Morning Report Dengan Dr Yasa Tgl 4 Juanuari 2019 3r2r5x

MORNING REPORT 03 JANUARY 2019 Team: Fitri, Siti, Fitriatul, Dinda, Rusmin SUPERVISOR: dr. I Gede Yasa Asmara, Sp.PD

RESUME Total patient: 8  Still at IGD: 6  Move to room 

O.Koko: 1  Lakey: 1 

BPL:  Died: 

PATIENT 1 Name  Gender  Age  Adress  MR Number  Diagnose  Other information 

: Ny. SN : Female : 56 years old : Dompu :611333 : CKD st V : Move to Lakey (2003)

PATIENT 2 Name  Gender  Age  Adress  MR Number  Diagnose  Other information 

: Ny. NKW : Female : 80 years old : Lingsar : 611339 : GEA mild dehidration : Move to O.Kokok (203)

PATIENT 3 Name  Gender  Age  Adress  MR Number  Diagnose  Other information 

: Ny. M : Female : 34 years old : Meninting, Lobar : 608769 : AMS ec susp enchepalopathy, sepsis : Still at IGD

PATIENT 4 Name  Gender  Age  Adress  MR Number  Diagnose  Other information 

: Ny. S : Female : 19 years old : Praya : 611340 : RHD MSI, CHF, TB Pulmo on treatment : Still at IGD

PATIENT 5 Name  Gender  Age  Adress  MR Number  Diagnose  Other information 

: Ny. WR : Female : 20-12-1937 : Denpasar, Bali : 611361 : Septic, cellulitis pedis, post AF : Still at IGD

PATIENT 6 Name  Gender  Age  Adress  MR Number  Diagnose  Other information 

: Tn. AK : Male : 01-05-1957 : Pancor : 611362 : Hepatoma : Still at IGD

PATIENT 7 Name  Gender  Age  Adress  MR Number  Diagnose  Other information 

: Tn. AZ : Male : 27-12-1979 : Rumak Barat Selatan : 611357 : Hematemesis melena : Still at IGD

PATIENT 8 Name  Gender  Age  Adress  MR Number  Diagnose  Other information 

: Tn. F : Male : 37 years old : Sakra, Lotim : 611355 : Hepatoma, susp. Metastasis paru, Asites : Still at IGD

PATIENT’S IDENTITY Name  Age  Gender  Address  Job  No. RM  Diagnosis  Date of assessment 

: Ny. NKW : 80 years : Female : Lingsar, Lombok Barart :: 611339 : GEA : 03 january2019

ANAMNESIS Main Complaint  Diarrhea  Current History of Disease  Patients come to RSUP NTB with complaints of diarrhea since 3 days ago. frequency of diarrhea 4-5 x/day. The stools are liquid, colour is yellow and a little bit of pulp but not accompanied by mucus mixed with blood or colored like rice washing water. Before diarrhea, the patient had a fever for 1 day ago and was taken to a primary health care and had treated. Patients also complain of nausea and vomiting when taking medication or eating. In addition, patients also complain of abdominal pain that has arisen since starting diarrhea. 

History of Past Illness Previously, patients had diarrhea since a month ago, but didn’t arrive at the hospital. hypertension (+) and routine take a medication, diabetes mellitus (-), asthma (-), heart diseases (-). Patients were treated at the damai pesona clinic with complaints of a diarrhea and get therapy IVFD RL 30tpm, ranitidin tablet 2x1, scopma plus 3x1, and zultrof forte 2x1.  History of Family History of similar symptoms (-), heart disease (-), hypertension (+), diabetes mellitus (-), stroke (-), asthma (-)  History of Allergic History of food allergies (-), drugs (-) 

GENERAL CONDITION General Conditions Awareness Blood Pressure Heart Rate Respiratory Rate Temperature SpO2

: weakness : Compos mentis (GCS E4V5M6) : 112/51 mmHg : 163 x/minute : 22 x/minute : 37,4 C : 90% without O2

PHYSICAL EXAMINATION Head  Shape and size: Normocephali  Facial edema: (-)  Malar Rash: (-)  N.VII Parese: (-)  Mass: (-)  Bleeding: (-)

PHYSICAL EXAMINATION

Eyes  Position: Symmetrical  Eyebrow: Normal  Exophthalmus: (- / -)  Ptosis: (- / -)  Palpebra Edema: (- / -)  Conjunctiva: Anemis (-/-)  Sclera: Jaundice (-)  Pupil: Isokor, 3 mm, round, pupillary reflex (+ / +)  Cornea: Normal  Lens: cloudy (- / -)  Retroorbita compressive pain: (- / -)  Sunken eyes : (-)

