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Morning Report
June 1st, 2016
Doctor in charge:
Dr. dr. Mohammad Isa, Sp.P (K)
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Patients Identity
Name : Mrs. NA
Se : Ma!eAge : 26 yo
"##upation : $
%ospita!ised sin#e : May &1t'
, 2016
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Summary o( )ata *aseMr. NA/ 26 yo /Male (Autoanamnesis and Heteroanamnesis)
Main complaining : Shortness of breath
Patient #omp!ained a+out 'er symptom sin#e 1 mont' ago, 'e
symptom #ame sudden!y a(ter doing mi!d a#ti-ity, and de#rease i(
tae a rest. S'e a!so #omp!ained a+out #oug' /it' mu#us sin#e &0
day ago. Mu#os /it' ye!!o/ #o!or and /it'out +!ood. Patient#omp!ained e-ery nig't eperien#ed a #o!d s/eat. %e a!so diarr'ea
sin#e &0 day ago. 'roat (ee!s dry, sprue , +ut t'e patient #an sti!!
eat. 'e patients -oi#e /as 'oarse and +are!y audi+!e. %is mi#tion
and de(e#ation is norma!. %e admit t'ere is de#reased in 'is
+ody/eig't in t'is 1 mont'. Patient appear /ea and !et'argi#.
Patient is prisoner 3P as a resu!t o( drug use, denied t'e drug
in4e#tion. Patient 'a-e +een di-or#ed and sometimes 'a-ing se /it'
anot'er /oman.
History of illness: DM (-) HT (-)
Histor of Famil illness: DM - HT -
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P'ysi#a! 5aminationGeneral appearance Looked moderately ill, onscio!s, GS : " # $
*!ood Pressure 11070 mm%g
Pu!se Rate 108 +pm regu!ar, strong
Respiration rate &1 ppm,
emp &7,90
%ead #on4un#ti-a anemis , Jaundi#e s#!era $$, de#reased -isua! a#uity $$,5dema pa!pe+ra $$, )ip!opia $, dis#'arge $$
Ne# 3ympati# node s/e!!ing $
'est %eart Inspe#tion : i#tus in-isi+!e Pa!pation : pa!pa+!e in MS IS ;
Rig't margin : Rig't : IS II$III 3.Ster ). ardia# /aist : Aus#u!tation : S1 < S2 sing!e, murmur $ ga!!op $
3ung Inspe#tion : Simetri#, +arre! #'est $Pa!pation : =; simetri#Per#ution : Aus#u!tation :S > S R > RS > S R > ;S > S ; > ;?'ee@ing $, Ron#'i respiratory mus#!e tra#tion
A+domen I : siatri $, %ernia $, aput Medusa $ Aus.: *o/e! perista!ti# soundnorma!.Per#usion: enderness: > > $ > $ > $ > > $ > $ > $ > > $ > $ > $3i-er Sp!een tida tera+a
5tremities Superior ) S : 5dema $, Pain $, ?eaness $, Pitting edem $In(erior ) S : 5dema $, Pain $, ?eaness $, Pitting edem $
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La%oratory &es!lt'*#+*$
Items Resu!t Norma! ;a!ue Bnit
ematology
%emog!o+ine 7,5 12.50 16.7 gd!
3euo#yte 11,3 4.65 10.3 t'ousandu!
5ritro#yte 5,07 4.10 6.00 mi!!ionu!
%emato#rit 24,4 42.00 52.00 ;o!C
rom+o#yte 435 150 356 Ri+uu!
MCV 48,3 75.0-96.0 Fl
MCH 14,7 28.0-32.0
MCHC 30.7 33.0-37.0
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Items Resu!t Norma! ;a!ue Bnit
Glukosa darah sewaktu 117
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D$Ray
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Pro+!ems )ata support
1. )yspneu
1.1 * paru ati(
1.2 S"P
1.& PP"E
-namnesis:
$ S'ortness o( +reat' sin#e 1 mont' ago
$ Mu#os ye!!o/ #o!or #oug' sin#e 1 mont' ago.
$ 5perien#ed a #o!d s/eat e-ery nig't.
$ )e#reased o( +ody/eig't.
ray
In/ltrat di %asal par!
Ka0itas di lapang atas par! de1tra dan sinistra
2. Anemia
2.1 Anemia mirositi 'iporomi
Anamnesis :
Patient appear /ea and !et'argi#
Eon4ungti-a anemis
La%oratory /nding:
de#reased o( %+ F 8,9
%ematorit F 2G,G
M; F G7,&
M% F 1G,8
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Pro+!ems )ata support
&. Imuno#ompremise
&.1 %I;
-namnesis:
)e#reased o( +ody/eig't
)iarr'ea sin#e 1 mont' ago
oug' sin#e 1 mont' agoSprue
%istory o( using drug and 'a-ing
se /it' anot'er /oman.
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Pro%lems PD1 P21 PMo Ped
1.)yspneu
1.1 * ati(
1.2 S"P
1.& PP"E
*A SPS,Spirometri,
35).
P 3a+ )R,=erritin,
I*, SI
"2 nasa! &$9!pmI;=) R3 20 tpm
In( !e-oHoa#in 11In4. "mepra@o!e
1G0mgIn4. e(triaone 21
Pro trans PR 2 o!(sd %*
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Pro%lems PD1 P21 PMo Ped
&. Imuno#ompremise
&.1 %I;
Reati( %I; $ Mo.Su+4e#ti-
e
Mo. ;ita!sign
5d. RisioPenu!aran
,aya'idupyangse'at.
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2hank yo!