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  • Morrep Rabu 13052014 Ok 3

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    Fauziah Rizki Ismaulidiya
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    Tn. Tuyan, a 63-year-old male, was diagnosed with sigmoid colon cancer and had a history of asthma, penile implant in 1995, and a broken thigh bone in 1995. His vital signs and physical examination were normal except for clear lung sounds and a soft abdomen. His lab results showed anemia and electrolyte abnormalities. Tn. Agus S, a 42-year-old male, was diagnosed with left periocular cyst and right wrist cyst. He reported a one-year history of lumps under his left eye and right wrist with no other medical issues. His vital signs and physical exam were normal except for elevated blood pressure. His lab results showed anemia and elevated liver enzymes

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    Tn. Tuyan, a 63-year-old male, was diagnosed with sigmoid colon cancer and had a history of asthma, penile implant in 1995, and a broken thigh bone in 1995. His vital signs and physical examination were normal except for clear lung sounds and a soft abdomen. His lab results showed anemia and electrolyte abnormalities. Tn. Agus S, a 42-year-old male, was diagnosed with left periocular cyst and right wrist cyst. He reported a one-year history of lumps under his left eye and right wrist with no other medical issues. His vital signs and physical exam were normal except for elevated blood pressure. His lab results showed anemia and elevated liver enzymes

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    14 views10 pages

    Morrep Rabu 13052014 Ok 3

    Uploaded by

    Fauziah Rizki Ismaulidiya
    Tn. Tuyan, a 63-year-old male, was diagnosed with sigmoid colon cancer and had a history of asthma, penile implant in 1995, and a broken thigh bone in 1995. His vital signs and physical examination were normal except for clear lung sounds and a soft abdomen. His lab results showed anemia and electrolyte abnormalities. Tn. Agus S, a 42-year-old male, was diagnosed with left periocular cyst and right wrist cyst. He reported a one-year history of lumps under his left eye and right wrist with no other medical issues. His vital signs and physical exam were normal except for elevated blood pressure. His lab results showed anemia and elevated liver enzymes

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    of 10

    MORNING REPORT

    RABU 13 MEI 2014


    OK 3
    Nama : Tn. Tuyan
    Usi a : 63 tahun
    No RM : 725372
    Ruang : kenanga
    Di agnosis : Ca Col on Si gmoi g
    Pro : Exp l ap

    Ri w asma (+) terakhir kambuh seki tar 1 bul an yg l al u, operasi
    (+) pasang pen tahun 1995, al ergi ( - ), j antung ( - ), HT (- ), DM (-
    ), batuk l ama ( - ), trauma (+) pada tahun 1995 patah tul ang
    paha ki ri
    1
    A : Clear, gipong (+), giyang (-), gisu (-), MP1
    B : spontan, RR 20 x/m, SD ves +/+, Rbh -/-,
    Rbk-/- Wh -/-
    C : TD : 100/60 mmHg, N 72 x/m reg isi dan
    teg cukup, s1>s2, m (-), g(-)
    D : BB 54 kg, S 36,9
    0
    C
    Lab O7062014
    Hb 11, 8 L
    Leu 6380
    Ht 35 L
    Eri 4, 0 j t
    Trb 176rb
    Ureum 26, 6
    Krea 1, 21
    Na 132 L
    K 3, 3 L
    Cl 101
    Ca 8, 2 L





    LABORATORIUM
    Lab 10052014
    PT 14, 3
    APTT 32, 6
    Total Protein 5, 86 L
    Al bumin 3,10 L
    Gl obulin 2, 76
    ACC ASA III
    KESIMPULAN
    2
    Nama : Tn. Agus S
    Usi a : 42 tahun
    No RM : 291388
    Ruang : Kenanga
    Di agnosis : Ki sta Peri orbita Si ni stra dan ki sta manus dextra
    Pro : exti rpasi

    S : Benj ol an di bawah mata sebelah ki ri dan pergelangan
    tangan kanan sej ak 1 tahun yg l al u
    Ri w asma (- ), operasi (- ), al ergi (- ), trauma (- ), dm - , ht -

    A : Clear, MP1
    B : spontan, RR 20 x/m, SD ves +/+, Rbh -/-,
    Rbk-/- Wh -/-
    C : TD 140/90, N 88 x/m, HR 88 x/m, s1>s2,
    m (-), g(-)
    D : BB 58 kg, S 36,5
    0
    C

    Lab 130514
    Hb 13, 1 L
    Leu 6420
    Ht 40 L
    Eri 5, 2 j t
    Trb 285rb
    PT 13, 9
    APTT 37, 7
    SGOT 23
    SGPT 37
    UR 14, 8
    KR 0, 77
    Na 137
    K 3, 4 L
    Ca 8, 6
    Cl 101
    GDS 238 H








    HASIL LABORATORIUM
    ACC ASA III
    KESIMPULAN
    TERIMA KASIH

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