MORNING REPORT

Monday, November 14th 2009

PHYSICIAN INCHARGE:
IA: dr. Nani, dr. Nurike
IB: dr. Dewi, dr. Mia
II: dr Adjunias
III: dr.Sri Sunarti , SpPD

Summary of Data Base

Mr. Dul Rawi/ 54 y.o/ W.27
Chief complain: upper abdominal pain
Patient suffered from upper abdominal pain
since one day before admission after he ate
mangous. The pain in the upper abdominal area
not radiated to back pain.Then in this morning
he complained black tarry stool once.
one week before admission he fetl
headache, and weakness, and his leg was weak
and swelling so he couldnt walk.than he went to
PHC and the complained releave.
his stomachce became bigger since 1 week
before admission.

He got shortness of breath since one week

before admission if he work hard or walk
for dinstance. Sometimes he wake in the
night becouse of shortness of breat. He
could slept with 2-3 pillows.
History of smooking since young

Physical examination
BP =120 / 80 mmHg

PR = 80 bpm

RR = 28 tpm

General appearance looked moderatly ill

GCS 456

Head

Anemic -

Icteric -

Neck

JVP R + 2 cm < 450

Thorax cor

Invisible Palpable at Ictus ICS V MCL S,

RHM SL D
LHM as ictus
S1 S2 single, mur mur -

lung

I:Simetric, P: SF D = S v v Rh - vv
-vv
--

Tax : 37,8 0C

Wh - ---

Abdomen

flat,BS + normal, Hepar unpalpable, liver span 8 cm. Slpeen unpalpable,

troube space dullnss. Shiffting dullnes +

Extermities

Oedema + inferior

Lab

Laboratory
finding
Value
Lab
Value

Leucocyte

11.600

3500;10000/L

PPT

K: 12,8 dtk

Haemoglobine

11,6

11,0-16,5g/dl

APTT

K: 30,0 dtk

MCV

91

80-97H um3

Bil Total

<1,10Mg/dl

MCH

29

26,5-33,5H pg

Bil Direct

< 0,25Mg/dl

PCV

36,4

35-50%

Bil Inderect

< 0,75Mg/dl

Trombocyte

250.000

150000-390000/L

Na

141

136-145Mmol / L

RBS

110

(<200)mg/dL

4,71

3,5-5,0Mmol / L

Ureum

67,8

10-50mg/dL

Cl

111

98-106Mmol / L

Creatinine

1,68

0,7-1,5mg/dL

SGOT

85

11-41U/L

Albumine

2,6

3,5-5,5g/dl

SGPT

79

10-41U/L

210-425 U/l

SG

LDH

1,025-1,029

urinalysis
SG = 1,010

PH = 5

Keton=-

Leucocyte 2+

Crystal

Amorf +

Glucose =-

Protein= 1+

Ery= 5+

Ery 12-18 /hpf

Leuco 3-5 /hpf

Chest X ray
CXR :
AP position, KV enough, symetric,
trachea in the midlle, bone and soft
tissue Normal, Phrenico costalis angle on
Right and Left sharp, Hemidiaphragm D
and S dome shape, lung D& Lung S
clear, cardiomegaly
Conclusion : Cardiomegaly

ECG

Sinus Rhytm, HR 107 x/mnt

PR Interval :0,16
QRS Interval : 0,06,low valtage
QT Interval : 0,32
Frontal axis : Normal
Horizontal axis: clock wise rotation
T inverted III
Conclusion : ischemia inferior

CUE AND CLUE

PL

IDx

PDx

PLANNING THERAPY

PMo

male /54 yo
1. Melena 1.1 gastritic
-black tarry stool
erosiva
-upper abdominal
1.2 PUD
discomfort and
pain
-nausea

Endon -IVFD NS 0,9 %

oscopy 10 dpm
UBT
-Insert NGT GL if
negative off

Symt
om
Fluid
in
NGT

Male/54 yo
2. HF ST
2.1 CAD
-dispnea,
C FCIII 2.2 ASHD
ortopnea
-paroximal
nocturnal
dispnea
-ascites,edema
-cardiomegaly
-ECG Q patologis

Echoc
ardiogr
aphy
Lipid
profile

RR
BP
Urin
produ
ction

-0xygen 2-4 L/mnt NC

-semifowler position
-furosemid 40-0 IV
-sprironolacton 25-0
po
-Captopril 3x6,25 po

CUE AND CLUE

PL

IDx

Male /54 yo
-albumin 2,6

3.
Hypoalbu
minemia

3.1
hyperkatabolic
state
3.2 low intake
3.1 reactive

Male,54 yo
T inverted at III

4.Iskemia
inferior

PDx

PLANNING
THERAPY

PMo

Transfusi albumin 20
%

Albu
min

ECG
ISDN 3x5 mg