Morning Report

26 june 2014



DOCTOR IN CHARGE :
dr. M. Darwin Prenggono Sp.PD

Patients Identity


Name : Mrs. RB
Sex : Woman
Age : 18 yo
Occupation : Student
Hospitalized since : 25 June 2014

Mrs. RB / 18 yo
Major Symptomp :

History of illness : thypoid (+) dm (-) ht (-)
Family history of illness : dm (-) ht (-).
Environtment : Father is a smoker
Physical Examination

BP = 90/60 mmHg HR = 120 bpm, teratur RR =24 tpm, normal
rhytm,
T : 38,8 C
Physical appearance is moderate ill GCS 4-5-6
Head Konjungtiva Anemis(- / -)
Sclera icteric (-/-)
Neck JVP (normal)
Chest Heart: Inspection : ictus cordis can not be seen
Perkution : Upper heart line: ICS II Linea Parasternalis Dextra/Sinistra
Right lower heart line: ICS IV parasternalis dextra
Left lower heart line: ICS IV Mid clavicularis sinistra
Palpation : Iktus Cordis is felt on ICS V midclavicularis sinistra
Auskultasi : S1, S2 single, murmur (-), gallop (-)
Lung: Inspection : Simetris
Palpation : FV Normal
Perkusion : Sonor
Auskultation: Breath sound is bronkovesikuler, Rh - / - Wh - / -
Abdomen

Pressure pain (+) epigastrium, left hipocondriaca, right - left hipogastrica
Extremities normal
Cue & Clue Problem List Initial
Diagnosis
Planning
Diagnosis
Planning
Terapi
Planning
Monitoring
Anamnesis:
Lips Swallow
Fever
Malar rash
Atralgya
Myalgia
Fatigue
History of melena
Nausea
History of
vomitus

History of seizure
Loss of weight
Hair loss
Cough
Odinofagia
Pemeriksaan Lab
Leukosit : 13.3 rb
1. Lupus
Eritematous
Systemic

Laboratory Result
Test Result Normal Value UNit
HEMATOLOGI
Hemoglobin 11 12,0-16,0 g/dl
Leukosit 8,7 4,0-10,5 ribu/ul
Eritrosit 4,6 4,50-6,00 Juta/ul
Hematokrit 35,6 42,00-52,00 Vol%
Trombosit 256 150-450 Ribu/ul
RDW-CV 14,1 11,5-14,7 %
MCV-MCH-MCHC
MCV 87,9 80,0-97,0 Fl
MCH 27 27,0-32,0 Pg
MCHC 30,8 32,0-38,0 %
PROBLEM LIST
PROBLEM LIST SUPPORTING DATA
Epigastric pain et cause DD :
1. Peptic ulcer
2. Pancreatitis
3. Cholelithiasis

1. Epigastric pressure pain
2. Murphy sign (-)
3. Hb = 11 gr/dl
4. Temp = 35,7C
Headache et cause decrease
oxygen saturation
1. RR 24x / minute
2. SaO2 : 96 %


Problem Planning Diagnose Planning Therapy Planning
Monitoring
1 1. OMD
2. Endoscopy







1. Blood test : plasma
amylase, plasma lipase,
CRP, Ca2+, Mg2+,
complete blood picture/.
2. Urine test : urinary
amylase
3. Plain Abdominal X ray
4. USG Abdomen



1,. Lab : bilirubbin direct
indirect, complete blood
picture, LFT (alkalin
fosfat dan GGF)


1. O2 saturation

Terapi Non-farmakologis :
Avoid eating hard, chilly, and
acid food

Terapi Farmakologis :
Inj. Farmakologis 2x1
Inj. Ranitidine 2x1
PO. Sukralfat 3x1

IVFD RL 20 tpm
Inj. Petidine
Inj. Seftriaxon



\




1. Surgical therapy





1. O2 canul if need
KU
TV
DL
Clinical sign
Thank
you