Morning Report 27th April 2013
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Transcript of Morning Report 27th April 2013
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MORNING Report
April 27th 2013
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Patients Identity
Name : Mr. A
Age : 20 y.o
Religion : MoeslimDate : April 25th 2013
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AnamnesisChief complaint: Fever Present illnes: patient complained about his
fever with chilled and sweating since 9 daysbefore hospitalized. His fever has increase atthe first day and felt more fever at night. It wasdecrease by taking medicine but after that, itwould be increased again. Nausea (-), vomit (-),headache (+), abdominal pain (-). Defecationnormal, and his urinations colour seen like tea.
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Anamnesis
History or past illness :- History of dengue fever haemorrhage, Hepatitis,
thypoid fever, malaria denial
History of family :- History of dengue fever haemorrhage, Hepatitis,
thypoid fever denial
History of sociality :- Patient about 12 days ago when to the Kalimantan
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Physic Examinations
General Appearance : Weak
GCS : 456 , Somnolen
Vital Sign
BP : 95/51 mmHg
Pulse : 96x / minutesRR : 20x / minutes
Temp : 37 C
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Physic ExaminationsHead and neck : Anemic +/ icteric +/ cyanosis -/
dyspneu -
Thorax : simetric bilaterally, retraction (-/-), Pulmo : ves/ves, rh (-/-), wh (-/-)
Cor : S1-S2 single, murmur(-), gallop(-)
Abdomen : flat, soepel, hepar 4cm under arcus
costae and lien S1H1, tenderness (-), meteorismus
(-), BU(+N)
Extremity : akral warm, wet, red (+), edema (-)
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Laboratory Findings
Diff count 0/0/54/30/16Hematocrit 22,3 %Haemoglobin 8,1 mg/dLLED 64/99
Leukocyte 2.300Trombocyte 40.000Alkali fosphatase 235Bilirubin direct 4,89 mg%Bilirubin total 8,1 mg%SGOT 71 u/LSGPT 54 u/L
Albumin 2,1 mg% Total protein 5,2 mg% Clorida serum 105 mol/l
Kalium serum 3,2 m mol/l
Natrium serum 138 m mol/l
Urea 74 mg/dl Serum creatinin 0,9 mg/dl
GDA 104 ICT MALARIA Positif :
Plasmodium falciparum
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Thorax APThorax photo seen
no abnormality.
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Clue and CueMale, 20 y.o
Fever
Nausea (-), vomit (-)
Urinations colour seenlike tea.
Patient about 12 daysago when to the
KalimantanPhysic Examinations :Anemic +, Icteric +,Hepatosplenomegaly
Laboratory Findings :
Diff count 0/0/54/30/16
Hematocrit 22,3 %
Haemoglobin 8,1 mg/dL
Leukocyte 2.300
Trombocyte 40.000
Alkali fosphatase 235
Bilirubin direct 4,89 mg%
Bilirubin total 8,1 mg%
SGOT 71 u/L
SGPT 54 u/L Albumin 2,1 mg%
Total protein 5,2 mg%
Urea 74 mg/dl
ICT MALARIA Positif : Plasmodium
falciparum
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Assessment
Malaria Tropicana
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Planning
Planning Dx : -
Blood smear
Planning Tx :
Infus Asering 1.500cc /24
hour
Inj. Methamizole 3x1
Inj. Ranitidin 2x1
Inj Ceftriaxone 2x1
Po Hepamax 1x1 Po aterakin 4 tablet 2
tablet 2 tablet
c/ Internist
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Dubia ad bonam
Prognosis Education
Explain to the family about
the condition of this patient
now, its disease, about itsexaminations, theraphy and
intervention will be done,
and also about complication
and prognosis.