MORNING REPORT

CASE
June 18th, 2012
 IDENTITY
• Name : HSN
• POB, DOB : Malang, April 6th 1952
• Age : 60 years old
• Sex : Male
• Religion : Islam
• Nationality : Indonesia
• Occupation : Enterpreneur
• Address : Jl. Pulau Kawe Gg 52 Buntu No 4,
Denpasar Selatan
• TOA : June 17th 2012 (06.06 pm)
 ANAMNESIS
Chief Complaint : Nausea

History of Present Illness

Nausea was felt since ± 6 hours BATH (June 17th 2012 at 12.00 am) it
was felt like full sensation in the stomach. The nausea was exaggerated
by ingestion of food. The nausea was not accompanied by vomiting.
But, the patient said when he ingested food he felt like he had an urge
to vomit. The nausea also wasn’t accompanied by pain burning
sensation or fever.
 Micturition was said to be normal. History of dereased visual acuity
was comfirmed.
 ANAMNESIS
History of Past Illness
 The patient was diagnosed with DM since 6 years ago. He
recived glibenclamid as the treatment. He said, that he didn’t
chek up his blood glucose level regulary.
 History of hipertension, heart disease, kidney disease were
denied
Family History of Illness
History of DM disease in his family was confirmed.

Personal and Social History

The patient was an active smoker but he quit smoking since 15
years ago.
 Physical examination
General condition : moderately ill
Level of conciousness: compos mentis, GCS E4V5M6
BP : 150/90 mmHg
T aks : 36OC
PR : 80 bpm, reguler
RR : 20 tpm, deep
VAS : 0/10
BW : 78 kg
BH : 165 cm
BMI : 28,65 kg/m2
 Physical examination
Eye : pale conjunctiva (-/-), icteric sclera (-/-), pupil reflex
(+/+) isocor, edema palpebra (-/-)
ENT : secret (-/-), hyperemia pharynx (-) Tonsil T1/T1
Neck : LN enlargement (-)
Thorax
Cor I precordial bulging (-), epigastrial pulsation(-),
ictus cordis unseen
Palp thrill (-), ictus cordis palpable at ICS V MCL left,
lifting(-)
Per LB ICS V MCL S, UB ICS II, RB PSL right
Aus S1S2 regular normal murmur (-)
 Physical examination
Po I simmetrical (+), retraction (+) suprasternal
Pal tenderness (-), VF (N/N)
Per sonor (+/+)
Aus vesicular (+/+), rhonchi (-/-), wheezing (-/-)

Abdomen
I distention (-)
Aus bowel sound (+) N
Per timpani (+),
Palp tenderness (+) epigastrium, hepatomegaly (-),
splenomegaly (-)
Extremities
Sianosis (-/-), warm (+/+), edema (-/-) CRT <2”
(-/-) (+/+) (-/-)
 Laboratory Findings
CBC (June 14th 2012 06.35 pm)
No Parameter Result Unit Range Remarks
1 WBC 8,27 X103 u/L 4,1-11,0 Normal
Neu 12,90 X103 u/L 2,50-7,50 Normal
Lym 1,30 X103 u/L 1,00-4,00 Normal
Mono 0,50 X103 u/L 0,10-1,20 Normal
Eos 0,60 X103 u/L 0,00-0,50 Normal
Baso 0,10 X103 u/L 0,00-0,10 Normal
2 RBC 5,11 X106 u/L 4,00-5,20 Normal
3 HGB 14,10 g/dL 12,00-16,00 Normal
4 HCT 40,90 % 41,00-53,00 Low
5 MCV 81,90 fL 80,00-100,00 Normal
6 MCH 27,30 Pg 26,00-34,00 Normal
7 PLT 244,70 X103 u/L 140,00-440,00 Normal
 Laboratory Findings
Blood Chemistry (June 14th 2012 06.35 pm)
No Parameter Result Unit Range Remarks
1 AST 22,10 U/L 11,00-33,00 Normal
2 ALT 21,20 U/L 11,00-50,00 Normal
3 Albumin 3,50 g/dl 3,40-4,80 Normal
4 BUN 4,00 mg/dl 8,00-23,00 Low
5 Creatinin 0,79 Mg/dl 0,70-1,20 Normal
6 Randon Blood 156,00 Mg/dl 70,00-140,00 High
Sugar
6 Na 141,00 mmol/L 136,00-145,00 Normal
7 K 2,4 mmol/L 3,50-5,10 Low
 Assessment
Diabetes Melitus type 2 + gastropati Diabeticum+
Hipertension stage 1
 Planning
THERAPY

IVFD NaCl 0,9% 20 dpm

Omeprazole 2 x 20 mg
Antasid syrup 3 x C1
Sukralfat syrup 3 x C1
Catropil 2 x 25 mg
Novorapid 3 x 8 IU SC
Lantus 0-0-0-12 IU SC
 Planning

Monitoring
Vital Sign
Improvement of symptoms

Diagnostic
Endoscopy
THANK YOU