MORNING REPORT

January 17th 2012

Coass Incharge : Kalaichelvi Regunathan

Summary of Data Base

Mr. T S/44 y.0/w. 24B Chief complain: general weakness Patient came to the Internal medicine policlinic with complaint of

general weakness yesterday morning. His complaint was accompanied with terrible stomach ache on the whole part of his stomach. Patient felt all those since half a month ago.. Besides that, patient also felt nauseous & headache

at times along with cold sweat at night.

Patient also complained of having lumps on his neck & upper folds of his upper thigh. Those lumps were not painful, well-defined, rubbery and mobile. Formerly, patient went went to RS Jember 2 months ago due to the complaint of having lumps & was diagnosed with lymphanedinitis TB and given medicine.

Summary of Data Base

The medicine was taken for 1 month & stopped as there were no improvements. Then, he took herbal medicines for 1 month and snothing changed. Also felt decreasing of appetite with weight loss of 9kg since two

months ago.
Patient was an active smoker since 20 years ago but stopped 1month ago due to his illness. No history of close contact with any TB patients plus no

family history too. No history of hypertension & diabetes mellitus.

General appearance Blood Pressure Pulse /Heart Rate Respiratory rate Head Neck

Looked moderately ill, GCS 456, look overweight 110/70 mmHg 60 bpm 20 tpm Anemic (+), Icteric (-) JVP R + 5 cm H2O 300 position, found multiple mass with diameter 3-5 cm, rubbery consistency, mobile & painless at both sides of the neck Ictus invisible , palpable in ICS V MCL S RHM = sternal line D, LHM = Ictus S1 S2 single, regular, murmur Symetric, normal percussion and normal breath sound at all areas of
lung, no additional breath sounds (ronchi or wheezing -)

Thorax Heart Lung Abdomen Extremities

Flat, Soefl, Liver span 13 cm, blunt edge, traube space tympani , BS (+) N, shifting dullness (-), Warm acral, no edema, found bilateral multiple mass with diameter 3-6 cm, rubbery consistency, mobile, painless at inguinal fold

Lab Leukocyte Lymphocyte Granulocyte monocyte

Value 1500 500 900 100

(Normal)
3.500-10.000/L

Lab Urinalysis Protein

+

Value

Haemoglobine 9.5
PCV Trombocyte 28.5 90000

11,0-16,5 g/dl
35-50% 150.000390.000/L 80-96 fl 26,5-33,5 pg 11-41U/L 10-41U/L

MCV MCH SGOT SGPT

83 27.5 89 75

ECG (16/1/2011)
Sinus tachycardi , heart rate 115 bpm Frontal Axis :N Horizontal Axis : CCWR PR interval : 0.12 QRS complex : 0.06 QT interval : 0.32 T inverted at lead V1-V4 Conclusion : Sinus tachycardi, withHR 115 bpm Ischemic myocard anteroseptal wall

CUE AND CLUE

PL

IDx

PDx

PTx

PMo

Male /44 yo Mass at neck Mass at inguinal fold Mass at armpit Decrease body weight,nausea General weakness Decrease appetite Conj anemis +/+ Neck: multiple mass, d 3-5 cm, rubbery const, mobile Liver span 13 cm Inginal: bilateral multiple mass, d 36 cm Leuco 1500 Hb 9.5 SGOT/SGPT 89/75 FNAB: lymphoma malignant

1. Lymphoma 1.1 Non malignant hodgkin lymphoma 1.2 Hodgkin lymphoma

Blood smear

Diet 1900 kcal/day Transfusion of PRC 1 pack & leukogen Chemotheraphy Radiotheraphy

Subj Mass VS Bleeding

CUE AND CLUE

PL

IDx

PDx

PTx

PMo

Male /44 yo Mass at neck Mass at inguinal fold Mass at armpit Decrease body weight,nausea Bloating sensation Decrease appetite Conj anemis +/+ Neck: multiple mass, d 3-5 cm, rubbery const, mobile Inginal: bilateral multiple mass, d 36 cm FNAB: lymphoma malignant

2. Dyspepsia syndrome

2.1 dt no 1 2.2 Peptic Ulcer disease

endoscopy inj. metoclopramide 3x10 mg IV

Subj

3. Pancytopenia 4. Transaminitis

3.1 True hepatitis 3.2 Reactive Hepatitis

FH Biopsy marrow Biopsy

Thank you