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MORNING REPORTDepartment of Internal Medicine

Christian University of Indonesia

October 3rd2013

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Subjective Data

Name: MR. Immanuel, 52 YO

Address : East Jakarta

CC : Bloody cough

TC : Tuesday/ 3rd October 2013 / 15:15

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n mnesis

Main Complaint

Bloody cough since 3 hours before

addmited

Weight loss

Additional Complaints

-

Autoanamnesis

on the date 3rd October 2013,

Time 15.15 WIB

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Anamnesis

Patient came to the hospital with main complaints bloodycough since 3 hours before hospital admission. The blood

that came out is a fresh red blood mixed with mucus as

much as a quarter of Aqua glass. Before patients are in

the early phase of tuberculosis treatment for 1 week. Patient

also complain of unexplained weight loss is pretty much for

1 month, from 79kg to 62kg.

nausea (-), vomit (-), intake (+).

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12/4/2013

Past Medical History andTreatment

History of trauma (-)Rifampisin 450mg, INH 300mg,

Pirazinamid 1000mg, Etambutol1000mg

Family History (-), smoking (-)

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Objective Data

Appearance :moderate illness awareness :

E4V5M6; CM

TD :120/80mmHg

HR : 86x /menit(adequate,

reguler)RR : 22x /menit Temp : 37C

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Objective Data

Head :Normocephali

Konjunctiva anemic +/+

Sklera Ikterik -/-

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Thorax

Pulmonal Left Right

Inspeksi Front Static and dynamic symmetric Static and dynamic symmetric

backStatic and dynamic symmetric Static and dynamic symmetric

Palpasi Front VF symmetricVF symmetric

BackVF symmetric VF symmetric

Perkusi Front Sonor Sonor

Back Sonor Sonor

Auskultasi Front BBS Vesicular, Rhonci -/-,

Wheezing -/-

BBS lost, Rhonci -/-, Wheezing -/-

Back BBS Vesicular, Rhonci -/-,

Wheezing -/-

BBS Vesicular, Rhonci -/-, Wheezing -

/-

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Abdomen

Inspeksi:

stomach looksflat

Palpasi:

LiverSpleenimpalpable ;ball -/-

;Pressure Pain,Acites -

Perkusi:

Tympani;PercussionPain -

Auskultasi:

Bowel sound(+) 4x/minutes

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Upper Extremities

Kanan Kiri

Muscle

Tonus Normotonus Normotonus

Massa Normal Normal

Joint in all directions in all directions

Move in all directions in all directions

Power +5 +5

Akral Warm Warm

Edema - -

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Lower Extremities

Kanan Kiri

Muscle

Tonus Normotonus Normotonus

Massa Normal Normal

Joint in all directions in all directions

Move in all directions in all directions

Power +5 +5

Akral Warm Warm

Edema - -

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LABORATORIUM

HEMATOLOGI HASIL NILAI RUJUKAN

Hemoglobin 10,3 12-14 g/dL

Leukosit 8,6 5-10 ribu/UL

Hematokrit 37,4% 37-47 %

Trombosit 362 150-400 ribu/uL

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Assessment

Diagnose:

Lung Tuberculosis in therapy

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Planning

Pro Hospitalized

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Department of Internal Medicine

Christian University of Indonesia

THANK YOU