PHYSICAL EXAMINATION Nose/Ear  Symmetrical (+), deformity (-), septal deviation (-)  Masses (-), lessions (-)  Nasal lobe breath (-/-)  Abormal secretions (-/-), bleeding (-) Mouth  Symmetrical mouth angle (+)  Cyanosis (-), lessions (-)  Gums, mucosa, and teeth are normal

PHYSICAL EXAMINATION Neck  Tracheal deviation (-)  Masses (-), lessions (-)  KGB enlargement (-), thyroid gland enlargement (-)  SCM muscle enlargement (-)  JVP increases (-)  Carotid artery  reguler, adequate, bruit (-)

PHYSICAL EXAMINATION Thorax Inspection  Shape and size are normal, symmetrical  Chest wall movement: right and left symmetrical chest  Chest surface: mass (-), scar (-), lessions (-)  Used of breath-assisting muscles (-), retraction (-)  Ribs and ribs: no widening or narrowing  Jugular fossa: normal, supra and infraclavicular fossa are normal  Ictus cordis pulsation (-)

PHYSICAL EXAMINATION Thorax Palpation  Mediastium position is normal  Right and left chest wall movement are symmetrical  Press pain (-), lump (-), crepitation (-), masses (-)  Ictus cordis is palpable on the ICS VII axilla line sinistra, thrill (-)

PHYSICAL EXAMINATION Thorax Sonor Sonor Percussion Sonor Sonor  Pulmo’s density* Sonor Sonor  Heart border Right : ICS VII parasternal line dextra Left : ICS VII axilla line sinistra  Border of pulmo-hepatic Inspiration

: ICS VI

Expiration

: ICS IV

PHYSICAL EXAMINATION Thorax Auscultation Vesicular Vesicular  Pulmo Breath sounds* Vesicular Rhonki* Wheezing*  Cor S1 S2 single regular Murmur (-) Gallop (-) -

Vesicular Vesicular Vesicular -

PHYSICAL EXAMINATION Abdomen  Inspection : Distention (-), masses (-), lessions (-), jaundice (-), collateral veins (-), scar (-), striae (-), rash (-)  Auscultation : Bowel sounds (+) normal, fr 16x/minutes, metallic sound (-)  Percussion* : Shifting dullness (-), undulation (-)  Palpation :Tenderness(+) in the left side of abdomen, hepatomegaly (-), splenomegaly (-), ballotement (-)

PHYSICAL EXAMINATION Upper Extremity  Deformity (-/-)  Warm acral (+/+)  Cyanosis (-/-)  Clubbing finger (-/-)  Oedema (-/-)

Lower Extremity  Deformity (-/-)  Warm acral (+/+)  Cyanosis (-/-)  Clubbing finger (-/-)  Pitting oedema (-/-)

RESUME A 80-year-old woman came to the RSUDP Province NTB with diarrhea since 3 days ago with frecuency 4-5x/day, fever for 1 day before, nausea, vomiting, and abdominal pain arisen since starting diarrhea.

From the physical examination, it was found that the general condition is weakness compos mentis (GCS E4V5M6), blood pressure 112/51 mmHg, heart rate 163 x/minute, respiratory rate 22 x/minute, temperature 37,4 C, and SpO2 90% without O2.

LABORATORY EXAMINATION LABORATORIUM

RESULT

NORMAL VALUE

Haemoglobin

11,3 g/dL

12.0-16.0

Leukocytes

10050/uL

4000-10000

3.65 juta/uL

3.50-5.00

231000/uL

150000-400000

32 %

36-48

MCV

87,1 fL

80.0-100.0

MCH

31,0pg

26.0-34.0

MCHC

35,5g/dL

32.0-36.0

Urea

77 mg/dL

10-50

Creatinine

2,0 mg/dL

0.6-1.1

Erythrocytes Platelets Hematocrit

LABORATORY EXAMINATION LABORATORIUM

RESULT

NORMAL VALUE

115 mg/dL

<160.00

Na

131 mmol/L

135-146

K

3,9 mmol/L

3.4-5.4

Cl

103 mmol/L

95-108

Blood glucose

ECG

RONTGEN THORAX Cardiomegaly  Aortosclerosis  Pulmo Edema  Efusi Pleura bilateral 

ASSESSMENT 

GEA dehidrasi ringan

PLANNING (DIAGNOSTIC) 

Analisis Feses

PLANNING (THERAPY) IVFD RL 10 tpm  Levofloxacin inj 500 mg/day  Omeprazole inj 1 vial/ day  Co cardiologist 

THANK YOU