morning report ruangan 31 desember 2013 interna

8/13/2019 Morning Report Ruangan 31 Desember 2013 Interna

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MORNING REPORT

DEPARTMENT OF INTERNA

MONDAY, DEC 31TH 2013



Patient identity•

Name : Ny W•Age : 72 years old

•Sex : Female

•Address : Lamongan

•Examination date : Dec 6th, 2013



ANAMNESIS

Chief Complaint

• dyspneu

Present illness History

• Pasien datang dengan keluhan sesak sejak 4 hari yll. Sesakterus2an, makin lama semakin parah, tidak berkurang sedikitdengan istirahat. Sudah dibawa ke RS Soegiri tetapi tidak adaperkembangan yang berarti. Pasien juga mengeluh perut tidakenak, badan terasa lemah, nafsu makan menurun, muntah -,BAK dbN, BAB – sejak 2 hr yll.

• Patient comes with dyspneu since 4 days ago. Dyspneu

continueous, getting worse day after day, not diminished a littlewith rest. Patients been taken to Public Hospital but nosignificant development. The patient also complained ofdiscomfort stomach, body feels weak, decreased appetite,vomiting -, BAKdbN, BAB - since 2 days ago.



Previously illness history

• HT + since 2 years ago, routine medication

• DM -

• Kidney disease + since 8 month ago

Family illnes History• Kidney disease denial

Medicine taking history

• -

Social history

• -



Vital Sign

•GCS : 456 looks anemic•Blood pressure : 182/105 mmHg

•Heart Rate : 94x /minutes

•RR : 28x /minutes•Axilla temperature : 36o C



• Head / neck : an (+), ict (-), cy (-), dys (-)• Thorax : Normal chest form, retraction (-),• Pulmonary

• I : symmetrical chest wall movement, increaserespiratory rate

• P : n/n• P : sonor/sonor• A : ves/ves, Rh-/-, Wh -/-

Cor• P : Dull, batas jantung kiri melebar• A : S1-S2 single, murmur (-), gallop (-)

•

Abdomen• I : flat• P : soefl, Liver / Splen not palpable, painless• P : thimpany• A : Bowel sound (+) Normal

• Extremity : odem (-), warm, dry, CRT < 2, turgor N



PLANNING DIAGNOSIS

• Complete blood

• RFT

• RBS

• Thoraks rontgen

• EKG

• Elektrolit serum

• BGA

• USG



THORAKS



LABORATORY FINDINGS

•Diffcount 2/0/87/5/6 (1-2/0-1/49-67/25-33/3-7)

•Hct 26,1 %

•Hb 5,6 mg/dl

•Leukocyt 11.700

•Thrombocyt 174.000

•Kalium 4.3

•SGOT/SGPT 145/136

•Chlorida serum 104•Kalium serum 137

•Natrium 144

•Clorida 104

•Creatinin 5,9

•

HbA1C 6.5•Ureum 251

•Ph 7,3

•pCO2 22,2



CLUE AND CUE

• Female, 72 years old

• Dispneu

• Weakness• Anemis

• Blood pressure : 182/105 mmHg

•

History kidney disease (+)



PLANING TERAPI

• IVFD Asering 500cc loading check vital sign kidmin 200cc/24 jam+ D5 1000cc

• Diet rendah protein(0,6-0,8gr/kgBB/hr) 30gr/hari

• Ranitidin inj 2x1

• Ondansentron 2x1

• Irbsartan 1x150 mg ?

• Nifedipin long acting (Adalat oros) 1x30mg

• Cavid D3 1x1• HD if GFR < 15, clinical finding is severe,

asidosis isn’t correction with medicine, ureum >200, kalium > 6.

• Consult internist



MONITORING

• Complaint

• Vital sign

• RFT• Risk factor profil

lipid



PROGNOSIS

•Dubia ad malam



EFECTIVE COMMUNICATIVE

EDUCATION

• Patient’s illness

morning report ruangan 31 desember 2013 interna

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