MORNING REPORT

st
WEDNESDAY, MAY 21 2019

MENTOR
Dr. dr. Mohamad Isa, Sp.P(K)

Presented by:
Coass Hardiandy G. Nugraha
Coass Een Amalia Pratiwi
Coass Larasati Gilang Puji Astuti
PATIENT’S
IDENTITY
Name : Mrs. SF

Sex : Female

Age : 75 y.o.

Religion : Muslim

Tribe : Banjarnese

Status : Widow

Address : Sungai lulut, Banjarmasin

Occupation : Housewife

Hospitalized since : May 20th, 2019

ANAMNESIS

Chief complaint : Shortness of breath

Patient came to the hospital with shortness of breath (SOB) as the chief complaint.
SOB since 2 days before hospitalized and become worse, SOB come if the patient get
a cough. Cough since a week ago with yellowish green sputum and blood cough is
denied. The patient also complaining fever but not too high since a week ago, she felt
the pain on the upper side of her abdomen and a chest pain if she get a cough, and also
experienced the night sweating. She claimed that she got loss of body weight about 3
kg in a week with a loss of appetite, but nausea and vomite is denied.
There is no complaint about hypertension, diabetes mellitus, and asthma.
ANAMNESIS

• Medical history : Six months of TB treatment in 2014

• Family medical history : HT (-) , DM (-) , Asthma (-) ,
no history of TB in family
• Social history : Not a smoker
• Allergic history : None

• Weight : 27 kg
• Tall : 147 cm
• BMI : 12,5 kg/m2 → Underweight
PHYSICAL EXAMINATION
BP = 90Τ50 mmHg HR = 69 times/minute RR = 20 times/minute T = 35,5 ◦C
SpO2 = 98 % w/ O2 2 LPM
General Condition : looked slighty ill GCS Compos Mentis E4V5M6
Head Pale conjunctiva (-) Skin = Turgor < 2 seconds
Icteric sclera (-)
Neck JVP = 5 cm H2O, Enlargement of lymph gland (-)
Thorax Cor: Ictus cordis visible, palpable on ICS 5th MCL sinistra
Single S1 S2, murmur (-)

Lung: Asymmetrical Breathing Rh - - Wh - -

= Vesicular
Retraction (-) sound - - - -
+ + - -
Abdomen Rounded shape, bowel sounds normally, liver span 8 cm, traube space tympani,
shifting dullness (-), venectasi (-), aortic pulse non-palpable.
Abdominal pain on palpation found on epigastric.

Extremities Edema (-)

LABORATORY
FINDING
Lab 20/05/2019 Value
Hb 12,8 14,0-18,0 g/dl
Leukosit 14,7 4,0-10,5 thou/ul
Eritrosit 4,38 4,10-6,00 million
Hematokrit 40,1 42,0-52,0 vol%
Trombosit 218 150-450 thou/ul
RDW-CV 12,4 12,1-14,0%
MCV 91,6 75,0–96,0 fl
MCH 29,2 28,0-32,0 pg
MCHC 31,9 33,0-37,0 %
Ureum 28 10-50 mg/dl
Creatinin 0,64 0,72-1,25 mg/dl
LABORATORY
FINDING
Lab 20/05/2019 Value
Bas% 0,1 0,0-0,1 %
Eos% 0,0 1,0-3,0 %
Gran% 89,5 50,0-81,0 %
Lym% 4,7 25,0-40,0 %
Mono% 5,7 2,0-8,0 thou/ul
Gran# 13,18 2,50-7,00 thou/ul
Limfosit# 0,7 1,25-4.0 thou/ul
Mono# 0,84 0,30-1,00 thou/ul
SGOT 19 5-34 u/l
SGPT 9 0-53u/l
Natrium 137 135-146 mmol/l
Kalium 4,2 3,4-5,4 mmol/l
LABORATORY
FINDING

Lab 21/05/2019 Value

LED / ESR 29 0 – 20 mm/hour
Total bilirubin 0,86 0,2 – 1,2 mg/dL
Direct bilirubin 0,4 0 – 0,2 mg/dL
Indirect bilirubin 0,46 0,2 – 0,8 mg/dL
Anti HIV rapid Non-reactive
HBsAg (Elisa) 0,29 < 1.00 s/co
 RO THORAX
FINDING

1. Right deviation on trachea

2. Cavities in the right upper
lobes
3. Asymmetry of the volumes of
two thoracic cavities
4. Volume loss on the right lung
5. Bihilar lymphadenopathy
6. Fibrocalcific scar on upper
lobes of two thoracic cavities
POMR
Problem
CUE AND CLUE Idx PDx PTx PMo
List
Mrs. SF / 75 y.o 1. SOB + Wet 1.1 TB relaps RO thorax - 3RHZE / 6RH Mo. Complain of
Shortness of breath since 2 days before cough + Night Sputum BTA drug’s side
hospitalized. Sweating Sputum smear effect,
Yellowish green sputum 1.2 CAP Gram Culture Vital sign
Night sweating Aerob sputum culture - Levofloxacin 1x750
Abdominal pain mg
History of TB
Ronki on lower regio of two lungs

BMI : 12,5 kg/m 2. Underweight - Diet high calories - BMI

- Co nutritionist
Thank You
 RO THORAX
FINDING

1. Right deviation on trachea

2. Cavities in the right upper
lung
3. Formation of the cavity on
the red circle