Morning Report

Sept 26 , 2017
th

Dept. of internal medicine

H27
LIST OB
Mrs. U Dyspepsia + DM type II
Mr. M TB paru + DM type II
Mr. A Chest Pain + LBBB
Mrs. M DMND + Hiperglikemi
Mr. K Asthma bronchiale + Appendicitis
Mrs S HT
Mr. S Hepatoma + Leukocytosis
Mrs. T TB par
Mrs I Mitral Regurgitation
Identity
Name : Mr. A
Age : 53 years old
Address : Galang RT 3 RW 2 Sukoanyar
Turi Lamongan
Admission : September 25th, 2017 at 21.21
 Chief Complaint

Chest pain

Present history
Patients present with chest pain since 1 week ago, complaints weigh
12 hours before entering the hospital. Pain is felt through the back
and radiates to the left arm, recurrent. Every attack > 15 menit.
Patients also complain short of breathness, weighing if walking into
the bathroom, sleeping with high pillows. Appetite has decreased
since this week. Defecate and urinate normally. Patient paralysis since
1 year ago, suddenly after waking up. Already treated to Soegiri
Hospital with TB bone diagnosis. Patients cough and short of
breathness, since that the activity assisted by wheelchair, but since
this week patients just feel asleep in a bed.
 Past history of Illness

DM (-)
HT (-)

Family history
 Social history

No social history related

Vital Signs
BP
120/65 mmHg
Pulse
78x/min, strong, reguler
Temp
36,60 C
RR
22 x/min
 A: clear, gargling (-), snoring (-), speak fluently (+),
potential obstruction (-)
B: spontan, RR 22x/min, ves (weak) / ves, rh -/-, wh -/-,
SaO2 96% without O2 support
C: extremity WDR, CRT <2, N 78x/min, BP
120/65mmHg
D: GCS 456, lat -, PBI 3mm/ 3mm, LP +/+
E: temp 36,6 C
GENERAL STATUS
 General condition : weak
Awareness : compos mentis
GCS : 456
H/N : a -/i-/c-/d-
lymph node enlargement at neck (-)
 Thorax
Inspection
Symmetrical, retraction -, macula eritematous -
Palpation
Thrill (-), fremitus WNL
Percussion
Lungs: sonor / sonor
Cor: N
Auscultation
Lungs: ves /ves, rh -/-, wh -/-
Cor: S1S2 single, M -, gallop -
 Abdomen
Inspection
Flat
Auscultation
Meteorismus -, bowel sound WNL
Palpation
Liver WNL, spleen WNL
Percussion
Tymphany
 Extremities
Inspection
Clubbing fingers (-), icteric (-), cyanosis (-), edema (-), macula
eritematous -
Palpation
Warm and dry, CRT <2
CLUE AND CUE
Male, 53 y.o
Chest pain
Cough
Short of breathness
Paralysis
Planning Diagnose
DL
ECG
Thorax photo
Assesment
Chest Pain
LBBB
 Laboratory Findings
Laboratorium
GDA 139
Kalium serum 2,9 (3,6-5,5)
Natrium serum 124 (135-155)
Clorida serum 89 ( 70-108)
Urea 31 (15-43)
Serum creatinin 0,8 (P 0,7-1,2
L 0,8-1,5)
SGOT 20 ( 0-35)
SGPT 18 (0-35)
Leukosit 13,0 (4-11)
Neutropil 78,0 (49-67)
Limfosit 16,0 (25-33)
Monosit 3,5 (3-7)
Eosinophil 1,1 (1-2)
Basofil 1,4 (0-1)
Eritrosit 4,09 (3,8-5,3)
Hb 11,4 (P 13-18 L 14-18)
Hct 36,2 (L 40-54 P 35-47)
MCV 88,5 (87.00-100)
MCH 27,90 (28.00-36.00)
MCHC 31,50 (31.00-37.00)
RDW 12 (10-16,5)
Trombosit 561 (150-450)
MPV 4 (5-10)
LED 1 : 99 (0-1)
LED 2 : 110(1-7)
Re-Assesment
LBBB
 Planning Therapy
O2 nasal 3 lpm
Inf RL 1500cc/24 jam
Inj Antrain 3x1 gr
Inj Ranitidin 2x50mg
Inj Ceftriaxone 2x1
Premix KCL 24 meq/24 jam
Tab ISDN 3x5 mg
Tab ASA 1x100mg
Tab simvastatin 1x10mg
Consul with cardiology
PLANNING MONITORING
Vital Signs
Patients complaint
Adverse effect
PLANNING EDUCATION
Explain to the patient and his family about the disease, cause,
complication, intervention of the therapy and prognosis.