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MORNING REPORT
C1
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A 78 year-old male was admitted toR.D. Kado! "os#ital at C1 ward o$riday % $e&r!ary '(1)
*it+ mai ,om#lait G!m &leedisi,e 7 days &.a
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Patiet/s idetity
Name Mrs R0Ae 78 years old
e2 Male
O,,!#atio $armer
Ed!,atio Middle "i+ ,+ool
Et+i,ity Mia+asa
Reliio C+ristia
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Preset Medi,al "istory
G!m &leedi si,e 7 days &.a.T+is+a##eed s!ddely. $re3e!,y &leedi 4%25day6 total ol!me 4 1( ,,5day. ores -9.
T+e &leedi was sto##ed today. T+is
+a##eed &e:ore ad sto##ed &y itsel:. No+istory o: !si ay dr! -9
$eer 496 s+ieri 496wea;ess 496a!sea -96 omit -9. Poor a##etite -96de,rease &ody wei+t -9
Dys#ea -96 ,o!+ -9
De:e,ati ad !riati +ad o ,om#lai.
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Past Medi,al "istory
Patiet +ad t+is disease at
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"istory o: allery
=;ow
"istory o: imm!i>atio =;ow
"a&it +istory
-
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$amily "istory
Noe e2#erie,ed t+e same illess
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Geeral aamesis reiew o: system 9
Geeral *ea;ess6 :eer6 s+ieri
;i -"ead ad e,; -
Eye -
Ear -Nose -
Mo!t+ ad t+roat !m &leedi
Res#iratory
C+est -
"eart -
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A&dome -
Geitalia -
Kidey -"ematoloy -
Edo,rie
M!s,!los,eletal -
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P+ysi,al E2amiatio
GC Moderate ill es CM C1:BP: 90/60mmHg, PR 80x/m, RR 20x/m, T 37,3C ER :BP: 110/70mmHg , N 64x/m, RR 16x/m, T 36,3 C ?* %( ;6 ?" 1%( ,m6 ?MI ''6' ;5m' Head :con! anem"c #$%, &c'! "c(e)"c#$%, *o+( : ce"'"("& #$%, -'eed"ng#$% Nec. : P 0 cmH20, 'm node& en'a)gemen( #$%, ()o"d #$% To)ax : Hea)( :
5n& : 5C no( "&"-'e Pa' : 5C no( a'a-'e, Pe)c : 'e( -o)de): 5C 1 cm 'a(e)a' m"dc'a"c+''a) '"ne
)"g( -o)de): 5C 5 1 cm 'a(e)a' a)a&(e)na' '"ne +&c : 5$55 )eg+'a), m+)m+) #$% &&(o'"c, ga''o #$%
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P+ysi,al e2amiatio
@! Is# ymmetri,Pal# stem :remit!s R @Per, soor 454A!s, esi,!lar6 ro,+i -5-6 w+ee>i -5-
A&d Is# $latPal# Teder6 #ai -96
@ier ad s#lee ot elaredPer, Tym#ai, i all reios6 s+i:tid!lless -9
A!s, ?owel so!d 49 ormal
*aist Pai o CBA e2am -5-9 E2tr warm6 edema -5-96 #!r#!ra 496
+ematoma49
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@a& Res!lt%5'5'(1) e+coc(e 300 E)" 293 H- 9, H( 29,2 P'a(e'e( 34,000 *CH 32,2 *CHC 32, *C 99,6
;) / c) 38/1,2 Na()"+m 13 ? 4,6
Malaria :al,i:ar!m 444
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Ro T+ora;
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RONTGEN INTERPRETATION
Rontgencomponents
Interpretation
Idetity ame as t+e #atiet
KB eo!+
ymmetri, ormal
Dia#+rama ormal
Mediasti!m ormali!s Costoerte&rae s+ar#
i!s Cardio#+rei,!s +ar#
?oe Ita,t
Cor 4 CTR 115'1 1(( %'
P!lmoaryPare,+yme
Iltrat -9
CONC@=ION ormal
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ECG i!s r+yt+m6 7125mi6RAD
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ECG INTERPRETATION
ECG components Interpretation
Value
R+yt+m i!s i!s R+yt+m
#eed 5 "Rtimes5mt9
7125mi 1%((5R-R/
A2is RAD Normal 5 RAD 5 @AD
Mor#+oloy P wae (6(8 se, @ead II D!ratio F(.1(6 "ei+tF'.%
PR Iteral (6'( se, (61' H (6'(
R ,om#le2d!ratio
(6(8 se, (6(% H (611JJ
T seme Normal Normal 5 Eleated 5 De#ressed
T wae Normal Normal 5 a&ormal
T Iteral (6% se, ,T T iteral 5 R-R/Iteral
= wae A&set A##ear 5 ot a##ear
CONC@=ION i!s ryt+m6 "R 7125m6 RAD
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Pro&lem @istNo CM %.'(.LL Ae 78 y.o
1. Mai ,om#lai
. G!m &leedi
'. Aamesis. G!m &leedi si,e 7 day &.a6 re#eated
. Geeral *ea;ess
. $eer6 s+ieri
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. P+ysi,al e2amiatio GC Moderate ill es CM ."n : P+)+)a #%, Hema(oma #%
4! @a& E)" 293 H- 9, H( 29,2 P'a(e'e( 34,000 *a'a)"a a'c"a)+m
! EC; : &"n+& )(m, 71x/mn(, R
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