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MORNING REPORT

CASE

January 09th, 2014

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Patient Identity

Name : NMD

Sex : Female

Age : 48 years old

Address : Br Dinas Kaja Jati Kuta Selatan Badung

Nationality : Indonesia

MR : 01.55.64.85

TC : 20.20 wita

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Anamnesis

Chief complain : Coughing blood Patient complaints of having bloody cough since 3

hours BATH. Patients cough is accompanied withspots of blood as much as 2 table spoons. The

spots of blood are fresh red in color.

The patient also complaints that she has beencoughing for the past 3 months and it has not

stopped. Patient claims to struggle to breath when she

coughs and her appetite to eat has declined.

Fever and weight loss was denied by the patient.

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Past illness history

: patients claims to have had the same symptoms 10 years ago

and that she has been medicated for her condition twice.Patient had full filled the full course of her treatment.

:History of diabetes, hypertension, asthma, and heart disease

was denied.

Medication History

she got the medication : Mucopect 3x1, Cravit 3x500,simflox 3x1

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Family history

:None of her family members have the same complaints

as the patient.

:History of DM, hypetension, asthma, and heart diseasewas denied by the patient.

Social historyNone of her neighbors had the same complaints as the patient.

There was no history of smoking.

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Physical examination

Appearance : moderate

Level of consciousness : E4V5M6

Blood pressure : 130/80 mmHgTemperatur axilla : 36,5OC

Pulse rate : 72x/min, reguler

Respiratory rate : 24 X/min

Eyes : Anemia -/-, icterus -/-, Pupil Reflex +/+

Mouth : WNL

Neck : JVP PR 0 cm H2O

Chest examinationHeart

inspection : Ictus cordis: not seenpalpation : Ictus cordis : not palpablepercussion : Upper border : ICS II

Right border : Right PSLLeft border : Left MCL

auscultation : S1 S2 single regular, murmur (-)

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Lung examination

inspection : symetric , active and passive

palpation : vocal fremitus is normal

percussion : sonor / sonor

auscultation : Bves +/- , Rh +/- , wh -/-

Abdomen

inspection : distention (-)auscultation : bowel sound normal

palpation :

liver : unpalpable

spleen : unpalpable

percussion : tymphani

Extremitieswarm + / +, edema - / -

Physical examination

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Laboratory

CBCWBC : 9.95

RBC : 4.51

HGB : 12.0

HCT : 38.7

PLT : 314

MCV : 85.8

MCH : 26.7MCHC: 31.1

RDW : 14.1

UL:

Specific Gravity: 1,010

PH : 5

Leucocyte : 25 (+)

KET : negative

Bilirubin: negative

ERY: negative

Chemist (AGD) :

PH : 7.43

PCO2 : 42

PO2 : 141HCO3 - : 27.9

TCO2 : 29,2

BE (B) : 3,6

SO2 (c): 99

Na : 139

K : 3,2

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CHEST X RAY AP

Heart: Batas kiri jantungtertutup perselubungan,

kesan jantung tertarik ke sisi

kanan

Lung:

Fibroinfiltrate (+) and

Multiple cavity in the right

parahiler and paracardial

Conclusion: menyokong

proses spesifik

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Assesment

Suspect Multi Drug Resistant (MDR) TB

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Therapy

Hospitalized

IVFD NaCl 0,9% 20 drops/ minloading 500 cc

Asam tranexamat 2 x 500mg Codein 3 x 10mg

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P/dx

- BTA 3x

- ESR

- Sputum gram culture

- Blood culture