MORNING REPORT

MORNING REPORT January 01st 2013

PHYSICIANS INCHARGE:IA: dr. Hengki, dr. , dr. (Cardio)IB: dr. , dr. II: dr. III: dr., SpPD-KMODERATOR: dr., SpPD-K

dr.Hengki-PPDS IPDSummary of Data BaseMr. / y.0/ w.Chief complain:Patient suffered from Summary of Data BasePhysical examinationER BP: mmHgWard BP: mmHgER PR: bpmWard PR: bpm

ER RR: tpmWard RR: tpmERTax: CWard Tax: C General appearance looked ly illER GCS: Ward GCS: HeadPale conjunctiva ( - )Icteric sclera ( - )NeckJVP R+ cmH2O position 30 degChest Heart:Ictus invisible and palpable atLHM ictus RHM: SL DS1, S2 single, murmur ( - ) Lung: Symmetric, SF D=S, P s s Ausc v v Rh - - Wh - - s s v v - - - - s s v v - - - -Abdomen

Soefl, bowel sound (+) normal, tenderness , liver span cm, traubes space tympani, shifting dullness ( - )ExtremitiesAcral warm, leg edema + / +ABI Score: D/ S/Rectal touche:Insp: mass (-)Palp: tonus sphincter ani (+) N, mucousa smoothProstate: consistency ;sulcus mediana ;lateral pole ;superior pole ;bulbus cavernosus reflex LABVALUE (NORMAL)LABVALUE (NORMAL)Hb11,0-16,5 g/dLNatrium136-145 mmol/LMCV80-96 flKalium3,5-5,0 mmol/LMCH26,5-33,5 pgChlorida98-106 mmol/LLeucocyte3.500-10.000/LRBS< 200 mg/dlEos / Bas / Neu / Limf / MonUreum10-50 mg/dL0 / 0 / / / %Creatinine0,7-1,5 mg/dLRDW11,5-14,5 %BUN/CrPCV35-50 %eGFRml/mnt/1.73 m2Plt150.000-390.000/LSGOT11-41U/LESRmm/hSGPT10-41U/LPPTK: secondAlbumin3,5-5,5 g/dLAPTTK: secondBilirubin Total< 1 mg/dLINRBilirubin Direct< 0,25 mg/dLPlasma SG1,025-1,029Bilirubin Indirect< 0,75 mg/dLTrop I 95 %BE(-3) - (+3) m mol/LTrue o2Conclusion :

BLOOD SMEARERYTHROCYTE:

LEUCOCYTE:

THROMBOCYTE:

FECAL SMEARFECAL SMEARLABVALUENORMALLABVALUENORMALColourResidual foodShapeMuscle fibers60ParasiteEgg wormNegativeLarvaNegativeTrophozoiteNegativeCysteNegativeASCITES FLUID ANALYSISLABVALUENORMALLABVALUENORMALMacroscopicProtein Total< 3 g/dLColourGlucose> 60 mg/dLClotTrigliseridaChylous >110 mg/dLPseudochylous 45-60 mg/dLExudat