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. K/ 66 y.o/ward 27
Autoanamnesa
Chief Complaint: Body weakness
History of Present Illness:
• Patients come to the emergency departement with complaints of body weakness 1 week
ago. In that 1 week, patient just lies down than doing activitie.
• Patient complained of fever 4 days ago
• Patients do not complain of coughing and tightness
• Nausea every meal for approximately in1 week. When eating feels full. Appetite
decreases.
• swollen legs a week ago, felt heavy to walk.
• History of DM since 2 years ago using the 0-10 unit. The highest sugar level is more than
200.
 Summary of Database
Past Medical History:

Family History:

Social History:

Review of System:
 Physical Examination
General appearance looked moderately ill Sat O2 97% on RA
GCS 456 VAS /10

BP 100/60 mmHg PR 90 bpm RR 20 tpm Tax 37 oC

Head Conjuctiva Anemic (-), Sclera Icteric ( ), Nystagmus (-), Meningeal Sign (-), Pupil
Isocor
Neck JVP R+ 0cmH20
Chest Symmetrical, retraction (-)
Lung Sonor | Sonor Vesicular | Vesicular Rhonkhi : + | - Wheezing :
-|-
Sonor | Sonor Vesicular | Vesicular

-|- -|-
Sonor | Sonor Vesicular | Vesicular

-|- - |-
Cardio Ictus invisible, palpable at MCL (S) ICS V
LHM ~ ictus, RHM ~ SL (D) S1 S2 single, regular,
murmur (-) gallop (-)
Abdomen Flat, soefl, Bowel Sound (+) Normal, shifting dullness (-)
 Laboratory Findings (14/07/2019)
LAB VALUE NORMAL LAB VALUE NORMAL

Leucocyte 9020 4.700 – 11.300 /µL Ureum 26,70 20-40 mg/dL

Hemoglobine 9,60 11,4 - 15,1 g/dl Creatinine 0,69 <1,2 mg/dL

PCV 38 - 42% Osm 275-295 mOsm/kg

Thrombocyte 299.000 142.000 – 424.000 /µL Natrium 127 136-145 mmol/L

MCV 79 80-93 fl Kalium 3,55 3,5-5,0 mmol/L

MCH 27,6 27-31 pg Chlorida 98 98-106 mmol/L

Eo/Bas/Neu/ 6,4/0,7/59/ 0-4/0-1/51-67/ RBS < 200 mg/dl

Limf/Mon 19,7/14,2 25-33/2-5
PPT 9.3-11.4 detik
SGOT 32 0-40 U/L APTT 24.8-34.4

SGPT 10 0-41 U/L INR 0.8-1.30

Albumin 1,98 3.5-5.5 g/dL Calcium 7,6-11,0

Bilirubin total <1.0 mg/dl EGFR ml/min/1.73 m2

Bilirubin direct <0.25 mg/dl BUN/Cr

Bilirubin indirect <0.75 mg/dl Ca

Gula Darah Sewaktu 103 <200 mg/dl P

 Urinalysis ()
LAB VALUE NORMAL LAB VALUE NORMAL
Turbidity 10 x
Color Epithelia ≤1
pH 4.5 – 8.0 Cylinder
SG 1.005 – 1.030 Hyaline
Glucose negative Granular
Protein negative Other
Keton negative
Bilirubin negative 40 x
Urobilinogen < 17 Erythrocyte ≤3
Nitrite negative Leukocyte ≤5
Leukocyte negative Crystal
Erythrocyte negative Bacteria ≤23 x 103/ml
Other
 Blood Gas Analysis (dd/mm/yy)

With Room Air/…. Normal

pH 7.35-7.45
pCO2 35 – 45 mmHg
pO2 80 – 100 mmHg
HCO3 21 – 28 m mol/L
O2 saturation > 95 %
BE (-3) - (+3) m mol/L
Temperature
Hb
Conclusion:
 Ascites Fluid Analysis (//)
LAB NORMAL LAB VALUE NORMAL
Macroscopic Protein Total < 3 g/dL
Colour Glucose > 60 mg/dL
Clot Trigliserida Chylous >110 mg/dL
Pseudochylous <50
mg/dL
Clarity Cholesterol Transudat >45-60 mg/dL
Exudat <45-60 mg/dL
LDH Transudat <320 U/L
Exudat >320 U/L
Erythrocyte count /µL
Leucocyte count /µL
PMN %
MN %
Electrocardiography (13/07/2019)
 Electrocardiography ()
• Sinus rhythm, HR 78 bpm regular
• Frontal Axis :
• Horizontal Axis :
• P wave : Normal ( <0,12 second, < 0,3mv)
• PR interval : Normal (0,12 second)
• QRS complex : Normal (0,08 second )
• Q wave : Normal ( < 0,04 second)
• QT interval : Normal ( 0,36 second)
• QT interval corrected :
• ST segment : Normal
• Others :

Conclusion :
Thorax X-Ray (30/06/2019)
 Thorax X-Ray (30/06/2019)
• AP position, symmetric, enough KV, enough inspiration
Soft tissue was thin and bone was normal
• Trachea in the middle
• Skeleton intact, there is no point lesions/blastik/fractures line
• Hemidiaphragm D and S was dome-shaped
• Phrenico-costalis angle D and S was sharp
• Pulmo: normal bronchovesicular, Normal Hillus D/S, there is
infiltrate in midle pulmo dextra and multiple calsification in
midle upper pulmo sinistra
• Cor: shape, size and site normal
• Soft tissue : Normal

Conclusion: - pneumonia
- fibercalsification pulmo bilateral e.c. ex-inflamation
Abdominal USG (/06/2019)
Abdominal USG (/06/2019)
Abdominal USG (/06/2019)
Abdominal USG (/06/2019)
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mr. Mrs. Ms./ yo/ w

Subjective

Objective

Laboratory
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mr. Mrs. Ms./ yo/ w

Subjective

Objective

Laboratory
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mr. Mrs. Ms./ yo/ w

Subjective

Objective

Laboratory
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mr. Mrs. Ms./ yo/ w

Subjective

Objective

Laboratory
Problem Analysis
 Risk Factors Analysis

Problem Theory Patient

Key Message Pathophysiology
Key Message Diagnosis
 Management Analysis

Problem Theory Patient

Key Message Management
Key Message Social
Condition This Morning
 Prognosis

• Ad vitam :
• Ad functionam :
• Ad sanationam :