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MORNING REPORT

DEPARTMENT OF INTERNA
(emergency unit)

Identity
Patient identity
Name : Mr. K
Age : 48years old
Sex : Male
Work : -
Address : Laren lamongan
Examination date : Oct 23th, 2013
Anamnesis
Chief Complaint
Abdominal Pain
Present illness History
patient complained of right upper abdominal
pain has been since last night, as in pain
knead, nausea (+), vomiting (-), fever (-),
patient complained of leg swelling since one
this week.
Previously illnes history
HT (-), DM (-), Renal disease (-), Heart disease (-), Respiratory disease (-)
liver disease (+), HIV (+)

Family illnes History
Denied
Social history
Smoking (+), Alcohol (+), free sex (+)
Physical examination
Vital Sign
GCS : 456
Blood pressure : 120/70 mmHg
Heart Rate : 80x /minutes
RR : 24x /minutes
Axilla temperature : 37
o
C
Head / neck : an (-), ict (-), cy (-), dys (-)
Thorax : Normal chest form, retraction (-), symmetrical chest
wall movement
Pulmonary
P : sonor/sonor, Symmetric
A : Ves/Ves, Rh-/-, Wh -/-
RR : 24x/minutes
Cor
P : Dull
A : S1-S2 single, murmur (-), gallop (-)
Abdomen
I : distended
P : soefl, palpable enlarged liver, 4 finger under the arch coste, hard
consistency, flat edge, tenderness (+) / Splen not palpable, painless
P : shifting dullnes (+)
A: Bowel sound (+) Normal
Extremity : warm, dry, CRT < 2, pitting edema +/+
Clue and cue
male, 48 years old
Right upper abdominal pain
liver disease (+), HIV (+) (Previously illnes history)
Smoking (+), Alcohol (+), free sex (+)
Hepatomegali (+)
Shifting dullnes (+)
pitting edema +/+








Laboratoty findings
Diffcount 3/0/69/15/13
Hct 34,9 %
Hb 11,9 mg/dl
LED 76/81
Leukocyt 9.500
Thrombocyt 131.000
SGOT 148
SGPT 32
Albumin 2,3
Globulin 3,5




Clorida serum 107
Kalium 3,0
Natrium 140
Creatinin 1,0
Urea 189
Uric acid 6,8
Random blood glucose
61 mg/dl

Problem list
Hypoglikemia
Hepatoma
AIDS



Initial diagnosis
Hypoglikemia e.c
hepatoma
AIDS

Planning diagnosis
USG
AFP
HBsAg
Biopsi
ELISA,
imonocromatografi


Planing terapi

MRS
IVFD assering 1500 cc/24 hours
Inj i.v dekstrosa 40% bolus glukosa 1 flakon
Ondansetron 3x1 amp i.v
Metamizole 3x1 amp i.v
Con Sp.PD





Monitoring
Complaint
Vital sign




Prognosis
Dubia ad malam