Morning Report ITP

7/25/2019 Morning Report ITP

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Morning Report january 25, 2016

Dept of internal medicineF24



IdentityName Mr! "idni #l$an#ge 16 year% old

&ccupation %tudent

#ddre%% 'amongan#dmi%%ion (anuary 24, 2016 at 01!26 )M



*+ief *omplaint

)re%ent +i%tory

&ut of lac- %pot%

)atient% pre%ent .it+ out of lac- %pot% on t+e ody %ince

t.o day% ago! /lac- %pot initially appeared on t+efore+ead, t+en appear% on t+e mout+, tongue and t+en%pread to t+e entire face and +and% and feet! pot%%uddenly appeared, at $r%t time initially %mall and t+enenlarged, not itc+y or .arm! )atient% al%o complained ofcoug+ %ince ten day% ago! ye%terday coug+ accompaniedy .+ite %putum and come out .it+ fre%+ lood ofpatc+e%! )atient% dont complain feer, epi%ta-%i%,atralgia, dip%nea! )atient% not ta-ing any medicine efore!#ppetite decrea%ed la%t fe. day%! no nau%ea or omiting!



)a%t +i%tory of Illne%%

Family +i%tory

• 3pile%pi %ince 1 year% ago• Neer +ad %ame complaint efore

No familial related



ocial +i%tory

*igarrete

*o7e #lco+ol



8ital ign%)ul%e94:;min

/)119;<2 mm=g

>emp?6,@ *

RR

?0:;min



# clear, gargling , %noring , %pea-Auently B, potential o%truction

/ %pontan, RR ?0:;min, e% ; e%, r+ ;,.+ ;, a &2 99 C .it+out &2 %upport

* e:tremity DR, *R> E2, N 94:;min, /)119;<2 mm=g

D * 456, lat , )/I ?mm; ?mm, ') B;B

3 temp ?6,@*



3N3R#' >#>G



eneral condition .ell

#.arene%% compo% menti%

* 456

=;N a ;i;c;d

/lac- %pot% at face, mout+, and tongue!



>+ora:

In%pectionymmetrical, retraction

)alpationFremitu% N', t+rill

)ercu%%ion'ung% %onor B;B

*or N

#u%cultation'ung% e% ;e%, r+ ;, .+ ;

*or 1 2 %ingle, mur , gall



#domen

In%pectionFlat, collaterral ein% , inAammation %ign%

#u%cultationMet , gut noi%e N'

)alpation3piga%tric pain Mc urney

>urgor N'

'ier;pleen i% untouc+ale

)ercu%%iontymp+any



3:tremitie%In%pection*luing $nger% , icteric , cyano%i%

/lac- %pot% on t+e ody

)alpationarm and dry, *R> E2



*'G3 #ND *G3

Male 16 year% old/lac- %pot% on t+e ody not itc+y or .arm)atient% not ta-ing any medicine efore



)lanning Diagno%e*/*'F>

N1



#%%e%mentI>)

DD D=F, FD3



'aoratory Finding%Di7count 3o 5!9;

/a 2!<, 'im ??!<;Neu 45!6; Mo 11!9

=ct ?<!6

= 12!<

'eu-o%it 9!<00

>romo%it 5!000

3ritro%it 4!61

&> ?0 N ?1 G;l

)> 29N ?1 G;l

N1 negatif

M*= 2@!<

M*=* ??!2

M*8 <?!@



)lanning >+erapyMRInf! #%ering 1500cc;24 jam

Inj! *eftria:one 2:1 gr

Inj! Metilpred ?:250mg %oluted y D5 100cc

>ran%fu%i >* 10 -olf .it+oud premed!

*on%ult to interni%t



)'#NNIN M&NI>&RIN

8ital ign%

>romo%it */*

)atient% complaint



)'#NNIN 3DG*#>I&N

3:plain to t+e patien and +i% family aout t+edi%ea%e, cau%e, complication, interention oft+e t+erapy and progno%i%!

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Morning Report ITP