MORNING REPORT August 13th 2015 Summary of Database Identity
:Mr G/23yo/W 2
!"ief !om#$ain: Genera$ Wea%ness Present Medical History Patient sufer rom general weakness since 1 month beore admission gradually onset and get worse since 3 day ago!He elt "owerless didn#t ha$e enough strength to do his daily basic %he "atient com"lain about decrease o a""etite since 1 week ago he only ate 5 s"oon o ood each meal! His bodyweight decreased in 1 month rom 53 kg to 3& kg! %he "atient "atient also com"lain com"lain about ha$ing ha$ing oral trush since 1 week ago went to '((A and gi$en )ucona*ole 1+150 mg! ,n the last 3 days he elt "ain in swallowing! %he "atient had already diagnosed H,- since 2 years ago and routinely took A'- ./u$iral and e$iral amilial History He work medicine salesman (ocial History he is single and a gay ga y .homose+ual
P"ysi&a$ E'amination Genera$ (##earan&e: moderate$$y i$$
)oo%ed: under*ei+"t
,(S S&ore:-
PR: 425 b#m
RR: 2.'/menit
G!S: .0
1P:/0 mm+
ead
Pu#i$ Pu#i$ iso%o iso%or r6 diamet diameter: er: 3 mm6 mm6 anemi anemi& & &on7un &on7un&t &ti8a i8a 6 i&teri& s&$erae - ora$ trus" 9
Ne&%
,P R9 &m 2O ;3<6 $ym#"node en$ar+ement -/-
!"est
Wa$$
Symmetri&6
Ta': 306!
I&tus 8isib$e6 #a$#ab$e at I!S I, 4 &m $atera$ M!) S Tri$$: ea8es: eart
RM = S) D
)M = i&tus
S4 and S2 sin+$e Stem >remitus N N R" - W" - )un+
- -
E'tremities
8
8
NN
Sonor Sonor
8
8
NN
Sonor Sonor
8
8
--
- (bdomen
Sonor Sonor
--
?at6bo*e$ sound N6 $i8er s#an @ &m6 TraubeAs s#a&e tym#ani6 s"iftin+ du$$ness -6 ?an% #ain Warm6 edema -/- 6 sensoris N/N6 $atera$isasi ;-< -/-
N/N
Brine Produ&tion
)aboratory Resu$t Parameter
Resu$t
Norma$ ,a$ue
b
@64
+/d)
43C. 45C5 +/d)
)eu&o&yte
@2.
/)
.C3-4C3/)
emato&rit
262
F
. .5 F
T"rombo&yte
34.
/)
4.2C.2.C/)
M!,
@56@
f)
@ 3 f)
M!
2@62
#+
25 34 #+
Dierentia$ &ount
6/
-./-4/4-
6/@.64/63/460F
05/2-33/2- F
Random 1$ood Su+ar
-
+/d)
H2 m+ /d$
SGOT
3@
B/)
-. B/)
SGPT
20
B/)
-.4 B/)
Breum
3563
m+/d)
40C0 .@C
!reatinine
6@5
m+/d)
H4C2
Determinan I,
-
Natrium (Na)
131
mmol/L
136 – 45 mmol/L
Kalium (K)
3,25
mmol/L
3.5 – 5.0 mmol/L
99
mmol/L
98 – 106 mmol/L
Chloride (Cl)
%4
E!G
437
'hythm
(inus tachycardia
'ate
116 b"m
rontal A+is
normal
Hori*ontal A+is
normal
P' inter$al
20!7
8'( com"le+
0&!7
8% inter$al
2&7
!on&$usion
: sinus ta&"y&ardia R44. b#m
!BE (ND !)BE
Prob$em )ist
Initia$ Dia+nosis
P$annin+ Dia+nosi s
P$annin+ T"era#y
Pmo Pedu
4C Ma$ e/23JO/W 2
1! :eneral 9eaknes s
1!Anemia ormocrom ormositer
;
;=2 6;> l"m nasal canula
( -(
istory 9eakness /ecrease o A""etite
1!1! drug induced A'1!2! related H,-
; 'eticulocy te count ;erritrin test
; ,-/ ( 0?@ 20 d"m ;HHP diet
Hb le$el Pedu managem ent disease treatment com"licati
ausea and $omite
inection
;%reat underlying disease
H,- on treatment A'./u$iral and e$iral
on
; (witch A'induced anemia
P"ysi&a$ E'amination
0 P' 12B '' 26 %a+ 3>!5 onCucti$a anemis
)ab: H< D &10 gd4 M- &B&0 4 MH &B&0 "g a 131 mmol4 %4 63B
2. Mal e /23 YO /W 29 History General Weakness Chronic Cough Oral Trush Decrease of o!y "eight #oitenely controle to #$$% an! consu&e
2. H'( stage '( on treat&ent
2. H'( stage '( on treat&ent
)
) HCH* !iet
CD,
) %#( as ao+e
$- ($ *e!u &anage&ent !iseasetreat&entco&lication
0DC %#( *hysical 1a&ination Ta 3-, Oral trush 456 7a H 8. g/!7 T7C ,3:
3Mal e /2 3 YO/W 29
3.Oral Trushl
History
3.Can!i!ias ofaringea l
KOH swab
Decrease of aetite
-In!sion "l!cona#ole loa$in% & x '(( m% I) contin!e with &x2(( m% I*+o
Dysfagia -,ystatin oral $ro+ 'x3cc
Oral trush
!b.ecti)e Oral tr!sh Pe$! mana%ement $isease0 treatment0 com+lication
Physical Examination Oral trush 456
'1 Mal e/23 YO/W 29 History #outenely control to #$$% an! take 0CD %#( Physical
,. 'ncrease of seru& transa&inas e
,.. Heatitis infection
Hs%
4onirm $ia%nose$
nti H4* ,.2 !t. %#( in!uce!
lb!mine
0* 6O70 6P7
4han%e$ 5* in$!ce$ transaminitis
Pe$! mana%ement $isease0 treatment0
Examination 'cteric sclerae ; 8ab $GOT 3<8 $G*T 2=
com+lication
