Morning &

Duty
Report
15 April 2020 MORNING & DUTY REPORT
 OVERVIEW

New Patients:

Emergency Patients
MMORNING AND DUREPORT

Non Emergency Patients

1

Name/Gender/Age/Ward

Chief Complaint:

Present Illness History

Past illness history

Family illness history

Physical Examination
VII

• General Appearance :

• Consciousness level:

• BP : mmHg

• HR : x/minute

• RR : x/minute

• T:ºC

• SaO2 :
• Eye VII
– conjunctiva anemic (-)
– Icteric sclera(-)
• Neck
– JVP 5-2 cmH20
• Lung:
– Inspection: statically & dynamically symmetric
– Palpation: fremitus right=left
– Percussion: sonor
– Auscultation: vesicular, Rh -/- Wh -/-
• Cor: VII
– Inspection: ictus is not seen.
– Palpation: ictus is palpated at 1 finger medial LMCS ICS V
– Percussion:
• Left border: 1 finger medial LMCS ICS V
• Right border: linea sternalis dextra
• Upper border: ICS II
– Auscultation: regular, murmur (-)
• Abdomen: VII
– Inspection: enlargement (-)
– Palpation: hepar and spleen is not palpable
– Percussion: tympani,
– Auscultation: bowel sound (+) N
– CVA : flank pain (-/-)

• Extremities:
– Oedema pretibia -/-
– Physiologic Reflex +/+
– Pathologic Reflex -/-
Laboratory
VII
Items Value
Hb gr/dl
Ht %
WBC /mm3
Platelet /mm3
Diff. Count
PT/APTT
RBG
Ur/Cr
SOGT/SGPT
Na/K/Cl/Ca
Alb/glo
Total bilirubin/direct/indirect
BGA
Chest X-Ray VII
ECG VII
Problems
Working Diagnosis
Differential Diagnosis
Therapy
Plan