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MORNINGREPORT

September 29th, 2014

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Patient’s IdentityPatient’s Identity

• NameName : KDP: KDP

• GenderGender : Female: Female

• AgeAge : 29 years old: 29 years old• ReligionReligion : Hindu: Hindu

• AddressAddress : Sesetan, Denpasar: Sesetan, Denpasar

• !!upational!!upational : House"i#e: House"i#e• StatusStatus : $arried: $arried

•  %A %A : Septem&er 29: Septem&er 29t't', 2()*+ (-((, 2()*+ (-((

pmpm

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AnamnesisAnamnesis

Chief Complaint: sore t'roat

Present History:P. !ame to 'ospital "it' !'ie# !omplaint o# sore t'roat

sin!e appro.imately ) 'our /A%H, a#ter s'e drun0 2sips o# !orrosi1e agent porte.3- %'e pain "as li0e

&urning in 'er t'roat- %'e pain also "as #ollo"ed &ydysp'agia

P. also !omplained o# nausea, &ut didn4t #ollo"ed &y1omiting- %'is !omplain #eel !ontinuously and didn4t

#eel &etter-

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P. also !omplained #atigue in all o# &ody sin!eappro.imately )( minutes a#ter ingestion- %'e#atigue didn4t &e impro1e &y rest-

History o# #e1er, &reat'lessness, and !oug' "asdenied &y patient

Past History:P. 'ad no 'istory o# same !omplain &e#ore- Historyo# gastrointestinal disease and ot'ers "as denied&y p.

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Family History:

None o# 'er #amily mem&ers 'a1e similar symptoms-

History o# !'roni! diseases in 'er #amily "as denied-S'e said t'at s'e 'a1e some pro&lems "it' 'er

'us&and

o!ial History:P. is a 'ouse"i#e "it' 2 !'ildren- Her 'us&and "or0s

a&road-

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Physi!alPhysi!al

E"aminationE"amination• General app- : $oderately ill

• 5onsioussness : 5ompos mentis

• G5S : 6*78$• /lood Pressure : )((( mmHg

• Heart Rate : 9.minute

• Respiration rate : 22.minute

•  %a. : ;(

5• 7AS : 2)(

• /ody "eig't : ( 0g

• /ody 'eig't : )8 !m

• /$< : 2*-; 0gm2

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• 6yes : anemis ==3, i0terus ==3, PR>>3

iso!'ori!, edema palpe&rae ==3

• 6N% : Tonsil# pharyn"# ton$%e# mo%th arehiperemi!

• Ne!0 : ?7P >( !mH2, node enlargement =3

•  %'ora. : Symmetri!al >3

5R@

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Physi!al E"aminationPhysi!al E"amination

PB$ > ron!'i = = "'eeCing = =  > > = = = =  > > = = = =

• A&domen

= > edema ==

  >> ==

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&a'oratory&a'oratory

E"aminationE"amination

Complete (lood Co%nt:Complete (lood Co%nt:

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(lood Chemistry Panel:(lood Chemistry Panel:

(lood Gas Analysis:(lood Gas Analysis:

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 %'ora. p'oto AP:

•5or: s'ape and siCe N

•Pulmo: no inEltrate ornodule "it' normal

&ron!'o1as!ular pattern

•Pleural sinus: s'arp

•/ot' diap'ragma arenormal

5on!lusion: Normal

Thora" Photo:Thora" Photo:

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AssessmentAssessment

 %o.i!ity o# !orossi1e agent Porte.3 %o.i!ity o# !orossi1e agent Porte.3

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Plannin$Plannin$

Therapy:Therapy:

• HospitaliCed

•

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THAN* +O,