Morning Report

january 25, 2016

Dept of internal medicine

F24

Identity
Name

:
Age
:
Occupation
Address
:
Admission :

Mr. Zidni Alfian

16 years old
: student
Lamongan
January 24, 2016 at 01.26 PM

Chief Complaint

Out of black spots

Present history
Patients present with out of black spots on the body since
two days ago. Black spot initially appeared on the
forehead, then appears on the mouth, tongue and then
spread to the entire face and hands and feet. Spots
suddenly appeared, at first time initially small and then
enlarged, not itchy or warm. Patients also complained of
cough since ten days ago. yesterday cough accompanied
by white sputum and come out with fresh blood of
patches. Patients dont complain fever, epistaksis,
atralgia, dipsnea. Patients not taking any medicine before.
Appetite decreased last few days. no nausea or vomiting.

Past history of Illness

Epilespi since 1 years ago

Never had same complaint before

Family history

No familial related

Social history
Cigarrete (-)
Coffe (-)
Alcohol (-)

Vital Signs
Pulse
94x/min

BP
119/82 mmHg

Temp
36,7 C

RR
30x/min

A: clear, gargling (-), snoring (-), speak

fluently (+), potential obstruction (-)

B: spontan, RR 30x/min, ves / ves, rh -/-,
wh -/-, Sa O2 99 % without O2 support
C: extremity WDR, CRT <2, N 94x/min, BP
119/82 mmHg
D: GCS 456, lat -, PBI 3mm/ 3mm, LP +/+
E: temp 36,7C

GENERAL STATUS

General condition

: well
Awareness
: compos mentis
GCS
: 456
H/N
: a -/i-/c-/dBlack spots at face, mouth, and tongue.

Thorax
Inspection
Symmetrical, retraction -

Palpation
Fremitus WNL, thrill (-)

Percussion
Lungs: sonor +/+
Cor: N

Auscultation
Lungs: ves /ves, rh -/-, wh -/Cor: S1 S2 single, mur -, gall-

Abdomen

Inspection

Flat, collaterral veins (-), inflammation signs (-)

Auscultation
Met -, gut noise WNL

Palpation
Epigastric pain (-)
Mc burneyTurgor WNL
Liver/Spleen is untouchable

Percussion
tymphany

Extremities
Inspection
Clubbing fingers (-), icteric (-), cyanosis (-)
Black spots on the body

Palpation
Warm and dry, CRT <2

CLUE AND CUE

Male 16 years old

Black spots on the body not itchy or warm

Patients not taking any medicine before

Planning Diagnose
CBC
LFT
NS1

Assesment
ITP

DD : DHF, FDE

Laboratory Findings
Diffcount Eo 5.9/

Ba 2.8, Lim 33.8/

Neu 45.6/ Mo 11.9
Hct 38.6
Hb 12.8
Leukosit 9.800
Trombosit 5.000
Eritrosit 4.61

SGOT 30 (N 31 U/l)
SGPT 29(N 31 U/l)
NS1 negatif
MCH 27.8
MCHC 33.2
MCV 83.7

Planning Therapy
MRS
Inf. Asering 1500cc/24 jam
Inj. Ceftriaxone 2x1 gr
Inj. Metilpred 3x250mg soluted by D5 100cc
Transfusi TC 10 kolf withoud premed.
Consult to internist

PLANNING MONITORING
Vital Signs
Trombosit (CBC)
Patients complaint

PLANNING EDUCATION
Explain to the patien and his family about the

disease, cause, complication, intervention of

the therapy and prognosis.