MORNING REPORT

September 24th 2016

Internal Medicine Department
I-25 group

OB Interna
Nama

Diagnosis

Ruangan

Mrs. F (55 yo)

GEA, Dehydration, dermatitis Atopic, Hypo

K, Electrolyte Imbalance

Marwah 7

Mrs. S (60 yo)

Mr. A.H. (38 yo)
Ms. L.N.R.L. (27
yo)
Mrs. K (60 yo)

OF

RJ

Septic Shock, Pneumonia, ARDS

HCU

Suspect Pancreatitis, Colic Abdomen

Marwah 8

Septic shock, hemorrhoid internal, melena,

hematocezia, susp. Gastritis Erosiva

Marwah 10

Mr. E. W (35 yo)

Nausea-vomitting

RJ

Mr. A.G (71 yo)

DM II, Alkalosis, Hypo K, Haematemesis,

Hyperglycemia

Marwah 8

Mr. N. M. (53 yo)

IMA Inferior Wall

HCU

Mr. M (50 yo)

Colic Abdomen

RJ

Identity
Name

: Mr. S

Age

: 38years old

Occupation

: employee

Address

: Pasinan RT12 RW6 Pasinan Baureno Bojonegoro

Admission

: September 23rd 2016 at 17:10

Chief Complaint

Shortness of breath

Present history (Aloanamnesis)

This condition occurs since 11 hours before admission (at

05:00am), patient feels that his complaint was worsening. Cough
denied, chest 0discomfort or pain denied too. 2 hours before
admission, he try to get some medication on Prima Medika Clinic
at Mantup and diagnosed as Decompensatio Cordis, patients BP
on arriving clinic was 120mmHg and after getting some medicine
such as 2tablets Aspilet, Ketorolac IV inj., and tab ISDN 5mg his
BO drops until 70mmHg and then he getting revered to RSML. He
also complained about his stomachache especially at epigastria
region, and his wife also said that he sometimes complained
about his left shoulder pain. He also sometimes complained about
his pelvic pain on the righ side that spreading to left stomach.
Pain when mictus -, he complained his mictus feels unfinished
and feels so uncomfortable about it.

Past history of Illnes

DM denied, HT denied
Allergy -, same condition history

Family history

No familial related

Social history

Smoking + >1pack/day

Vital Signs

BP
71/55 mmHg

Pulse
132x/min

Temp
37.80 C

RR
34x/min

Primary Survey
A.

:Clear, gargling (-), snoring (-), speak

fluently (+), potential obstruction (-)

B.

: Spontaneously, RR 34x/min, ves/ves, Rh

-/-, Wh +/+ minimal, SaO2: 86% w/o O2
support93% w/NRBM 10 LPM

C.

: distal extremity HKM, CRT < 2 N

132x/min TD 71/55mmHg

D.

: GCS 456, lateralisation-, PBI 3mm/3mm,

RC +/+

E.

: temp 37.8 C

General condition : weak

Awareness
: compos mentis
GCS
: 456
HEAD/NECK
: a -/i-/c-/d+
lymph node enlargement at neck (-)

THORAX
Inspection
Symmetrical, retraction -,
Palpation
Thrill (-), fremitus WNL
Percussion
Lungs: sonor /sonor
Cor: N
Auscultation
Lungs: ves /ves, rh -/-, wh +/+ minimal
Cor: S1S2 single, murmur -, gallop -

GENERAL STATUS

ABDOMEN
Inspection
flat
Auscultation
Bowel sound WNL
Palpation
Soepel, Liver /Spleen within normal limit, Tenderness + on
epigastria region, defans muscular -.
Percussion
Tymphany, meteorismus -.

GENERAL STATUS

EXTREMITY
Inspection
Clubbing fingers (-), anemic (-), icteric (-), cyanosis (-),
edema (-)
Palpation
Warm red and dry, CRT <2

CLUE AND CUE

Male 41 years old

tachypnea
Tachycardia

Planning Diagnosis
DL
Elektrolit serum
BGA
Cardiac Marker
LFT, RFT, Glucose test
Ro thorax PA
ECG

Assesment

Shock Susp. septic shock

Eritrosit 5.38 ()
.Hemoglobin 16.0 (N)
.Laju Endap Darah 1 1 (N)
.Laju Endap Darah 2 5 (N)
.Limposit 8.5 ()
Basofil 5.4 ()
Eosinopil 1.6 (N)
Hematokrit 48.6 (N)
Lekosit 14.0 ()
MCH 29.70 (N)
MCHC 32.90 (N)
MCV 90.30 (N)
Monosit 5.5 (N)
MPV 4 ()
Neutropil 79.0 ()
RDW 11 (N)
Trombosit 208(N)

Clorida Serum 100 (N)

Kalium Serum 3.9 (N)
Natrium Serum 132 ()

LA
BO
RA
TO

RY
FI

ND
IN

GS

TH
OR
AX
AP

EC
G

EC
G

Re-Assesment

Septic shock
Pneumonia
Susp. ARDS

Planning Therapy
A-B:O2 NRBM 10 lpm
Nebul Vellutin 1amp tiap 8 jam
C: IV line and Catheter for controlling input and output
fluids
Inf PZ loading 500cc/hour and monitoring BP, HR, RR and
respiratory voicemaintenance Ringer Asetat1500/24jam
Inj Ceftriaxon 2x1g iv
Supportive/symptoms medication:
Inj. IV Na Metamizole 3x1g
Consult to:
Sp.P
Sp.An

Pro ICU and complete urine test

PLANNING MONITORING

Vital Signs (BP,HR and RR)

Respiratory Voice
BGA
Patients complaint
Adverse effect

PLANNING EDUCATION

Explain to the patient and his family

about
the
disease,
cause,
complication, intervention of the
therapy and prognosis.