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MORNING REPORT
16 APRIL 2013
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Name : IMKS
Sex : Male
Age : 39 yrs old
Nationality : Indonesia
Job : Private Sector
Religion : Hindu
Marital status : Married
Address : Br Pegambangan, Batubulan, Gianyar
Date of admission: 15/04/2013
Time of admission: 13.00
Patients Identity
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ANAMNESISChief Complaint : Itchiness
Present History : Patient came to the emergency department complaining
itchiness since 1 day BATH. Itchiness claimed to be present
whole over the body and its told to be very disturbing until
patient could not conduct his daily activities.
This complain started at 17.00 oclock one day BATH. His skin
became reddish with patches soon after he felt the itching
Complain of itchiness arise after taking medication such as
Paracetamol and Ibuprofen. This medication was taken 2 days
before BATH.
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Present History :
Complains such as having watery and red eyes. palpitation,breathlessness, nausea, vomiting, abdominal discomfort or
collapse was denied by the patient.
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ANAMNESIS
Past Medical History : Patient have not experience the same complain before.
History of drug or food allergy was denied by the patient
History of asthma, dermatitis atopic or rhinitis allergic was
denied by the patient. History of heart disease, hypertension, diabetes were denied by
the patient.
Medication History :
Paracetamol and Ibuprofen was given for the past 2 days BATH
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ANAMNESIS
Family History : None of the patients family members have the similar complain
Patients mother suffers from asthma since she was a teenager
History of diabetes , cardiovascular disease, hypertension were
denied.
Social History :
Smoking (+). 10 butts of cigarette per day
Alcohol consumption were denied
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Physical examination
Appearance : Mildi ill
Level of conciousness : E4V5M6
Blood pressure : 130/90 mmHgTemperatur axilla : 36,7OC
Pulse rate : 84x/min, reguler
Respiratory rate : 20 X/min thoracoabdominal type
Eyes : Anemia +/+, ict -/-, RP +/+ isocoric , oedem
palpebra - -/- - watery eyes -/-
ENT : Tonsil, Pharynx, tongue WNL
Neck : JVP PR0 cm H2O, enlargement (-)
Chest examination
Heartinspection : Ictus cordis: not seenpalpation : Ictus cordis : not palpablepercussion : Upper border : ICS II
Right border : Right PSLLeft border : ICS 5 MCL Sinistra
auscultation : S1 S2 single regular, murmur (-)
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Lung examination
inspection : symetric
palpation : vocal fremitus is normalpercussion : sonor / sonor
auscultation :Ves +/+ , Rh -/- , wh -/-
Abdomen
inspection : distention (-)
auscultation : normal bowel sounds
palpation :
liver : unpalpable
spleen : unpalpabletenderness: -
ballotement: -
percussion : tymphani
Physical examination
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Extremity : Pitting edema - -/ - - warm + + /+ +
Others : Macula Erytematous all over his body with various size ( + )
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Parameter Result Unit Remarks Referencerange
WBC 6.223 103/L 4,1 10,9
-Ne 4.337% 103/L 2,5 7,5
-Ly 1,185% 103/L 1,0 4,0
-Mo 0,40% 103/L 0,1 1,2
-Eo 0.27 % 103/L 0,0 0,5
-Ba 0.01 % 103/L 0,0 0,1
RBC 4.709 106/L 4,00 5,20
HGB 12.6 g/dL 12,00 16,00
HCT 40,24 % 36,0 46,0
MCV 94.3 fL 80,0 100,0
MCH 32.6 pg 26,0 34,0
MCHC 34.6 g/dL 31,0 36,0
RDW 11,19 % 11,0 14,8
PLT 327,0 103/L 150 440
MPV 6.8 fL 0,0 100,0
COMPLETE BLOOD COUNT
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BLOOD CHEMISTRY PANEL
Parameter Result Remarks Reference rangeSGOT 28, 32 11-33
SGPT 32, 54 11-50
BUN 14, 82 10-23
Creatinin 0, 78 0.5-1.2
BS 104,00 70,00-140,00
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Sinus rhythmHR :75x/mnt, reguler
Axis : Normal
P wave : Normal
PR interval : Normal
ORS complex : Normal
ST-T segment changes: (-)
Result: Normal ECG
ECG
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Assesment
Hypersensitivity Reaction e.c susp drugs
(Ibuprofen, Paracetamol)
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Treatment
Hospitalized IVFD NaCl 0,90 20 dpm
Methylprednisolone 2 x 62.5 mg
Dipenhydramine 3 x 10mgStop suspecting substances
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Diagnostic Planning : IgE total
Monitoring: Vital Sign and Complaints
Planning
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