Morning Report

February 15th 2019

Nama / RM DPJP Assessment Objective Therapy Plan

1. Andi Main Doctor : 1. External otitis Patien transferred from lontara 3 to 1.Ceftriaxone
Hasni/66 th THT-KL media supurative IC, because acid fast basili was positif. 1gr/12 hours/iv
: dr. Muh. Ilyas, Cough for 3 weeks, white sputum, Ketorolac 30 mg/8
Sp.PD, K-P, Sp.P(K) history of hemoptisis (-). shortness of jam/iv
breath (-), chest pain (-). Fever (+) Metilprednisolon
intermitten for the last 2 weeks. 125mg/8 jam/iv
sweat without activity (+)
otalgia (+) since 2 months ago, Otore
2. pulmonary (+), tinitus (+), hearing loss at the 2. rifastar 4 FDC/3
tuberculosis on auris sinistra. tabs/oral
treatment, new history of tuberculosis treatment (-),
case, intensive contact with tuberculosis patient (-),
phase day 1 There is a history of diabetes melitus
> 10 years but didnt take medicine 3. Apidra 6-6-6
3. Diabetes melitus regularly. Lantus 0-0-10
type 2 non obbese
Nama / RM DPJP Assessment Objective Therapy Plan

1. Andi Main doctor : 1. pulmonary Patien transferred from lontara 3 to rifastar 4 FDC/3 Observation
Hasni/66 th KJS : dr. Muh. Ilyas, tuberculosis on IC, because acid fast basili was tabs/oral drug side effect
Sp.PD, K-P, Sp.P(K) treatment, new positive.
case, intensive Cough for 3 weeks, white sputum,
phase day 1 history of hemoptisis (-). shortness of
breath (-), chest pain (-). Fever (+)
intermitten for the last 2 weeks. sweat
without activity (+)
history of tuberculosis treatment (-),
contact with tuberculosis patient (-),
There is a history of diabetes melitus
> 10 years but didnt take medicine
regularly.

Physical examinations:
Thorax :
Inspection : symmetrically in dynamic
and static
Palpation : vocal fremitus Same at the
both hemithorax
Percussion : sonor at the both
hemithorax
Auscultation: bronchovesicular, no
rhonchi and wheezing
 Nama /
DPJP Assessment Objective Therapy Plan
RM

Mr. A/ 53 Main doctor : 2. Chronic otalgia (+) since 2 months ago, Ceftriaxone Ct scan
th/872492 KJS : dr. Muh. supurative External Otore (+), tinitus (+), hearing loss 1gr/12 hours/iv mastoid with
Ilyas, Sp.PD, K-P, otitis media sinistra at the auris sinistra Ketorolac 30 mg/8 contrast
Sp.P(K) jam/iv
Physical examination: Metilprednisolon
Auris sinistra : thympany 125mg/8 jam/iv
membrane intake
Auris dextra :thympany
membrane granulation
 Nama /
DPJP Assessment Objective Therapy Plan
RM
Mr. A/ 53 Main Doctor : 3. Diabetes There is a history of diabetes - Apidra 6-6-6 Random
th/87249 THT-KL melitus type II > 10 years didnt take - Lantus 0-0- blood
2 : dr. Muh. non-obese medicine regularly 10 glucose
Ilyas, Sp.PD, K- daily
P, Sp.P(K) Laboratorium findings :
Random blood glucose 267
Fasting blood glucose 309
Post prabndial blood glucose
348
HbA1C 9.9
 LABORATORIUM FINDINGS normal range
WBC 7.7 4.00 – 10.00
HB 10.9 12.00 – 16.00
PLT 407.000 150 – 400
NEUTROFIL 91.1 52.00 – 75.00
LYMPHOSIT 5,6 20.00 – 40.00

Sputum BTA 1 Negative Negative

Sputum BTA 2 Negative Negative
Sputum BTA 3 Positive (+3) Negative
 TERIMA KASIH DAN
MOHON BIMBINGANNYA