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MORNING Report

April 27th 2013

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Patients Identity

Name : Mr. A

Age : 20 y.o

Religion : MoeslimDate : April 25th 2013

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AnamnesisChief complaint: Fever Present illnes: patient complained about his

fever with chilled and sweating since 9 daysbefore hospitalized. His fever has increase atthe first day and felt more fever at night. It wasdecrease by taking medicine but after that, itwould be increased again. Nausea (-), vomit (-),headache (+), abdominal pain (-). Defecationnormal, and his urinations colour seen like tea.

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Anamnesis

History or past illness :- History of dengue fever haemorrhage, Hepatitis,

thypoid fever, malaria denial

History of family :- History of dengue fever haemorrhage, Hepatitis,

thypoid fever denial

History of sociality :- Patient about 12 days ago when to the Kalimantan

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Physic Examinations

General Appearance : Weak

GCS : 456 , Somnolen

Vital Sign

BP : 95/51 mmHg

Pulse : 96x / minutesRR : 20x / minutes

Temp : 37 C

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Physic ExaminationsHead and neck : Anemic +/ icteric +/ cyanosis -/

dyspneu -

Thorax : simetric bilaterally, retraction (-/-), Pulmo : ves/ves, rh (-/-), wh (-/-)

Cor : S1-S2 single, murmur(-), gallop(-)

Abdomen : flat, soepel, hepar 4cm under arcus

costae and lien S1H1, tenderness (-), meteorismus

(-), BU(+N)

Extremity : akral warm, wet, red (+), edema (-)

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Laboratory Findings

Diff count 0/0/54/30/16Hematocrit 22,3 %Haemoglobin 8,1 mg/dLLED 64/99

Leukocyte 2.300Trombocyte 40.000Alkali fosphatase 235Bilirubin direct 4,89 mg%Bilirubin total 8,1 mg%SGOT 71 u/LSGPT 54 u/L

Albumin 2,1 mg% Total protein 5,2 mg% Clorida serum 105 mol/l

Kalium serum 3,2 m mol/l

Natrium serum 138 m mol/l

Urea 74 mg/dl Serum creatinin 0,9 mg/dl

GDA 104 ICT MALARIA Positif :

Plasmodium falciparum

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Thorax APThorax photo seen

no abnormality.

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Clue and CueMale, 20 y.o

Fever

Nausea (-), vomit (-)

Urinations colour seenlike tea.

Patient about 12 daysago when to the

KalimantanPhysic Examinations :Anemic +, Icteric +,Hepatosplenomegaly

Laboratory Findings :

Diff count 0/0/54/30/16

Hematocrit 22,3 %

Haemoglobin 8,1 mg/dL

Leukocyte 2.300

Trombocyte 40.000

Alkali fosphatase 235

Bilirubin direct 4,89 mg%

Bilirubin total 8,1 mg%

SGOT 71 u/L

SGPT 54 u/L Albumin 2,1 mg%

Total protein 5,2 mg%

Urea 74 mg/dl

ICT MALARIA Positif : Plasmodium

falciparum

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Assessment

Malaria Tropicana

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Planning

Planning Dx : -

Blood smear

Planning Tx :

Infus Asering 1.500cc /24

hour

Inj. Methamizole 3x1

Inj. Ranitidin 2x1

Inj Ceftriaxone 2x1

Po Hepamax 1x1 Po aterakin 4 tablet 2

tablet 2 tablet

c/ Internist

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Dubia ad bonam

Prognosis Education

Explain to the family about

the condition of this patient

now, its disease, about itsexaminations, theraphy and

intervention will be done,

and also about complication

and prognosis.