mr paru grup bohay.pptx

7/25/2019 MR paru grup bohay.pptx

1/12

Morning Report

June 1st, 2016

Doctor in charge:

Dr. dr. Mohammad Isa, Sp.P (K)


2/12

Patients Identity

Name : Mrs. NA

Se : Ma!eAge : 26 yo

"##upation : $

%ospita!ised sin#e : May &1t'

, 2016


3/12

Summary o( )ata *aseMr. NA/ 26 yo /Male (Autoanamnesis and Heteroanamnesis)

Main complaining : Shortness of breath

Patient #omp!ained a+out 'er symptom sin#e 1 mont' ago, 'e

symptom #ame sudden!y a(ter doing mi!d a#ti-ity, and de#rease i(

tae a rest. S'e a!so #omp!ained a+out #oug' /it' mu#us sin#e &0

day ago. Mu#os /it' ye!!o/ #o!or and /it'out +!ood. Patient#omp!ained e-ery nig't eperien#ed a #o!d s/eat. %e a!so diarr'ea

sin#e &0 day ago. 'roat (ee!s dry, sprue , +ut t'e patient #an sti!!

eat. 'e patients -oi#e /as 'oarse and +are!y audi+!e. %is mi#tion

and de(e#ation is norma!. %e admit t'ere is de#reased in 'is

+ody/eig't in t'is 1 mont'. Patient appear /ea and !et'argi#.

Patient is prisoner 3P as a resu!t o( drug use, denied t'e drug

in4e#tion. Patient 'a-e +een di-or#ed and sometimes 'a-ing se /it'

anot'er /oman.

History of illness: DM (-) HT (-)

Histor of Famil illness: DM - HT -


4/12

P'ysi#a! 5aminationGeneral appearance Looked moderately ill, onscio!s, GS : " # $

*!ood Pressure 11070 mm%g

Pu!se Rate 108 +pm regu!ar, strong

Respiration rate &1 ppm,

emp &7,90

%ead #on4un#ti-a anemis , Jaundi#e s#!era $$, de#reased -isua! a#uity $$,5dema pa!pe+ra $$, )ip!opia $, dis#'arge $$

Ne# 3ympati# node s/e!!ing $

'est %eart Inspe#tion : i#tus in-isi+!e Pa!pation : pa!pa+!e in MS IS ;

Rig't margin : Rig't : IS II$III 3.Ster ). ardia# /aist : Aus#u!tation : S1 < S2 sing!e, murmur $ ga!!op $

3ung Inspe#tion : Simetri#, +arre! #'est $Pa!pation : =; simetri#Per#ution : Aus#u!tation :S > S R > RS > S R > ;S > S ; > ;?'ee@ing $, Ron#'i respiratory mus#!e tra#tion

A+domen I : siatri $, %ernia $, aput Medusa $ Aus.: *o/e! perista!ti# soundnorma!.Per#usion: enderness: > > $ > $ > $ > > $ > $ > $ > > $ > $ > $3i-er Sp!een tida tera+a

5tremities Superior ) S : 5dema $, Pain $, ?eaness $, Pitting edem $In(erior ) S : 5dema $, Pain $, ?eaness $, Pitting edem $


5/12

La%oratory &es!lt'*#+*$

Items Resu!t Norma! ;a!ue Bnit

ematology

%emog!o+ine 7,5 12.50 16.7 gd!

3euo#yte 11,3 4.65 10.3 t'ousandu!

5ritro#yte 5,07 4.10 6.00 mi!!ionu!

%emato#rit 24,4 42.00 52.00 ;o!C

rom+o#yte 435 150 356 Ri+uu!

MCV 48,3 75.0-96.0 Fl

MCH 14,7 28.0-32.0

MCHC 30.7 33.0-37.0


6/12

Items Resu!t Norma! ;a!ue Bnit

Glukosa darah sewaktu 117


7/12

D$Ray


8/12

Pro+!ems )ata support

1. )yspneu

1.1 * paru ati(

1.2 S"P

1.& PP"E

-namnesis:

$ S'ortness o( +reat' sin#e 1 mont' ago

$ Mu#os ye!!o/ #o!or #oug' sin#e 1 mont' ago.

$ 5perien#ed a #o!d s/eat e-ery nig't.

$ )e#reased o( +ody/eig't.

ray

In/ltrat di %asal par!

Ka0itas di lapang atas par! de1tra dan sinistra

2. Anemia

2.1 Anemia mirositi 'iporomi

Anamnesis :

Patient appear /ea and !et'argi#

Eon4ungti-a anemis

La%oratory /nding:

de#reased o( %+ F 8,9

%ematorit F 2G,G

M; F G7,&

M% F 1G,8


9/12

Pro+!ems )ata support

&. Imuno#ompremise

&.1 %I;

-namnesis:

)e#reased o( +ody/eig't

)iarr'ea sin#e 1 mont' ago

oug' sin#e 1 mont' agoSprue

%istory o( using drug and 'a-ing

se /it' anot'er /oman.


10/12

Pro%lems PD1 P21 PMo Ped

1.)yspneu

1.1 * ati(

1.2 S"P

1.& PP"E

*A SPS,Spirometri,

35).

P 3a+ )R,=erritin,

I*, SI

"2 nasa! &$9!pmI;=) R3 20 tpm

In( !e-oHoa#in 11In4. "mepra@o!e

1G0mgIn4. e(triaone 21

Pro trans PR 2 o!(sd %*


11/12

Pro%lems PD1 P21 PMo Ped

&. Imuno#ompremise

&.1 %I;

Reati( %I; $ Mo.Su+4e#ti-

e

Mo. ;ita!sign

5d. RisioPenu!aran

,aya'idupyangse'at.


12/12

2hank yo!

mr paru grup bohay.pptx

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