MORNING REPORT

Date : 14-07-2019

Physician in charge

I :

II CVCU : dr.

II HCU : dr.

II UGD : dr.

Chief on duty : dr.

Consultant on duty : dr.

Facilitator : dr.
 Summary of Database
Mr. S/ 55 y.o/ward 24B Bed 8C
Autoanamnesa
Chief Complaint: Back Pain
History of Present Illness:
• Back pain 1 month ago, intermittent. Getting worst by standing or sitting. The patient can
only lie down. Pain is felt like being stabbed.
• Nausea vomiting since 1 week ago. Vomiting after eating and drinking, appetite decreases.
Vomiting contains water and leftovers. Complaints improved two days.
• Patients post car accidents 1.5 years ago, and got right shoulder fractures.
• Six months ago, patient fell while carrying 25 kilos of rice. Tilted to the left, then the
patient had difficulty turning to the left.
 Laboratorium (26/07/2019)
LAB VALUE NORMAL
Protein Elektroforesis
TOTAL PROTEIN : 6.51 g/dL
ALBUMIN : 3.12 g/dL 3.5 – 5.01 g/dL
ALPHA -1 GLOBULIN : 0.49 g/dL
ALPHA -2 GLOBULIN : 0,73 g/dL
BETA GLOBULIN : 0.29 g/dL Beta 2 = 1.57
GAMA GLOBULIN : 0.30 g/dL
ALBUMIN 48% 60 – 71 %
ALPHA -1 GLOBULIN 7.6% 1.4 – 4.9 %
ALPHA -2 GLOBULIN 11.2% 7 – 11 %
BETA GLOBULIN 4.5% Beta 2 = 24.1
GAMA GLOBULIN 4.6% 9 - 16 %
 Abdominal USG (27 /07/2019)
• Liver: Normal shape and size. Flat edge. The lobe sinistra is
sharp. Parenchym is homogeneous. Normal echo intensity.
Billiard system, portal vein, normal vasculair. There is no cyste,
nodule, calcificatie.
• Gall Bladder: Normal shape and size. The wall does not thicken
There is no stone / sand. Normal CBD.
• Pancreas / lien: Normal. Lien did not look abnormal.
• Ren Dextra / left: The shape and size of the right and the size of
the left are normal. the cortex and right / left kidney medulla
are firm. Pelviocalyceal system of the right / left kidney is
normal. There is no cyaste, nodule, stone (-).
• Vesica urine: Normal. There is no stone or tumor mass.
• Prostate: Normal.
• Mc Burney point: Normal. There is no appendix inflammation.

conclusion:Abdomen ultrasound is currently normal echo.

 CT Scan Cervical (01 /03/2019)
• VC 4 compression appears accompanied by a
description of VC3 and 4 osteopenia.
• Good alignment, normal curve.
• Trabeculation outside lesions is normal.
• Superior-inferior endplate looks good
• Corpus outside the lesion, pedisle and
intervertebral spatium look good
• Not seen soft tissue / swelling

Impression: VC 4 compression is accompanied by a

description of VC3 and 4 osteopenia