MORNING REPORT

Date :

Physician in charge
I :
II CVCU :
II HCU :
II UGD :
Chief on duty :
Consultant on duty :
Facilitator :
 Summary of Database
Mrs. ID/36 yo/ward 25 bed 3.1
Autoanamnesa and heteroanamnesis with her husband
Chief Complaint:
pro chemotheraphy
History of Present Illness:
Patient was admitted to the hospital to undergo chemotheraphy 1 cycle 3/6 with Cisplatin-
Dacarbazine. There is no complaint anymore but sometimes nausea without any vomiting
presented. Her left foot seldom felt like tingling. Patient was diagnosed with Malignant
Sarcoma (Peripheral Nerve Sheath Tumour) since April 2018 from the biopsy.
 Summary of Database
Past Medical History:
Numerous time of hospitalized for chemotheraphy
Family History:
no malignancy history
Social History:
she is a housewife with 2 children
Review of System:
fever (-), headache (-), weakness (-)
 Physical Examination
General appearance look moderately ill Sat O2 97% room air
GCS 456 CM
BP 120/80 mmHg PR 92 bpm regular strong RR 20 tpm Tax 36,7oC
Head Conjuctiva Anemic (+), Sclera Icteric (-), Nystagmus (-), Meningeal Sign (-), Pupil Isocor
Neck JVP R+ cmH20
Chest Symmetrical, retraction (-)
Lung Sonor | Sonor Vesicular | Vesicular Rhonkhi: -| - Wheezing : -| -
Sonor | Sonor Vesicular | Vesicular -|- -|-

Sonor | Sonor Vesicular | Vesicular -|- - |-

Cardio Ictus invisible, palpable at MCL (S) ICS V
LHM ~ ictus, RHM ~ SL (D) S1 S2 single, regular,
murmur (-) gallop (-)
Abdomen Flat, soefl, Bowel Sound (+) normal, shifting dullness (-)
Liver/ unpalpable, liver span 10 cm, epigastrium tenderness (-)
Lien/ Traube space tympany
Extremities Edema (-), pale (-), MMT 5 | 5 , Pathologic Reflex (-); Lateralization (-)
5|5
 Laboratory Findings (6/9/2018)
LAB VALUE NORMAL LAB VALUE NORMAL

Leucocyte 2670 4.700 – 11.300 /µL Ureum 23,8 20-40 mg/dL

Hemoglobine 6,9 11,4 - 15,1 g/dl Creatinine 0,66 <1,2 mg/dL

PCV 20% 38 - 42% Osm 275-295 mOsm/kg

Thrombocyte 343.000 142.000 – 424.000 /µL Natrium 135 136-145 mmol/L

MCV 74,9 80-93 fl Kalium 4,14 3,5-5,0 mmol/L

MCH 25,8 27-31 pg Chlorida 104 98-106 mmol/L

Eo/Bas/Neu/ 0/0/53,9/30,4 0-4/0-1/51-67/ RBS - < 200 mg/dl

Limf/Mon /15,7 25-33/2-5
PPT - 9.3-11.4 detik

IHK (24/5/2018)
CD 117 : negative on tumour cell
SMA : positive patchy

Intra-abdominal Biopsy Left Adnexa (20/4/2018)

Spindle Mesenchymal Tumour suspected Low Grade Malignancy dd:
1. Leiomyosarcoma
2. GIST
3. Malignant Perpipheral Nerve Sheath Tumour
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mr. Mrs. Ms./ yo/ w

Subjective

Objective

Laboratory
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mr. Mrs. Ms./ yo/ w

Subjective

Objective

Laboratory
 POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mr. Mrs. Ms./ yo/ w

Subjective

Objective

Laboratory
Problem Analysis
 Risk Factors Analysis

Problem Theory Patient

Key Message Pathophysiology
Key Message Diagnosis
 Management Analysis

Problem Theory Patient

Key Message Management
Key Message Social
Condition This Morning
 Prognosis

• Ad vitam :
• Ad functionam :
• Ad sanationam :