MORNING REPORT

Date : Thursday, September 16th 2021

Physician in charge
IA :
IB :
II HCU :
II Medical Consultation :
II Incovit :
II ER :
II ER Incovit :
Chief on duty :
Consultant on duty :
Facilitator :
 Summary of Database
Mr. AW / 60 y.o / Ward 25
Chief Complaint: lump on the left neck
History of Present Illness:
- The patient complains of a lump on the left neck. Pain (-)
- Previously the lump was on the left neck with the size of a soybean seed then in 4

months it grew as big as a duck egg and spread to the left armpit.
- He also complaint about weight loss approximately 10kg for the last one year.
- Nausea vomiting (-), heartburn (-), shortness of breath (-).
- The patient was diagnosed with Non Hodgkin Lymphoma since April 2021 and

undergone chemotherapy.
 Summary of Database
Past Medical History:
Patient has no past medical history related to current condition.
Family History:
Patient has no family history of malignancy.
Social History:
‒ Patient works as a meatball seller who delivers orders.
Review of System:
‒ General: patient felt easily tired, decrease of body weight
‒ Respiratory: within normal limit
‒ Gastrointestinal: decrease appetite.
 Physical Examination
General appearance looked moderately ill 97 % Sat O2 in Room Air
GCS 456, Compos mentis
BW : 50 kg, H : 170cm. BMI : 17,3kg/m 2 (underweight) KS 90%

BP 132/101 mmHg PR 78 bpm RR 20 tpm Tax 36,7 oC

Head Conjuctiva Anemic (+)

Neck Solitary mass on Colli S, size 5cmx5cm, not well defined, tender (-), mobile, solid, smooth surface.

Chest Symmetrical, retraction (-)

Sonor | Sonor Vesicular | Vesicular Rhonkhi : -|- Wheezing : -|-

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

Ictus visible, palpable at ICS V, MCL S

Cardio LHM ~ ictus, RHM ~ SL (D) S1 S2 single, regular,
murmur (-) gallop (-)

Flat, soefl, Bowel Sound (+) normal,

Abdomen Liver/ unpalpable, liver span 10 cm
Lien/ Traube space tympany
Inguinal lymph node enlargement D/S (-)

Extremities Pitting Edema (-), Pale (-), CRT <2 detik

 Laboratory Findings (15/09/21)
LAB VALUE NORMAL LAB VALUE NORMAL

Leucocyte 5.450 4.700 – 11.300 /µL Sodium 139 136-145 mmol/L

Hemoglobine 13,00 11,4 - 15,1 g/dl Potassium 3,62 3,5-5,0 mmol/L
Hct 38,60% 38 - 42% Chloride 111 98-106 mmol/L
Thrombocyte 293.000 142.000 – 424.000 /µL ANC 2.370
MCV 93,20 80-93 fl
MCH 31,40 27-31 pg
Eo/Bas/Neu/ 17,4/1,3/43,5/1 0-4/0-1/51-67/ Swab Antigen Negatif
Limf/Mon 4,9/22,9 25-33/2-5 SARS Cov-2
Electrocardiography (15/09/2021)
 Electrocardiography (15/09/2021)
• Sinus rhythm, HR 78 bpm regular
• Frontal Axis : normal
• Horizontal Axis : normal
• P wave : 0,04 second
• PR interval : 0,12 second
• QRS complex : 0,08
• QT interval : 0,32 s (0,35 QTc)
• ST segment : isoelectric
• T Wave : normal
Conclusion : Sinus Rythm with HR 78 bpm
Chest X-Ray (22/07/2021)
 Chest X-Ray (22/07/2021)
• PA position, symmetric, enough KV, enough inspiration
• Soft tissue and visualized bones within normal limit
• Right and left costophrenicus angles are sharp
• Right and left hemidiaphraghm are dome-shaped
• Trachea in the middle
• Cor: Site and shape within normal limit, CTR 50%, aorta elongation (-)
• Pulmo: Bronchovascular pattern within normal limit, no opacities and infiltrate
• Soft tissue : Soft tissue mass region colli left
Multiple opacity was seen with firm borders, lobulated edges in the right perihilar and left paraaortic
that formed an obtuse angle with the mediastinum.

Conclusion:
• Multiple opacities in the mediastinum bilateral anterior mediastinal lymphadenopathy new lesions
• Soft tissue mass region colli suspected ec lymphadenopathy
Ultrasound Colli (14/4/2021)
• Multiple lymphadenopathy partially conglomerate
malignant characteristics in the bilateral perijugular
region, submental, bilateral submandibular, bilateral
posterior colli
• Bilateral thyroid gland, bilateral parotid gland, bilateral
submandibular gland within normal limits

Abdominal ultrasound (29/6/2021)

• No intra-abdominal or nodular lymphadenopathy was
seen in the spleen.
 IHK (21/06/2021)

• CD 3: Positive Diffuse in T . Lymphocytes

• CD 20: Diffuse positive on tumor cell membranes
• Ki67 : Positive in 90% of tumor cell nuclei with
strong intensity
• Conclusion: Immunophenotype corresponds to
NHL B Cell Type High Grade