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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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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
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