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Morning Report

12 December 2018
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Morning Report

 Day and Date : Wednesday, 12th December 2018

 Mentor : dr. Sumardi, Sp.PD –KP

 Co – Assistants :

Ward : Lovira Ladieska

E.R. : Amelia

Erinda Rambu
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Identity

 Name : Mr. S

 Age : 36 yrs old

 Gender : Male

 Address : Jeruklegi

 Occupation : Labor

 Medical record : 9053xx

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Anamnesis

 Chief Complaint: Enlarged stomach

 Current Medical History:

1 Month before admitted to the hospital: Patient had fever with intermitten pattern
(increasing temperature on the evening) and stomachache. Then patient went to a clinic,
he did a blood test and roentgen thorax. Afterwards, he was diagnosed with Typhoid Fever.
Patient was given couples of medicine including antibiotics but he forgot the names.

The day he was admitted to the hospital: He had complaints of enlarged stomach,
nausea, vomit, dyspnea, headache, and black watery stool for a week, with frequency
around 5 to 6 times a day. Watery stool had no mucus nor blood. Patient feels nausea
almost everytime after he eats, but he still could eat in decreased amount compared to the
usual, and he easily get full everytime he eats. He sometimes vomiting after he had a
meal. Vomit consists of the food that he just eat. Patient feels comfortable sleeping with
one pillow, PND (-) orthopnea (-) dyspnea on effort (-) chronic cough (-) night fever and
chills (-). And also he got gum bleeding. Patients haven’t had consumed any medicines
except the ones from the clinic. Patient doesn’t smoke, rarely consumed pain killer and
NSAID, has never done any blood transfusion, and doesn’t consume alcoholic beverages.
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Anamnesis

 Past medical history:

Hospitalized due to Typhoid Fever (10 yrs ago)

Hypertension (-)

DM (-)

Dyslipidemia (-)

Allergy (-)

Malignancy (-)
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Anamnesis

 Family medical history:

Similar complaint (-)

Hypertension (-)

DM (-)

Dyslipidemia (-)

Allergy (-)

Malignancy (-)
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Organ System’s Anamnesis

 Skin : no complaint  Throat : no complaint

 Neck : no complaint
 Head : headache
 Cor : no complaint
 Eye : no complaint
 Pulmo : dyspnea
 Ear : no complaint  GI tract : enlarged
 Nose : no complaint stomach, stomachache,
black watery stool
 Mouth : gum bleeding
 Genitourinary: no
complaint
 Neuromuscular: no
complaint
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Physical Examination

 General Condition : Compos Mentis

 Weight and Height : 55kgs, 160 cm

 Vital Signs:

BP : 100/70 mmhg

RR : 22 bpm

HR : 80 bpm

Temp : 36.6
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General Examination

 Skin : Jaundice (+) Cyanosis (-), Vulnus (-)

 Eyes : Anemic conjunctiva (+/+), Icteric sclera (+/+)

 Ear : Simmetrical (+), tenderness (-), discharge (-)

 Nose : Simmetrical (+), discharge (-) hyperemic (-)

 Mouth : Gum bleeding (+) cracked lips (+) dry mucosa (-)

 Pharynx : Hyperemic (-), tonsil edema (-)

 Neck : lymph nodes are not palpable, JVP in normal range (not
increasing), spider nevi (-)

 Extremity : Warm, CRT < 2 secs, cyanosis (-), palmar erythema (-)
edema (+/+) in lower extremities
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Thorax Examination

Anterior Dextra Sinistra

Inspection Symmetrical, retraction (-) chest
expansion right = left
Palpation Tenderness (-) tactile fremitus
right = left
Percussion Sonor
Auscultation Vesicular (+/+) RBK (-/-) RBB
Ves (+/+)
(+/+) wheezing (-/-)
Posterior Dextra Sinistra
Inspection Symmetrical, retraction (-) chest
expansion right = left
Palpation Tenderness (-) tactile fremitus
right = left
Percussion Sonor
Auscultation Vesicular (+/+) RBK (-/-) RBB
(+/+) wheezing (-/-)
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Thorax Examination

o Inspection : Ictus cordis not seen

o Palpation : Ictus cordis palpable on ICS 4 LMC S

o Percussion :

Superior: ICS 2 LMCS

Dextra : ICS 4 LPSD

Sinistra : ICS 5 LAAS

Cardiomegaly (-)

o Auscultation : S1- S2 normal, regular, S3 (-), S4(-)

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Abdominal Examination

o Inspection : distention (+) caput

medusae (-)

o Auscultation : peristaltic sound (+)

15x/min, bruit aorta (-)

o Percussion : tympanic on umbilicus

(+) dull on lateral (+),
hepatosplenomegaly (+) schuffner 2,
shifting dullness (+)

o Palpation : tenderness in epigastric

region (+), hepar and spleen are palpable
(+) tumor/mass (-), ballottement (-)
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Extremity Examination

 Superior  Inferior

CRT <2 seconds CRT <2 seconds

Warm Warm

Edema (-/-) Edema (+/+)

Weakness (-/- Weakness (-)

Pulsation a. radialis regular, Pulsation a. tibialis: regular,

strong, symmetrical strong, symmetrical
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Lab Examination

Examination Result Reference Range

Hemoglobin 11.9 13.5 – 17.5
Leucocyte 12.900 4400 - 11300
Hematocrit 33.8 40 – 52
Erythrocyte 3.42 4.5 – 6.5
Thrombocyte 40.000 150.000 – 400.000
MCV 98.8 80 - 100
MCH 34.8 26 - 34
MCHC 35.2 32 - 36
Basophile 0 0-1
Eosinophile 0 1-6
Rods 0 3-5
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Lab Examination

Examination Result Reference Range

Segment 78% 40 – 70
Limphocyte 15% 30 - 45
Monocyte 7% 2 - 10
HBsAg Reactive Non reactive
AST (SGOT) 209 17 - 59
ALT (SGPT) 176 21 - 72
Ureum 35.0 15 - 50
Creatinine 0.84 0.8 – 1.5
Blood Glucose Level 90 <140
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Assessment

 Ascites et causa susp cirrhotic hepatic

 Hepatitis B Infection

 Dyspepsia dismotility type

 Acute diarrhea

 Thrombocytopenia et causa suspect related cirrhotic hepatic

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Emergency Room Treatment

 Ringer Lactate Infusion 20 drip per minute

 Inj. Pantoprazole 1A/12 hrs

 Inj. Ondancetrone 1A/8 hrs

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Plan

 Sucralfat 3 x 1 cth  Checks for:

albumin
 Propranolol 2 x 10 mg
conjugated and unconjugated
 Inj. Lasix 1A/12 hrs bilirubin

 Spironolactone 2 x 25 mg electrolytes

routine fecal examination

 Tab curcuma 2 x 1
urinalysis
 New diatab 2 x 1
PT INR APTT

 Abdominal USG
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Thank You