MR 6 Februari 2016 Gum Bleeding

7/24/2019 MR 6 Februari 2016 Gum Bleeding

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MORNING REPORT

C1


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A 78 year-old male was admitted toR.D. Kado! "os#ital at C1 ward o$riday % $e&r!ary '(1)

*it+ mai ,om#lait G!m &leedisi,e 7 days &.a


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Patiet/s idetity

Name Mrs R0Ae 78 years old

e2 Male

O,,!#atio $armer

Ed!,atio Middle "i+ ,+ool

Et+i,ity Mia+asa

Reliio C+ristia


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Preset Medi,al "istory

G!m &leedi si,e 7 days &.a.T+is+a##eed s!ddely. $re3e!,y &leedi 4%25day6 total ol!me 4 1( ,,5day. ores -9.

T+e &leedi was sto##ed today. T+is

+a##eed &e:ore ad sto##ed &y itsel:. No+istory o: !si ay dr! -9

$eer 496 s+ieri 496wea;ess 496a!sea -96 omit -9. Poor a##etite -96de,rease &ody wei+t -9

Dys#ea -96 ,o!+ -9

De:e,ati ad !riati +ad o ,om#lai.


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Past Medi,al "istory

Patiet +ad t+is disease at


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"istory o: allery

=;ow

"istory o: imm!i>atio =;ow

"a&it +istory

-


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$amily "istory

Noe e2#erie,ed t+e same illess


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Geeral aamesis reiew o: system 9

Geeral *ea;ess6 :eer6 s+ieri

;i -"ead ad e,; -

Eye -

Ear -Nose -

Mo!t+ ad t+roat !m &leedi

Res#iratory

C+est -

"eart -


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A&dome -

Geitalia -

Kidey -"ematoloy -

Edo,rie

M!s,!los,eletal -


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P+ysi,al E2amiatio

GC Moderate ill es CM C1:BP: 90/60mmHg, PR 80x/m, RR 20x/m, T 37,3C ER :BP: 110/70mmHg , N 64x/m, RR 16x/m, T 36,3 C ?* %( ;6 ?" 1%( ,m6 ?MI ''6' ;5m' Head :con! anem"c #$%, &c'! "c(e)"c#$%, *o+( : ce"'"("& #$%, -'eed"ng#$% Nec. : P 0 cmH20, 'm node& en'a)gemen( #$%, ()o"d #$% To)ax : Hea)( :

5n& : 5C no( "&"-'e Pa' : 5C no( a'a-'e, Pe)c : 'e( -o)de): 5C 1 cm 'a(e)a' m"dc'a"c+''a) '"ne

)"g( -o)de): 5C 5 1 cm 'a(e)a' a)a&(e)na' '"ne +&c : 5$55 )eg+'a), m+)m+) #$% &&(o'"c, ga''o #$%


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P+ysi,al e2amiatio

@! Is# ymmetri,Pal# stem :remit!s R @Per, soor 454A!s, esi,!lar6 ro,+i -5-6 w+ee>i -5-

A&d Is# $latPal# Teder6 #ai -96

@ier ad s#lee ot elaredPer, Tym#ai, i all reios6 s+i:tid!lless -9

A!s, ?owel so!d 49 ormal

*aist Pai o CBA e2am -5-9 E2tr warm6 edema -5-96 #!r#!ra 496

+ematoma49


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@a& Res!lt%5'5'(1) e+coc(e 300 E)" 293 H- 9, H( 29,2 P'a(e'e( 34,000 *CH 32,2 *CHC 32, *C 99,6

;) / c) 38/1,2 Na()"+m 13 ? 4,6

Malaria :al,i:ar!m 444


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Ro T+ora;


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RONTGEN INTERPRETATION

Rontgencomponents

Interpretation

Idetity ame as t+e #atiet

KB eo!+

ymmetri, ormal

Dia#+rama ormal

Mediasti!m ormali!s Costoerte&rae s+ar#

i!s Cardio#+rei,!s +ar#

?oe Ita,t

Cor 4 CTR 115'1 1(( %'

P!lmoaryPare,+yme

Iltrat -9

CONC@=ION ormal


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ECG i!s r+yt+m6 7125mi6RAD


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ECG INTERPRETATION

ECG components Interpretation

Value

R+yt+m i!s i!s R+yt+m

#eed 5 "Rtimes5mt9

7125mi 1%((5R-R/

A2is RAD Normal 5 RAD 5 @AD

Mor#+oloy P wae (6(8 se, @ead II D!ratio F(.1(6 "ei+tF'.%

PR Iteral (6'( se, (61' H (6'(

R ,om#le2d!ratio

(6(8 se, (6(% H (611JJ

T seme Normal Normal 5 Eleated 5 De#ressed

T wae Normal Normal 5 a&ormal

T Iteral (6% se, ,T T iteral 5 R-R/Iteral

= wae A&set A##ear 5 ot a##ear

CONC@=ION i!s ryt+m6 "R 7125m6 RAD


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Pro&lem @istNo CM %.'(.LL Ae 78 y.o

1. Mai ,om#lai

. G!m &leedi

'. Aamesis. G!m &leedi si,e 7 day &.a6 re#eated

. Geeral *ea;ess

. $eer6 s+ieri


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. P+ysi,al e2amiatio GC Moderate ill es CM ."n : P+)+)a #%, Hema(oma #%

4! @a& E)" 293 H- 9, H( 29,2 P'a(e'e( 34,000 *a'a)"a a'c"a)+m

! EC; : &"n+& )(m, 71x/mn(, R

MR 6 Februari 2016 Gum Bleeding

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