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  • Morning Report: Tuesday, February 25 2014

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    Arif Prianggara
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    1. A 60-year-old male presented with weakness, diarrhea, fever, and decreased consciousness for the past 1-2 days. Physical examination revealed low blood pressure, rapid pulse and breathing, fever, and signs of dehydration. 2. Laboratory tests found anemia, low platelet count, elevated creatinine and urea, suggesting acute kidney injury (AKI) and possible sepsis or hypovolemic shock. 3. The initial diagnoses were septic or hypovolemic shock and AKI. Treatment plans included IV fluids, antibiotics, oxygen, and monitoring of vital signs and lab tests.

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    1. A 60-year-old male presented with weakness, diarrhea, fever, and decreased consciousness for the past 1-2 days. Physical examination revealed low blood pressure, rapid pulse and breathing, fever, and signs of dehydration. 2. Laboratory tests found anemia, low platelet count, elevated creatinine and urea, suggesting acute kidney injury (AKI) and possible sepsis or hypovolemic shock. 3. The initial diagnoses were septic or hypovolemic shock and AKI. Treatment plans included IV fluids, antibiotics, oxygen, and monitoring of vital signs and lab tests.

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    5 views7 pages

    Morning Report: Tuesday, February 25 2014

    Uploaded by

    Arif Prianggara
    1. A 60-year-old male presented with weakness, diarrhea, fever, and decreased consciousness for the past 1-2 days. Physical examination revealed low blood pressure, rapid pulse and breathing, fever, and signs of dehydration. 2. Laboratory tests found anemia, low platelet count, elevated creatinine and urea, suggesting acute kidney injury (AKI) and possible sepsis or hypovolemic shock. 3. The initial diagnoses were septic or hypovolemic shock and AKI. Treatment plans included IV fluids, antibiotics, oxygen, and monitoring of vital signs and lab tests.

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    © All Rights Reserved
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    of 7

    MORNING REPORT

    TUESDAY, FEBRUARY 25th 2014

    TUTOR : dr. Rofika Hanifa, Sp.PD

    Summary of Data Base


    Male / 60 yo Chief complain : weakness Patient suffered from weakness since 1 day. All his body feel weak. He also got diarrhea since 2 days and each days hes got diarrhea 5 times, dregs (+), mucus (+) and nausea without vomiting. He also got febris since 2 days and it was continues.

    o o

    Physical examination
    General appearance BP = 60/40 mmHg PR = 88 bpm looked severely ill GCS 456 RR = 40 tpm Tax : 37,2C

    Head Neck Chest Heart

    Anemic JVP R + 6 cm

    Icteric -

    cyanosis -

    Invisible palpable ictus cordis Pain pressure (-) S1 S2 single, mur mur -, gallop -

    lung

    Symmetric, pain -, rh -/-, wh -/-

    Abdomen Extremities

    Flat soft, BS + normal, Edema -/-/-

    Laboratory finding
    Laboratory finding
    Leucocyte Trombocyte Ureum HCT 12.600 89,000 /l /L mg/dL %

    Value
    N: 4000 11.000 N: 150.000 450.000

    96
    59,4 2,8 103,9 27,0

    N: 15-45
    N: 40-54 N: 0,6 1,4 80-97 27-31

    Creatinine
    MCV MCH

    mg/dL
    Fl pg

    CUE AND CLUE

    PROBLEM LIST

    INITIAL DIAGNOSE

    PLANNING DIAGNOSE

    PLANNING THERAPY

    PLANNING MONITORING

    Male/60 yo. Weak all his body, decreased of consciousness, nausea, diarrhea > 5 times a day since 2 days ago, febris since 2 days,.

    1. Decreased of consciousn ess+shock condition

    1.1. septic shock 1.2 hypovolemi c shock

    HB UL LF

    BP : 60/40, PR :88bpm, RR: 40 tpm, t: 37,2


    Leukosit: 12.600 diffcount: 1/-/1/83/10/5 Tromb: 89rb Hct: 59,4

    Futrolit VS 20tpm HB O2 2-4 lpm nasal canals Diet soft 6x200cc/kg BW/day Rantin 2x1mg amp (iv) Metoklopra mid 3x10mg (iv) Metronidazo le 3x500mg Levofloxacin 1x500mg TC 4 flask/d until tromb >100.000

    CUE AND CLUE

    PROBLEM LIST

    INITIAL DIAGNOSE

    PLANNING DIAGNOSE

    PLANNING THERAPY

    PLANNING MONITORING

    Male/ 60 yo Ureum: 96 Creatinine: 2,8

    2. Azotemia

    2.1 AKI

    Ur/Cr

    Ur/Cr

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