This document contains a morning report from a hospital that includes: - The physician and consultants on duty - A summary of a patient's history, examination, lab results, imaging studies, and problem oriented medical record - An analysis of the patient's problems, risk factors, pathophysiology, diagnosis, management, and prognosis

1. MORNING REPORT
Date :
Physician in charge
I :
II CVCU :
II HCU :
II UGD :
Chief on duty :
Consultant on duty :
Facilitator :

2. Summary of Database
Mr/Mrs/Ms/yo/ward
Autoanamnesa/Heteroanamnesa
Chief Complaint:
History of Present Illness:

3. Summary of Database
Past Medical History:
Family History:
Social History:
Review of System:

4. Physical Examination
Generalappearance
GCS
SatO2 ….on…lpm
VAS0/10
BP mmHg PR bpmregularstrong RR tpm Tax oC
Head ConjuctivaAnemic(-), ScleraIcteric(-),Nystagmus(-),MeningealSign(-),PupilIsocor
Neck JVPR+cmH20
Chest Symmetrical,retraction(-)
Lung Sonor | Sonor Vesicular|Vesicular Rhonkhi: -|- Wheezing: -|-
Sonor | Sonor Vesicular|Vesicular -|- -|-
Sonor | Sonor Vesicular|Vesicular -|- -|-
Cardio Ictus invisible, palpable at MCL (S) ICS V
LHM ~ ictus, RHM ~ SL (D) S1 S2 single, regular,
murmur (-) gallop (-)
Abdomen Flat, soefl, Bowel Sound (+) normal, shifting dullness (-)
Liver/ unpalpable, liver span 10 cm, epigastrium tenderness (-)
Lien/ Traube space tymphany
Extremities Edema(-),pale(-),MMT5|5,PathologicReflex(-);Lateralisation(-)
5|5
RT Tonussphincterani(+);colonmucousslippery;melena(-);hematoschezia(-)

5. Laboratory Findings (dd/mm/yy)
LAB VALUE NORMAL LAB VALUE NORMAL
Leucocyte 4.700 – 11.300 /µL Ureum 20-40 mg/dL
Hemoglobine 11,4 - 15,1 g/dl Creatinine <1,2 mg/dL
PCV 38 - 42%
Thrombocyte 142.000 – 424.000 /µL Natrium 136-145 mmol/L
MCV 80-93 fl Kalium 3,5-5,0 mmol/L
MCH 27-31 pg Chlorida 98-106 mmol/L
Eo/Bas/Neu/
Limf/Mon
0-4/0-1/51-67/
25-33/2-5
RBS < 200 mg/dl
PPT 9.3-11.4 detik
SGOT 0-40 U/L APTT 24.8-34.4
SGPT 0-41 U/L INR 0.8-1.30
Albumin 3.5-5.5 g/dL Calcium 7,6-11,0
Bilirubin total <1.0 mg/dl
Bilirubin direct <0.25 mg/dl Osm 275-295 mOsm/kg
Bilirubin indirect <0.75 mg/dl

6. Urinalysis (dd/mm/yy)
LAB VALUE NORMAL LAB VALUE NORMAL
Turbidity 10 x
Color Epithelia ≤1
pH 4.5 – 8.0 Cylinder
SG 1.005 – 1.030 Hyaline
Glucose negative Granular
Protein negative Other
Keton negative
Bilirubin negative 40 x
Urobilinogen negative Erythrocyte ≤3
Nitrite negative Leukocyte ≤5
Leukocyte negative Crystal
Erythrocyte negative Bacteria ≤23 x 103/ml
Other

7. Blood Gas Analysis (dd/mm/yy)
With Room Air/…. Normal
pH 7.35-7.45
pCO2 35 – 45 mmHg
pO2 80 – 100 mmHg
HCO3 21 – 28 m mol/L
O2 saturation > 95 %
BE (-3) - (+3) m mol/L
Temperature
Hb
Conclusion:

8. Electrocardiography (dd/mm/yy)

9. Electrocardiography (dd/mm/yy)
• Sinus rhythm, HR ….. bpm
• Frontal Axis :
• Horizontal Axis :
• P wave :
• PR interval :
• QRS complex :
• ST segment :
• QT interval :
• T wave :
Conclusion :

10. Chest X-Ray (dd/mm/yy)

11. Chest X-Ray (dd/mm/yy)
• AP position, symmetric, enough KV, enough inspiration
• Soft tissue was thin and bone was normal
• Trachea in the middle
• Hemidiaphragm D and S was dome-shaped
• Phrenico-costalis angle D and S was sharp
• Pulmo: bronchovesicular pattern was normal
• Cor: site N, size CTR 55%, shape N, elongation aorta (-), cardiac
waist (+)
Conclusion: normal chest x-ray

12. Lumbal X-Ray (dd/mm/yy)

13. Lumbal X-Ray (dd/mm/yy)
 Alignment : Normal, no visible listhesis
 Trabeculation : Normal
 Curve : Normal
 Corpus : Normal, osteophyte (-)
 Intervertebral space : Narrowing (-)
 Proc. Tranversus/spinosus : Normal
 Pedicle : Intact
 Soft Tissue : Normal
Conclusion: normal lumbal x-ray

14. Abdominal USG (dd/mm/yy)

15. Abdominal USG (dd/mm/yy)
 Hepar : size was normal; smooth surface; echoparenchym was homogen;
VH/VP was normal; no visible mass
 Gall bladder : size and shape were normal; no visible stone/mass/sludge; wall
thickening (-)
 Pancreas : size was normal; homogenous parenchym; calcification (-)
 Lien : size was normal; mass (-); cyst (-)
 Renal D/S : size was normal; echo cortex normal; margin of sinus cortex was
definite; ectasis at pelvicocalyceal (-); no visible stone/mass/cyst
 Vesica urinaria : enough content; smooth wall, mass (-), calcification (-)
 Prostat : size was normal, mass (-), calcification (-)
 No visible mass/lymph nodes nodules/intraabdominal free fluid
Conclusion: normal abdominal USG

16. POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mr. Mrs. Ms./ yo/ w
Subjective
Objective
Laboratory

17. POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mr. Mrs. Ms./ yo/ w
Subjective
Objective
Laboratory

18. POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mr. Mrs. Ms./ yo/ w
Subjective
Objective
Laboratory

19. POMR (Problem Oriented Medical Record)
CUE AND CLUE PL IDx PDx PTx PMo&Ed
Mr. Mrs. Ms./ yo/ w
Subjective
Objective
Laboratory

20. Problem Analysis

21. Risk Factors Analysis
Problem Theory Patient

22. Key Message Pathophysiology

23. Key Message Diagnosis

24. Management Analysis
Problem Theory Patient

25. Key Message Management

26. Key Message Social

27. Condition This Morning

28. Prognosis
• Ad vitam :
• Ad functionam :
• Ad sanationam :