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MORNING REPORT

C3
A 64 year-old Male was admitted to R.D. Kandou
Hospital at C3 ward on 23 August 2017

With main complaint: Yellow discoloration of


skin since 1 months ago
Patients identity
Name : Mr AK
Age : 64 yrs
Sex : Male
Occupation : Unemployed
Education : Junior High School
Ethnicity : Minahasa
Religion : Christian
Present Medical History
Yellow discoloration of the skin since 1 months ago.
History of previous yellow discoloration of the skin was
denied.
Nausea, Vomiting since 1 weeks b.a,
Abdominal pain, especially at upper right quadrant,
intermittent, since 1 months b.a
Itchy on skin , since 1 months ago following
discoloration of the skin
Present Medical History
Poor appetite (+), decrease body weight (-)
Deep yellow-coloured urine &
Grey Stool
Past Medical History

History of previous heart, liver, DM,, high cholesterol,


hypertension, uric acid was denied.
History of kidney disease(+)
History of intermittent upper right abdominal pain
especially after eating too much since 6 month b.a
Patient was hospitalized in Prof. Kandou hospital 1
months b.a for Dx Choledolithiasis from Surgery
Departement
History of allergy :
Unknown
History of immunization :
Unknown

Habit history :
Alkoholism (-), Smoking (-)
Family History
None experienced the same illness
General anamnesis ( review of system )
General : Nausea, poor appetite, fever
Skin : Yellow discoloration
Head and neck : -
Eye :-
Ear :-
Nose : -
Mouth and throat: -
Respiratory :-
Chest : -
Heart : -
Abdomen : Upper right abdominal pain,
Genitalia :-
Kidney : Deep yellow colored urine
Hematology :-
Endocrine :-
Musculosceletal :-
Physical Examination
GC: Moderate ill Sens : CM
C1:BP: 120/70mmHg, PR 88x/m, RR 20x/m, T 36,5C
ER :BP: 110/80mmHg , N 93x/m, RR 18x/m, T 36,3 C
BW 70 kg, BH 170 cm, BMI 24.2 kg/m2
Head : conj. anemic (-), scl. icteric(+),
Neck : JVP 5+0 cmH20, lymph nodes enlargement (-), thyroid (-)
Thorax :
Heart :
Insp : IC not visible
Palp : IC not palpable,
Perc : left border: ICS V midclavicullar line
right border: ICS IV parasternal line
Ausc : SI-II regular, murmur (-), gallop (-)
Physical examination
Lung : Insp : Symmetric
Palp : stem fremitus R = L
Perc : sonor +/+
Ausc : vesicular, ronchi -/-, wheezing -/-
Abd :
Insp : Flat
Palp : pain (+) in the right hypochondrium and epigastrium
region; Murphy sign(+)
Liver and spleen not enlarged
Perc : Tympanic in all regions, shifting dullness (-)
Ausc : Bowel sound (+) normal

Extr : warm, edema (-/-)


Lab Result
9/01/2016 (Ratumbuysang)
Leucocyte 10.000 9/01 2016 Urinalysis :
RBC 3,79 Leu + Blo +2
Hb 12.5
Ht 40 Nit - SG 1.030
Platelet 126 Uro +2 Ket -
MCH 33
MCHC 31,3 Prot + Bil +2
MCV 105,6
RBS 108
pH 6 Glu -
Ureum 188,7
Creatinin 6,0
Uric Acid 14,9
Gamma GT 326
Bilirubin Total 9,76
Bilirubin Direk 8,72
Bilirubin Indirek 1,05
Lab Result
10/01/2016(Kandou) 10/01 2016 Urinalysis :
Natrium 128 Leu + Blo +2
Kalium 2,8
Chloride 100 Nit - SG 1.030
SGOT 63,1 Uro +2 Ket -
SGPT 64,3
Anti HCV - Prot + Bil +2
HbsAg - pH 6 Glu -
HIV -
Malaria -
Problem List
No CM : 45.88.75 Age : 61 y.o
1. Main complain:
Yellow discoloration of skin
2. Anamnesis:
Upper right Abdominal pain
Decrease appetite
Deep yellow colored urine
Grey stool
Nausea vomiting
3. Physical examination:
GC: Moderate ill Sens : CM
Head : conj. anemic (-), scl. icteric(+),
Abd :
Insp : Flat
Palp : pain (+) in the right hypochondrium and
epigastrium region, Murphy sign (+)
Liver and spleen not enlarged
Perc : Tympanic in all regions, shifting dullness (-)
Ausc : Bowel sound (+) normal
Thorak PA
Interpretation of Radiology
Rontgen components Interpretation
Identity Same as the patient
KV enough
Symmetric yes
Diaphragma normal
Mediastinum Normal
Sinus Costophrenicus sharp
Sinus Cardiophrenicus sharp
Bone Not intact
Cor + CTR <50%
Pulmonary Parenchyme Infiltrat (-)
CONCLUSION : Normal
ECG : Sinus rhythm, 75 x/min
ECG INTERPRETATION
ECG components Interpretation Value
Rhythm Sinus Sinus Rhythm
Speed / HR (times/mnt) 67x/min 1500/R-R
Axis Normal Normal / RAD / LAD
Morphology P wave 0,1 sec Lead II : Duration 0.10, Height 2.5
PR Interval 0,16 sec 0,12 0,20
QRS complex duration 0,07 sec 0,05 0,11``
ST segmen Normal Normal / Elevated / Depressed
T wave Normal Normal / abnormal
QT Interval 0,32 sec cQT = QT interval / vR-R Interval
U wave Appear Appear / not appear
CONCLUSION : Sinus rythm, HR 75x/m
N Problem List Plan Dx Plan Tx Non pharm tx Plan Monitoring
o
1 Yellow
discoloration of
Alkaline
Phosphatase
o
Consultation to
department of
Educate the
family about the
Observation for
vital signs.
the skin surgery condition of the
abdominal pain ERCP patient and plans
History of ahead.
previous USG Abdomen
intermittent Diet
upper right modification:
abdominal pain avoid meaty, fatty
food; high fat
GC: Moderately ill. food
Sens : CM
Sclera Icteric (+)
Abd: palp. pain on
right hypochondric
and epigastrium
region
Lab:
Obstructive
jaundice ec dd
choledocholithiasis
dd cholesystitis dd
cancer of the head
of the pancreas
N Problem List Plan Dx Plan Tx Non pharm tx Plan Monitoring
o
3 General
weakness (+)
SI, TIBC,
Transferin
o
Treat
Underlying
Educate the
family about
Observation for
vital signs.
Blood smear Disease the condition of
PE: Retikulosit the patient and Hb control
plans ahead.
Head : conj.
anemic (+)
RT: Melenic
stool (+)

Lab:
Hb 9.4
Ht 26,2%
MCH 34.3
MCHC 36
MCV 95.3
Anemia
Normochrom
Normocitic ec
GIT bleeding
dd/ renal
disease
Conclusion
Has been reported A 61 year-old man admitted to R.D.
Kandou Hospital at C4 ward on January 10th, 2016 at
04.10 with main complain Yellow discoloration of the
skin, from anamnesis, physical examination an
laboratory diagnosed with obstructive jaundice ec
suspect acute cholangitis, dd choledocholithiasis, dd
cancer of the head of the pancreas + Hypo Na+ Hypo K
+ Hyperuricemia
Prognosis
Ad Vitam : Dubia ad Malam
Ad Functionam : Dubia ad Malam
Ad Sanationam : Dubia ad Malam
Thank You