MORNING REPORT

IDENTITY
Name : Tn. M
Age : 57 years old
Sex : Male
Address : Kendari
Admission : November, 06th 2019 (19.15 WITA)
Doctor in Charge : dr. Farully, Sp. B (K) Onk
 HISTORY TAKING
 Main complaint: Painfull swallowing
 Anamnesis
Referral patient from RS. D. R Ismoyowith tongue cancer and complaints of painful swallowing since two
years ago but was worsen since two months ago, was originally derived from the sharp teeth touch thr
thongue and make cancer sores and blisters on the night side of the thongue since 2017.
 History
There was not history of the same complain
There was not history of other disease
There was not history of nausea and vomiting
There was medical treatment history at 2017, but the patients family didn’t know it
There was history smoking since the age of 20th.
 Physical examination

The patient was conscious with severe ill.

BP = 120/80 mmHg
Pulse = 76x/m, regular, strong
RR = 18x/m, regular
Temperature = 36,7oC
 Generalized status
Head : Within normal limit
Face : Within normal limit
Eyes : Within normal limit
Nose : Within normal limit
Mouth : Localized state
Ears : Within normal limit
Neck : Within normal limit
Chest : Within normal limit
Extremity : Within normal limit
Clinical Documentation
Plan of Diagnostic

 Routine Blood
 Chemical blood
Diagnostic

Tumor Colli
Management

•IVFD
•Antibiotic
•Analgetic
•Antiemetik