (+)
parasternal 2 ICS bowel sounds
Right heart border: ICS 4 dextrinal Palpation: tenderness + regio
external line hypochondriac dextra
Left heart limit: ICS 5 left Percussion: timpani
midclavicularis
Auscultation: Regular S1 - S2,
Murmur (-), additional heart
sounds (-) gallop (-)
Extremitas:
 Warm hearted, cyanosis (-) in all four extremities, CRT <2 "
 Pitting Edema (-)
LABORATORY

Hb 10,6 L 13 - 18
Hematokrit 38,7 L 40 - 54
MCV 72,7 L 81 - 96
MCH 25,1 L 27 - 36
Leukosit 7.36x103 N 4 - 10
Trombosit 388x103 N 150 - 400
268
GDS H 200
HbsAg non reaktif
HIV Non reaktif