Morning Report

June 1st, 2016

Doctor in charge:
Dr. dr. Mohammad Isa, Sp.P (K)

Patients Identity
Name
:
Sex
:
Age
:
Occupation
:
Hospitalised since

Mrs. NA
Male
26 yo
: May 31th, 2016

Summary of Data Base

Mr. NA/ 26 yo /Male (Autoanamnesis and Heteroanamnesis)
Main complaining : Shortness of breath
Patient complained

about her symptom since 1 month ago, The

symptom came suddenly after doing mild activity, and decrease if

take a rest. She also complained about cough with mucus since 30
day ago. Mucos with yellow color and without blood. Patient
complained every night experienced a cold sweat. He also diarrhea
since 30 day ago. Throat feels dry, sprue (+), but the patient can still
eat. The patients voice was hoarse and barely audible. His miction
and defecation is normal. He admit there is decreased in his
bodyweight in this 1 month. Patient appear weak and lethargic.
Patient is prisoner LP as a result of drug use, denied the drug
injection. Patient have been divorced and sometimes having sex with
another woman.
History of illness: DM (-) HT (-)
History of Family illness: DM (-), HT (-)

Physical Examination
General appearance

Looked moderately ill, Conscious, GCS : 4 5 6

Blood Pressure

110/80 mmHg

Pulse Rate
Respiration rate
Temp

107 bpm regular, strong

31 ppm,
38,50C

Head

conjunctiva anemis (+/+), Jaundice sclera (-/-), decreased visual acuity (-/-),
Edema palpebra (-/-), Diplopia (-), discharge (-/-)

Neck

Lympatic node swelling (-)

Chest Heart

Inspection : ictus invisible

Palpation : palpable in MCS ICS V
Right margin : Right : ICS II-III L.Ster (D). Cardiac waist : (+)
Auscultation : S1 > S2 single, murmur (-) gallop (-)

Lung

Abdomen

Extremities

Inspection : Simetric, barrel chest (-)

Palpation : FV simetric
Percution :
Auscultation :
S | S
R |R
S | S
R |V
S | S
V|V
Wheezing (-), Ronchi (+) respiratory muscle traction (+)
I : sikatrik (-), Hernia (-), Caput
normal.
Percusion:
T | T |T
T | T |T
T | T |T
Liver / Spleen/ tidak teraba

Medusa (-) Aus.: Bowel peristaltic sound

Tenderness:
-|-|- |- |- |- |-

Superior D & S : Edema (-), Pain (-), Weakness (-), Pitting edem (-)
Inferior D & S : Edema (-), Pain (-), Weakness (-), Pitting edem (-)

Laboratory Result
31/05/2016
Items

Result

Normal Value

Unit

Hemoglobine

7,5

12.50 16.7

g/dl

Leukocyte

11,3

4.65 10.3

thousand/ul

Eritrocyte

5,07

4.10 6.00

million/ul

Hematocrit

24,4

42.00 52.00

Vol%

Trombocyte

435

150 356

Ribu/ul

MCV

48,3

75.0-96.0

Fl

MCH

14,7

28.0-32.0

MCHC

30.7

33.0-37.0

Hematology

Items

Normal Value

Unit

117

<200

mg/dl

SGOT

69

0-46

U/I

SGPT

36

0-45

U/I

Ureum

39

10-50

Mg/dl

Creatinin

0,5

0.7-1.4

Mg/dl

Glukosa darah sewaktu

Result

X-Ray

Problems

1. Dyspneu
1.1 TB paru aktif

Data support
Anamnesis:
- Shortness of breath since 1 month ago
- Mucos yellow color cough since 1 month ago.

1.2 SOPT

- Experienced a cold sweat every night.

1.3 PPOK

- Decreased of bodyweight.
Xray
Infiltrat di basal paru
Kavitas di lapang atas paru dextra dan sinistra

2. Anemia
2.1 Anemia mikrositik hipokromik

Anamnesis :
Patient appear weak and lethargic
Konjungtiva anemis

Laboratory finding:
decreased of Hb = 7,5
Hematokrit = 24,4
MCV = 48,3
MCH = 14,7

Problems

Data support

3. Imunocompremise

Anamnesis:

3.1 HIV

Decreased of bodyweight
Diarrhea since 1 month ago
Cough since 1 month ago
Sprue (+)
History of using drug and having
sex with another woman.

Problems
1. Dyspneu
1.1 TB aktif

PDx

PTx

PMo

Ped

BTA SPS,
Spirometri,
LED.

O2 nasal 3-5lpm
IVFD RL 20 tpm
Inf levofloxacin 1x1
Inj. Omeprazole
1x40mg
Inj. Ceftriaxone 2x1
Pro trans PRC 2 kolf
sd HB>8

Mo.
Subjectiv
e

Ed.
Penyakit

1.2 SOPT
1.3 PPOK

Mo. Vital
sign
Mo. DL

Cara
batuk dan
pengguna
an
masker

2. Anemia
2.1 Anemia mikrositik
hipokromik

Px Lab DR,
Ferritin,
TIBC, SI

Po : as Folat 3x1
Vit B6/B12 3x1

Mo.
Subjectiv
e
Mo. Vital
sign
Mo. Kadar
Hb
DL

Edukasi
makanan
yang
dapat
meningka
tkan HB

Problems
3. Imunocompremise
3.1 HIV

PDx

PTx

PMo

Ped

Reaktif HIV

Mo.
Subjectiv
e

Ed. Risiko
Penularan
,
Gaya
hidup
yang
sehat.

Mo. Vital
sign

Thank you