Morning: January 16 2017
Morning: January 16 2017
Morning: January 16 2017
REPORT
January 16th 2017
DM Inggrid, DM Rises
IDENTITY
Name : Mr. MR
Age : 46 y.o
Sex : Male
Address : Alak
HISTORY TAKING
Chief complain : pain at wound on patients bottom.
History of present illness: patient came to the hospital with pain at
wound on his bottom since 1 month ago. The pain was sharp and
located only around its wound. There were no aggravating or
mitigating factors toward his complaint. Firstly the wound emerged as
considerable small abscess which then burst and discharged yellowish
and foul smelled pus. Patient had fever a week after and drastic weight
loss since then. Urinating and defecating were normal, there were no
symptoms of nausea and vomiting.
past medical history: there wasnt any history of any disease
family history of disease: there were no family members with same
disease or same complaint
treatment history: patients had previously been treated in a clinic and got four types
of oral medication, but he couldnt mention any of those medications.
PHYSICAL EXAMINATION
GCS : E4 V5 M6
Eye: anemic (+/+), direct light reflex (+/+), icteric (-/-)
Mouth : leucoplakia (+)
Nose : normal findings
Throat : normal findings
Chest :
Symemetrical chest expansion, no retraction
Normal heart and lung sounds, no additional sound
Abdomen : normal finding
Gluteus : Location status: there are multiple ulcers with soiled base
. Extremity : normal finding
LABORATORY RESULTS
Hb : 5,7 g/dl
RBC : 2,44x10^6/uL
HT : 18,1 %
Lekosit :20,43x 10^3/uL
Trombosit : 161 x10^3/uL
GDS: 104 mg/dL
Ureum : 73,90 mg/dL
Kreatinin : 0,62 mg/dL
ASSESMENT
IVFD RL 20 tpm
Inj. Ketorolac 3% 1 A/iv
Paracetamol 3x500 mg tab
blood transfusion 1 bag per day
Wound toilet
THANK YOU